After considering the report from the ED, the nurse identifies abnormal findings that require further evaluation and assessment.
Drag from the Word Choices to complete the sentence.
The nurse identifies abnormal findings including
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C","dropdown-group-3":"D"}
Rationale for correct choices:
- Weight gain: The client reports recent weight gain, which is a common symptom of atypical or seasonal depression.
- Carbohydrate cravings: Increased appetite, especially for carbohydrates, is a noted feature of seasonal affective disorder (SAD).
- Fatigue: Persistent low energy and hypersomnia indicate significant functional impact and are characteristic depressive symptoms.
Rationale for incorrect choices:
- Menstrual cycle: The client reports a regular 30-day cycle; this is within normal limits.
- Heart rate / Blood pressure: Vital signs are within normal ranges (HR 72 bpm, BP 122/68 mm Hg), so no abnormality is noted.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Crackles may indicate fluid accumulation in the lungs due to left-sided heart failure, which can occur in chronic aortic regurgitation. While important, crackles develop gradually and may not indicate immediate hemodynamic instability.
B. A soft S1 is a common finding in aortic regurgitation due to premature closure of the mitral valve. This is expected and chronic in nature, and while it should be documented, it does not represent an acute change requiring immediate intervention.
C. Although bradycardia may affect cardiac output, it is less immediately threatening compared to hypotension unless severe or symptomatic. It is not the most urgent change in this context.
D. This is the most critical finding to report immediately. Aortic valve regurgitation can compromise forward cardiac output, and hypotension may indicate acute decompensation, cardiogenic shock, or severe regurgitation, which is life-threatening. Prompt notification allows for urgent assessment, possible medication adjustments, or advanced interventions to stabilize the client.
Correct Answer is C
Explanation
A. Instructing the UAP to return and perform handwashing is unnecessary in this situation. Alcohol-based hand rubs are an acceptable and recommended method for hand hygiene when hands are not visibly soiled. There is no indication that the UAP performed the technique incorrectly or that soap and water are required, so this action is not appropriate.
B. Wearing gloves for all vital sign measurements is not required and may lead to inappropriate overuse of gloves. Standard precautions indicate glove use only when there is potential contact with blood, body fluids, or contaminated surfaces. This option does not address the observed action.
C. Proper use of alcohol-based hand rub requires rubbing hands together until they are completely dry to ensure effective microbial kill. Reinforcing correct technique supports infection control practices and promotes safe, evidence-based care.
D. Supervising the UAP later does not address the current opportunity for immediate teaching. The nurse should provide timely feedback to reinforce proper technique rather than delay evaluation.
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