A nurse is reviewing the medical record of a client
Click to highlight below the findings that require immediate follow-up.
| Body System | Findings |
|---|---|
| Neurological | Alert and oriented to person, place, and time; deep tendon reflexes 4+ |
| Musculoskeletal |
Generalized weakness with equal bilateral muscle strength and mild leg cramping |
| Respiratory | : Lungs clear |
| Cardiovascular | : Heart rate irregular, Heart rate 95/min |
| Gastrointestinal | Bowel sounds hyperactive x 4 quadrants |
deep tendon reflexes 4+
Heart rate irregular
Bowel sounds hyperactive x 4 quadrants
Generalized weakness with equal bilateral muscle strength and mild leg cramping
Lungs clear
Heart rate 95/min
Alert and oriented to person, place, and time;
The Correct Answer is ["A","B","C","D"]
An irregular heart rhythm could indicate potential cardiovascular issues. Additionally, deep tendon reflexes graded at 4+ suggest hyperreflexia, which may be associated with neurological disorders and should be investigated further.
Hyperactive bowel sounds in all four quadrants could indicate gastrointestinal hypermotility, which might require prompt assessment to determine the underlying cause.
Generalized weakness and mild leg cramping also require follow-up to determine the cause.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A) "We will use an electric blanket to keep your partner warm." - While maintaining warmth is important, this statement does not address communication or understanding between the partner and the client.
B) "Encourage your partner to eat three large meals each day." - Encouraging large meals may not be appropriate for a client at end-of-life care, and this statement doesn't address communication either.
C) "Assume your partner can hear you, even if they do not respond." - This statement acknowledges the importance of communication and connection with the client, even if they are not responsive.
D) "Opioids will be restricted if your partner develops respiratory distress." - This statement may be relevant in certain contexts but is not as directly related to communication and support for the partner.
Correct Answer is B
Explanation
A. Aspirated stomach contents' pH measures 6.5 (less than 5): A gastric pH greater than 5 suggests alkaline stomach contents, which may indicate bile reflux, but it is not necessarily an urgent concern.
B. Residual volume of stomach contents measures 90 mL: A residual volume greater than 50-100 mL may indicate delayed gastric emptying, which can affect medication absorption and increase the risk of aspiration. This finding should be reported to the provider for further evaluation.
C. Hyperactive bowel sounds are present: Hyperactive bowel sounds may indicate increased gastrointestinal motility but are not directly related to the administration of medications via a gastrostomy tube.
D. Stomach contents are yellowish-green in color: The color of stomach contents may vary based on diet and gastric secretions and does not necessarily indicate a need for immediate intervention.
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