Exhibits

Click to highlight the findings below that would indicate that the client has a potential problem. To deselect a finding, click on the finding again.

Nurses' Notes

1000:

Client reports tightness in chest that radiates to left arm. States pain as 7 on a scale of 0 to 10. Started to feel nauseous after breakfast. Client states, "I had scrambled eggs and bacon like I do every morning." Client is diaphoretic and short of breath. Heart rate irregular and tachycardic. Alert and oriented to person, place, and time. Lungs clear to auscultation in all lobes. Bowel sounds are present in all 4 quadrants. +1 pedal pulses. Skin is cool to touch. Capillary refill less than 2 seconds.

A Clearing the area is essential to prevent injury during a seizure. The client may move or thrash around, and any objects nearby (e.g., furniture, medical equipment, or sharp objects) can potentially cause harm. However, this can be done after lowering teh client.

B. This action is crucial to protect the client from injury during the seizure. It provides a safe environment for the client to have the seizure without risk of falling or hitting their head on objects.

C. Assessing vital signs can wait until after the seizure has ended and the client's immediate safety has been ensured. During a seizure, the nurse should focus on managing the seizure and preventing complications.

D. This action is important for comfort and safety but is secondary to ensuring a safe environment and managing the seizure itself.

A Sputum cultures for AFB are used to detect the presence of Mycobacterium tuberculosis, the bacteria causing TB. A negative result means that the sputum samples tested do not contain viable TB bacteria that can be transmitted to others. It indicates that the client's TB treatment has been effective in reducing the bacterial load to non-infectious levels.

B. The Quantiferon-TB Gold test is a blood test used to detect TB infection based on the immune response to TB antigens. A positive result indicates TB infection but does not differentiate between latent TB infection (not infectious) and active TB disease (potentially infectious).

C. The Mantoux tuberculin skin test (TST) is another test used to detect TB infection based on a delayed- type hypersensitivity reaction to TB antigens. An induration of less than 1 mm is considered negative and suggests that the client does not have a significant immune response to TB antigens, which could mean they are not infected with TB or the infection is not significant. This finding does not provide information on the client's infectiousness.

D. This indicates improvement in the client's symptoms, as coughing up blood-tinged sputum (hemoptysis) is a common symptom of active pulmonary TB. While improvement in symptoms is an important aspect of TB treatment, it does not directly indicate whether the client is no longer infectious. Infectiousness is primarily determined by microbiological tests such as sputum cultures for AFB.