Exhibits

For each assessment finding, click to specify if the finding is consistent with diabetes, pancreatitis, or hyperthyroidism. Each client finding may support more than one disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.

A. A client who had an appendectomy and has a urine output of 260 mL over 8 hr: A urine output of 260 mL over 8 hours is average (around 32.5 mL/hr), and it does not require immediate intervention. It is important to monitor, but there is no acute concern at this time.

B. A client who is immobile and has had an episode of urinary incontinence: While urinary incontinence can lead to skin breakdown and other issues, it is not immediately life-threatening. The nurse should address it with appropriate interventions, but it is not urgent.

C. A client who has COPD and an oxygen saturation of 99%: An oxygen saturation of 99% in a client with COPD is within normal limits. This indicates that the client’s respiratory status is stable and does not require immediate intervention.

D. A client who has a concussion and has developed aphasia: Aphasia after a concussion can indicate a serious complication, such as increased intracranial pressure or a brain injury. This requires immediate intervention to assess the severity of the condition and prevent further neurological damage.

Rationale for Correct Choices:

• Instruct the client to rise slowly from a sitting position: The client is showing signs of orthostatic hypotension, with a drop in blood pressure when changing positions. Providing instructions to rise slowly helps prevent dizziness and potential falls, especially in the presence of anemia-related fatigue and reduced oxygen delivery.
• Evaluate a stool sample for occult blood: The client has anemia (Hgb 8 g/dL, Hct 24%) and is taking naproxen, a nonsteroidal anti-inflammatory drug (NSAID) known to cause gastrointestinal bleeding. Occult GI blood loss is a common cause of iron deficiency anemia in such clients. Identifying hidden bleeding is a priority to determine the cause of anemia.

Rationale for Incorrect Choices:

• Draw a blood sample for arterial blood gases: There is no evidence of acute respiratory distress or hypoxemia requiring blood gas analysis. The client’s oxygen saturation is 94% on room air, and breath sounds are clear, making this action unnecessary at this time.
• Perform a 12-lead ECG: Although the client has tachycardia (HR 108/min), this is likely a compensatory response to anemia. Without chest pain or other signs of cardiac compromise, a 12-lead ECG is not the most immediate action.
• Administer an inhaled bronchodilator: The client reports dyspnea with exertion, but there is no indication of bronchospasm or wheezing. Breath sounds are clear bilaterally, so a bronchodilator is not indicated and would not address the underlying issue of anemia.