After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment finding(s) should the nurse report to the healthcare provider? (Select all that apply.)

Red blood cell count (RBC).

Core body temperature.

Swollen lymph nodes in the groin.

Location of the initial intravenous (IV) site.

White blood cell count (WBC).

Answer and Explanation

Correct Answer : B,C,E

A)   Incorrect - Red blood cell count (RBC) is not directly relevant to the assessment of infection and its spread.
B)   Correct- Core body temperature can be an indicator of systemic infection and needs to be reported to the healthcare provider for assessment and intervention.
C)   Correct- Swollen lymph nodes in the groin suggest local and regional lymphatic involvement, indicating possible spread of infection. This finding needs further assessment and intervention.
D)   Incorrect - The location of the initial intravenous (IV) site is not directly relevant to the assessment of infection and its spread.
E)   Correct- An elevated white blood cell count (WBC) can indicate an inflammatory response to infection. This finding should be reported to the healthcare provider for further evaluation and treatment.

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Correct Answer is B

Explanation

A) Incorrect- A blood pressure of 130/80 mm Hg is within a generally acceptable range for a person with diabetes and coronary artery disease. It may not directly indicate a complication related to the episodes of confusion. While blood pressure management is important for clients with diabetes and coronary artery disease, this particular blood pressure reading is not necessarily a significant finding in relation to the client's confusion.
B) Correct- Cervical spine stiffness or neck stiffness is a potential neurological symptom that can indicate a serious complication in a client with type 2 diabetes and coronary artery disease. The stiffness of the neck may be a sign of meningeal irritation, which can result from various conditions including infections such as meningitis. The client's medical history includes both type 2 diabetes and coronary artery disease, which are risk factors for cardiovascular events, including cerebrovascular accidents (strokes). Confusion can be a symptom of a stroke, and neck stiffness can be indicative of meningeal irritation secondary to a stroke or another neurological condition.
C) Incorrect- Dark yellow urine can be a sign of dehydration, which can be a concern for someone with diabetes. However, it is not directly related to episodes of confusion. Dehydration can cause various symptoms, but confusion is not typically associated with mild dehydration.
D) Incorrect- Excessive perspiration (diaphoresis) can occur for various reasons, including increased sympathetic nervous system activity, fever, anxiety, and physical activity. While it can be a symptom of certain complications, such as hypoglycemia (low blood sugar) or heart attack, it alone may not directly relate to the episodes of confusion in this client.

A. Bends from the waist to pick trash off the floor. B. Widens stance while working near the sink. C. Locks knees while preparing food on the counter. D. Brings a heavy can close to body before lifting. E. Leans forward to pull a pan from a high shelf

Correct Answer is ["B","D"]

Explanation

A) Incorrect- This behavior is not safe for maintaining balance. Bending from the waist can increase the risk of falling. Clients should bend at the knees and use proper body mechanics to pick up objects from the floor.
B) Correct- Widening the stance provides a broader base of support, which can help improve balance and stability while working near the sink. This is a safe behavior to maintain balance.
C) Incorrect- Locking the knees while standing can lead to instability and decreased balance. It is recommended to keep the knees slightly flexed to maintain better balance.
D) Correct- Bringing a heavy object close to the body before lifting minimizes strain on the back and helps maintain balance. This is a safe behavior when lifting objects.
E) Incorrect- Leaning forward to pull an object from a high shelf can disrupt the center of balance and increase the risk of falling. It's important to use a step stool or ask for assistance when reaching for items on high shelves.

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After a spider bite on the lower extremity, a client is admitted for treatment of an infection that is spreading up the leg. Which admission assessment finding(s) should the nurse report to the healthcare provider? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with type 2 diabetes and coronary artery disease who is experiencing episodes of confusion. Which finding alerts the nurse that the client may be experiencing a complication?

Correct Answer is B

Explanation

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. Which behavior(s) indicate the client understands how to maintain balance safely? (Select all that apply.)

Correct Answer is ["B","D"]

Explanation

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