Click to highlight the findings that require immediate follow-up. (Select all that apply)
Respiratory rate 11/min
SpO2 > 94% on room air
Lungs clear to auscultation
Reports pain worsening in right forearm.
States right hand is “tingly.”
Able to move fingers
The Correct Answer is ["D","E"]
Choice A reason: A respiratory rate of 11/min is slightly below normal (12-20/min) but not immediately concerning in a stable elderly client without respiratory distress. It warrants monitoring but does not require urgent follow-up compared to neurological or musculoskeletal symptoms.
Choice B reason: SpO2 > 94% on room air is normal, indicating adequate oxygenation. This finding does not suggest respiratory compromise, so it does not require immediate follow-up, aligning with expected respiratory status in a stable client.
Choice C reason: Clear lung auscultation is a normal finding, indicating no airway obstruction or fluid. It does not suggest respiratory pathology, so it does not require immediate follow-up, reflecting stable pulmonary function in the client’s assessment.
Choice D reason: Worsening forearm pain after a fall suggests potential fracture, compartment syndrome, or nerve injury, especially in an elderly client. This escalating symptom requires immediate imaging and evaluation to prevent complications like tissue damage, making it critical for follow-up.
Choice E reason: Tingling in the right hand indicates possible nerve compression or injury, such as radial nerve damage from a fall. This neurological symptom demands urgent assessment to prevent permanent impairment, making it a priority for immediate follow-up.
Choice F reason: Ability to move fingers is a positive finding, suggesting some preserved motor function. While reassuring, it does not negate the need to address worsening pain and tingling, so it does not require immediate follow-up compared to other symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Excessive sweating is a hallmark of serotonin syndrome, a life-threatening condition from serotonin excess, often with sertraline. It accompanies agitation, hyperthermia, and muscle rigidity, requiring immediate reporting to prevent complications like seizures or organ failure due to serotonin toxicity.
Choice B reason: Dry mouth is a common side effect of sertraline but not specific to serotonin syndrome. It results from anticholinergic effects, not serotonin excess, and does not require immediate reporting unless severe, making it an incorrect choice for urgent monitoring.
Choice C reason: Constipation is a side effect of sertraline due to slowed gastrointestinal motility but is not indicative of serotonin syndrome. It is manageable with lifestyle changes and does not signal a medical emergency, making it irrelevant for immediate reporting.
Choice D reason: Insomnia is a side effect of sertraline, often resolving with time, but not a symptom of serotonin syndrome. It does not indicate acute toxicity requiring urgent intervention, unlike sweating, which signals systemic serotonin overload, making this incorrect.
Correct Answer is B
Explanation
Choice A reason: Preeclampsia is not a contraindication for misoprostol; it may be used cautiously for labor induction in such cases under close monitoring. Transverse lie is a contraindication. Assuming preeclampsia contraindicates misoprostol risks unnecessary avoidance, potentially delaying necessary induction, critical for maternal and fetal safety in labor management.
Choice B reason: Transverse fetal lie is a contraindication for misoprostol, as it increases risks of uterine rupture or cord prolapse during labor induction due to improper fetal positioning. Cesarean delivery is preferred. Recognizing this prevents complications, ensuring maternal and fetal safety, critical in labor induction planning for malpresented fetuses.
Choice C reason: Intrauterine growth restriction is not an absolute contraindication for misoprostol; it may be used with caution if induction is indicated. Transverse lie is a clearer contraindication. Assuming restriction contraindicates risks delaying induction, potentially compromising fetal well-being, critical for timely labor management in growth-restricted pregnancies.
Choice D reason: Postterm pregnancy is an indication, not a contraindication, for misoprostol to induce labor and prevent fetal risks. Transverse lie is the contraindication. Assuming postterm contraindicates misoprostol risks delaying necessary induction, increasing risks like stillbirth, critical for ensuring safe delivery in prolonged pregnancies.
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