Exhibits
The nurse reviews the electronic health record.
Highlight the finding(s) that require the nurse's attention. Select all that apply.
Heart rate 88 beats/minute
Blood pressure 122/72 mm Hg
Temperature 100.5° F (38° C)
Reports of pain with ambulation
Respirations 20 breaths/minute
Left lower leg with erythema, warm, and swollen
Blood glucose 252 mg/dL (13.9 mm
Heart rate 88 beats/minute
Blood pressure 122/72 mm Hg
Temperature 100.5° F (38° C)
Reports of pain with ambulation
Respirations 20 breaths/minute
Left lower leg with erythema, warm, and swollen
Blood glucose 252 mg/dL (13.9 mm
The Correct Answer is ["C","D","F","G"]
Heart rate 88 beats/minute: This is within the normal range (60-100 bpm) and does not require immediate intervention.
Blood pressure 122/72 mm Hg: This is within a normal range and does not indicate an urgent issue.
Temperature 100.5°F (38°C): An elevated temperature suggests a possible infection, such as cellulitis or deep vein thrombosis (DVT), which requires further evaluation.
Reports of pain with ambulation: Pain with walking, especially in a client with peripheral vascular disease and diabetes, may indicate worsening circulation, infection, or DVT.
Respirations 20 breaths/minute: This is within the normal range (12-20 breaths/minute) and does not require immediate intervention.
Left lower leg with erythema, warm, and swollen: These are signs of inflammation or infection, such as cellulitis or a possible DVT, both of which require urgent medical attention.
Blood glucose 252 mg/dL (13.9 mmol/L): Elevated blood glucose can impair wound healing, increase the risk of infection, and contribute to further complications in a client with diabetes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A 40-year-old client who smoked cigarettes as a teen. While smoking is a known risk factor for several cancers, a brief history of smoking in adolescence does not pose as high a risk as a strong family history of breast cancer. Long-term smoking exposure is more strongly linked to lung and other cancers.
B. A 50-year-old woman with a maternal history of breast cancer. A family history of breast cancer, especially in a first-degree relative (mother, sister, or daughter), significantly increases the risk of developing breast cancer. This client may also carry genetic mutations such as BRCA1 or BRCA2, further elevating the risk.
C. A woman who had a total hysterectomy 5 years ago for a grade 4 Pap smear. A grade 4 Pap smear indicates severe cervical dysplasia or carcinoma in situ, but a total hysterectomy removes the uterus and cervix, significantly reducing the risk of cervical cancer recurrence.
D. A man with no tumor marker elevation 3 years after prostate cancer treatment. This client is in remission with no current signs of active cancer. While prostate cancer survivors require monitoring, his risk is lower compared to someone with an active familial predisposition to cancer.
Correct Answer is A
Explanation
A. Thyroxine (T4). Congenital hypothyroidism is diagnosed by measuring low levels of thyroxine (T4) and elevated thyroid-stimulating hormone (TSH). Infants with hypothyroidism have delayed metabolism, poor growth, and developmental delays. Reporting low T4 levels is critical for early treatment with levothyroxine to prevent intellectual disability and growth impairment.
B. Growth hormone (GH) levels. While GH is important for growth, it is not the primary diagnostic test for congenital hypothyroidism. GH deficiency is a separate endocrine disorder.
C. Follicle-stimulating hormone (FSH) levels. FSH is involved in reproductive development and is not relevant for diagnosing hypothyroidism in an infant.
D. Luteinizing hormone (LH) levels. LH plays a role in pubertal development and reproductive function, but it is not used to diagnose congenital hypothyroidism.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
