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A nurse on a medical-surgical unit is reviewing the electronic health record of a client who is being admitted from the emergency department.

Exhibits

After reviewing the client's EHR, which of the following client's findings require further follow-up by the nurse?

Click to highlight the client's findings that require further follow-up by the nurse. To deselect a finding, click on the finding again.

Body System

Findings

Gastrointestinal

Client reports abdominal pain as a 9 on a pain scale of 0 to 10.

Abdomen is distended and firm.

Bowels sounds are distant and hypoactive.

Integumentary

Skin is warm and dry.

Perianal skin is excoriated, and small ulceration is noted.

Fluid balance

Tenting of skin for 4 seconds is noted.

Capillary refill is 2 seconds.

Temperature 38.7° C (101.7° F)

Mucous membranes are dry.

Respiratory rate 20/min

Client reports abdominal pain as a 9 on a pain scale of 0 to 10

Abdomen is distended and firm

Bowels sounds are distant and hypoactive

Skin is warm and dry

Perianal skin is excoriated, and small ulceration is noted

Tenting of skin for 4 seconds is noted

Capillary refill is 2 seconds

Temperature 38.7° C (101.7° F)

Mucous membranes are dry

Respiratory rate 20/min

Answer and Explanation

The Correct Answer is ["A","B","C","E","F","H","I"]

Rationale for Correct Choices:
• Client reports abdominal pain as a 9 on a pain scale of 0 to 10: Severe abdominal pain indicates significant underlying pathology. In the presence of vomiting, distention, and altered bowel sounds, it could reflect obstruction, ischemia, or peritonitis, requiring urgent intervention.

• Abdomen is distended and firm: Distention and firmness suggest accumulation of gas or fluid within the abdomen. This is concerning for bowel obstruction or peritonitis, which can compromise circulation and lead to sepsis if untreated.

• Bowel sounds are distant and hypoactive: Diminished bowel sounds point to decreased peristalsis. In a client with abdominal pain and distention, this strongly suggests obstruction or ileus, requiring prompt diagnostic and therapeutic measures.

• Perianal skin is excoriated, and small ulceration is noted: Frequent diarrhea has led to skin breakdown and ulceration. This not only causes pain and discomfort but also increases the risk of secondary infection, requiring local wound care and protection.

• Tenting of skin for 4 seconds is noted: Delayed skin turgor indicates poor hydration status. Given this client’s vomiting, diarrhea, and low oral intake, this is a strong indicator of fluid volume deficit needing IV replacement.

• Temperature 38.7 °C (101.7 °F): Fever signals the presence of infection. With gastrointestinal complaints, this may be due to bacterial gastroenteritis, abscess formation, or other intra-abdominal infection that warrants further evaluation.

• Mucous membranes are dry: Dry mucous membranes reflect fluid volume depletion. This is consistent with the client’s history of poor intake, vomiting, and diarrhea, and further confirms dehydration.

Rationale for Incorrect Choices:

• Skin is warm and dry: Warm, dry skin suggests adequate peripheral perfusion and does not require follow-up compared to more urgent findings like dehydration and abdominal changes.

• Capillary refill is 2 seconds: A refill time under 3 seconds indicates sufficient peripheral circulation. This finding is within normal limits and does not require additional intervention.

• Respiratory rate 20/min: A respiratory rate within the range of 12–20 breaths/min is considered normal for adults. This shows stable respiratory function and does not require follow-up.

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","B","C","E"]

Explanation

A. Establish the client's learning needs: Identifying what the client needs to know about managing type 2 diabetes is essential for creating a focused and effective teaching plan. This ensures the teaching is relevant and addresses gaps in knowledge.

B. Determine the client's literacy level: Assessing literacy helps the nurse tailor educational materials and teaching methods so the client can understand instructions, especially when managing medications, diet, and blood glucose monitoring.

C. Evaluate the client's readiness for learning: Readiness includes emotional, cognitive, and physical factors. A client who is stressed, anxious, or fatigued may not retain information effectively, making this assessment crucial before teaching.

D. Verify the client's computer access: While useful for online education, access to technology is not a prerequisite for general diabetes teaching. Education can be provided through verbal instruction, print materials, or demonstrations.

E. Identify the client's learning style: Understanding whether the client learns best through visual, auditory, or kinesthetic methods allows the nurse to adapt teaching strategies, improving comprehension and retention of diabetes self-management skills.

A. "I should breathe normally while I am performing this relaxation technique." B. "I should imagine myself in a peaceful, garden-like setting as I begin." C. "I'll compare the sensations I feel when I tense my muscles to what I feel when I relax them." D. "I'll use a series of stretches when I practice this technique."

Correct Answer is C

Explanation

A. "I should breathe normally while I am performing this relaxation technique.": Progressive relaxation often involves focused, deep, and controlled breathing to enhance muscle relaxation. Simply breathing normally may not maximize the effectiveness of the technique.

B. "I should imagine myself in a peaceful, garden-like setting as I begin.": Visualizing a calming scene is a technique used in guided imagery, not progressive muscle relaxation. While relaxation may result, this reflects a different stress-reduction method.

C. "I'll compare the sensations I feel when I tense my muscles to what I feel when I relax them.": Progressive relaxation involves systematically tensing and then relaxing specific muscle groups while focusing on the contrast in sensations.

D. "I'll use a series of stretches when I practice this technique.": Stretching is part of physical exercise routines and differs from progressive relaxation. The focus in progressive relaxation is on controlled tension and release of muscle groups, not performing stretches.

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Body System	Findings
Gastrointestinal	Client reports abdominal pain as a 9 on a pain scale of 0 to 10. Abdomen is distended and firm. Bowels sounds are distant and hypoactive.
Integumentary	Skin is warm and dry. Perianal skin is excoriated, and small ulceration is noted.
Fluid balance	Tenting of skin for 4 seconds is noted. Capillary refill is 2 seconds. Temperature 38.7° C (101.7° F) Mucous membranes are dry. Respiratory rate 20/min

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning teaching for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following actions should the nurse take prior to performing the teaching? (Select all that apply.)

Correct Answer is ["A","B","C","E"]

Explanation

A nurse is teaching a client to manage stress by using progressive relaxation techniques. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is planning care for a group of clients. Which of the following clients should the nurse recognize is most at risk for social isolation?

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