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","D","E"]
Explanation
A. Explain that the child is likely to grow into her weight. This is incorrect because a BMI at the 85th percentile indicates that the child is overweight. Without intervention, the risk of continued excess weight gain and future obesity increases.
B. Obtain the child's 3-day diet history based on the mother's input. Assessing the child's dietary habits helps identify potential areas for improvement, such as reducing sugary drinks or increasing fruit and vegetable intake. Understanding the child’s nutrition is essential for developing a healthy eating plan.
C. Tell the mother that girls hit their growth spurt before boys so eating more is expected. While girls do experience growth spurts earlier than boys, this does not justify excessive weight gain. Encouraging healthy eating and physical activity is more appropriate than assuming the child will "grow out of it."
D. Inquire as to whether or not the school has a physical education program. School-based physical activity plays an important role in weight management. If the school lacks a structured program, additional strategies for physical activity should be explored.
E. Determine the child's usual physical activity pattern. Assessing the child’s activity level helps identify if sedentary behaviors (e.g., excessive screen time) are contributing to weight gain. Encouraging regular physical activity is a key part of managing childhood obesity.
Correct Answer is C
Explanation
A. Offer a low sodium formula between breast feedings. Congenital hypothyroidism is not managed with dietary sodium restrictions. The priority is thyroid hormone replacement, not sodium intake adjustments.
B. Stimulate the infant during feedings to ensure adequate intake. Infants with congenital hypothyroidism may have poor feeding due to lethargy, but stimulation during feedings is not the primary intervention. The most critical aspect of care is thyroid hormone replacement to support normal growth and brain development.
C. Administer supplemental thyroid hormone daily. Lifelong thyroid hormone replacement with levothyroxine is essential to prevent intellectual disability and growth delays. Early and consistent treatment ensures normal neurological and physical development. Missing doses or delaying treatment can result in irreversible cognitive impairment.
D. Monitor the infant's daily intake and weekly weight. While monitoring growth and nutrition is important, it is secondary to ensuring proper thyroid hormone therapy, which directly affects metabolism, weight gain, and developmental outcomes.
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