A nurse is reviewing the medical record of a client.
|
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+
Generalized weakness
mild leg cramping
Lungs clear
Heart rate irregular
Bowel sounds hyperactive x 4 quadrants
The Correct Answer is ["A","B","C","E","F"]
Deep Tendon Reflexes 4+: This indicates hyperreflexia, which can be associated with electrolyte imbalances, particularly magnesium deficiency, or central nervous system issues. In this context, the client has a low magnesium level (0.7 mEq/L), which can cause neuromuscular irritability and potentially dangerous complications.
Generalized Weakness and Mild Leg Cramping: While muscle strength is reported as equal, the generalized weakness and cramping suggest possible electrolyte imbalances or neurological issues. The combination with low magnesium levels raises concern for further complications.
Heart Rate Irregular: An irregular heart rate can indicate potential cardiac issues, especially in the context of electrolyte imbalances such as hypomagnesemia and the use of hydrochlorothiazide, which can contribute to electrolyte disturbances.
Bowel Sounds Hyperactive x 4 Quadrants: Although hyperactive bowel sounds can be associated with various conditions, in this case, they may be linked to the client's history of vomiting and possible electrolyte imbalance, warranting follow-up to ensure appropriate management of gastrointestinal symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Providing snug-fitting nightwear may not help with insomnia; loose-fitting clothing is generally more comfortable for sleep.
B. Keeping the door to the client's room closed can help minimize disturbances and create a more tranquil environment, which is beneficial for a client with insomnia.
C. Administering diuretics in the evening can increase nighttime urination, which may exacerbate insomnia rather than alleviate it.
D. Using overhead lighting can disrupt the client's ability to relax and fall asleep; softer lighting is generally more conducive to a restful environment.
Correct Answer is A
Explanation
A. Asking the child to share more about mealtime can provide valuable insight into the client's eating habits and challenges, promoting an open dialogue.
B. While probing for reasons may seem appropriate, it could come off as accusatory and may not encourage the child to share their concerns.
C. Dismissing the concern as "nothing serious" does not address the issue and could minimize the child's feelings and worries.
D. Suggesting the need for a feeding tube is premature and alarming; it does not help in assessing the current situation effectively.
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