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Exhibits

Select the 3 findings that require immediate follow-up by the nurse.

Mucus membranes

Integumentary findings

Emesis

Behavior

AST result

Vital signs

Movement of hands and fingers

Answer and Explanation

Correct Answer : B,D,F

A. Mucous membranes: Although they are noted to be dry, this alone is not an urgent finding. Mild dehydration may be monitored, especially when the client is stable and has IV access established.
B. Integumentary findings: Scratch marks and intense pruritus are consistent with cholestasis from liver dysfunction. This can lead to excoriation, infection, or indicate worsening hepatic failure, especially in the context of jaundice and elevated bilirubin.
C. Emesis: No vomiting or emesis is mentioned anywhere in the case details, making this an irrelevant and unsupported option for follow-up.
D. Behavior: The client is disoriented to time and displaying agitation with inappropriate language. In a client with alcohol use disorder and cirrhosis, this behavior can indicate the onset of hepatic encephalopathy which can rapidly progress and require immediate attention.
E. AST result: The AST level is significantly elevated (208 units/L), but liver enzymes are not immediate threats requiring urgent action. They confirm liver injury but do not direct acute intervention.
F. Vital signs: The client has a significantly elevated blood pressure (188/94 mmHg), tachycardia (120/min), and an increased temperature (38.4°C). These may reflect an acute withdrawal syndrome, sepsis, or intracranial injury—all of which demand urgent follow-up.
G. Movement of hands and fingers: There is no indication of tremors, asterixis, or motor deficits in the notes. Therefore, hand and finger movement does not currently present as a priority concern.

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Correct Answer is ["A","C","D"]

Explanation

A. The client slept 5 hr the previous night: Acute manic episodes often involve severe sleep deprivation, sometimes going days without sleep. Achieving 5 hours of rest indicates reduced hyperactivity and a positive response to treatment.
B. The client takes 2 short naps during the day: While napping may seem beneficial, in manic clients it can indicate ongoing disrupted sleep-wake cycles. Full, restorative nighttime sleep is a more reliable sign of improvement.
C. The client consumes 8 oz of high-calorie fluids each hour: During mania, clients often neglect nutritional needs. Actively consuming adequate fluids suggests improved awareness, cooperation, and decreased impulsivity.
D. The client engages in quiet activities in their room: Initially, the client was extremely restless and disruptive. Choosing calm, solitary activities reflects improved impulse control and reduced manic energy.
E. The client appears to listen to unseen others: This suggests persistent auditory hallucinations, indicating that psychotic symptoms remain present and untreated or only partially managed. This is not a sign of improvement.

A. Systemic lupus erythematosus B. Increased gastric motility C. Parkinson's disease D. Celiac disease

Correct Answer is C

Explanation

A. Systemic lupus erythematosus: SLE primarily affects connective tissue and organs through inflammation but rarely impacts the neuromuscular coordination needed for swallowing. It does not significantly raise aspiration risk during enteral feeding.
B. Increased gastric motility: Increased gastric motility helps clear stomach contents more quickly, decreasing the chance of regurgitation and aspiration. It is not typically considered a risk factor for aspiration.
C. Parkinson's disease: Parkinson’s disease impairs muscle coordination, including muscles used for swallowing. This dysphagia increases the risk of aspiration, especially with liquid feedings via a nasogastric tube.
D. Celiac disease: Celiac disease affects the small intestine’s ability to absorb nutrients but does not interfere with the swallowing reflex. It does not increase the risk of aspiration with tube feedings.

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Exhibits Select the 3 findings that require immediate follow-up by the nurse.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is continuing to care for the client. Exhibits The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

A nurse is caring for a client who is receiving enteral feedings via a nasogastric tube. Which of the following conditions places the client at risk for aspiration?

Correct Answer is C

Explanation

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Exhibits

Select the 3 findings that require immediate follow-up by the nurse.