Exhibits
Which information from the history and physical, nurses' note, and flow sheet requires further evaluation? Select all that apply.
Occupation of legal secretary
Stiffness in hands for 3 months
Radial and pedal pulses 2+
Pain in bilateral hands and wrists
History of asthma using albuterol inhaler PRN
Capillary refill 2 seconds
Body mass index (BMI) of 31 kg/m2
Client's hobbies
Correct Answer : A,B,D,G,H
A. Occupation of legal secretary: The client works as a legal secretary, which may involve extensive typing or repetitive hand movements. This can contribute to musculoskeletal stress or strain, potentially exacerbating symptoms like pain and stiffness in the hands.
B. Stiffness in hands for 3 months: The client reports stiffness in both hands and wrists for the past 3 months, which could suggest an inflammatory arthritis such as rheumatoid arthritis (RA). This warrants further evaluation, especially given her family history of arthritis.
C. Radial and pedal pulses 2+: A rating of 2+ for radial and pedal pulses is normal, indicating no circulation issues, and does not need further evaluation.
D. Pain in bilateral hands and wrists: Persistent, symmetrical pain in the hands and wrists, particularly with palpation, may indicate a condition like rheumatoid arthritis. This symptom, in combination with morning stiffness, needs further investigation.
E. History of asthma using albuterol inhaler PRN: The client's history of well-controlled asthma, managed with an albuterol inhaler as needed for exacerbations, does not directly relate to her current presentation of hand pain and stiffness.
F. Capillary refill 2 seconds: A capillary refill time of 2 seconds is within the normal range, indicating adequate peripheral perfusion. This finding suggests that there are no immediate circulatory issues contributing to her hand pain and stiffness and does not require further evaluation.
G. Body mass index (BMI) of 31 kg/m²: A BMI of 31 falls within the obese range, which can increase the risk for musculoskeletal issues and other chronic conditions. This factor should be evaluated further, as obesity may affect joint health.
H. Client's hobbies: The client enjoys hobbies like gardening and crocheting, which involve repetitive hand movements. These activities could exacerbate the pain and stiffness in her hands, making it important to evaluate whether these hobbies are contributing to her symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Ask if the client is experiencing any change in bowel habits: Changes in bowel habits are not directly related to the confusion or memory loss seen in pernicious anemia. The concern here is primarily with vitamin B12 deficiency.
B. Determine if the client is taking iron and folic acid supplements: While iron and folic acid are important, they don't directly address the memory loss and confusion related to B12 deficiency. The immediate focus should be on the effects of the B12 treatment.
C. Encourage the husband to bring the client to the clinic for a complete blood count: A CBC can help monitor anemia, but it doesn't address the memory issues. The nurse should first explain the symptoms related to B12 deficiency.
D. Explain that memory loss and confusion are common with vitamin B12 deficiency:
Memory loss and confusion are known symptoms of vitamin B12 deficiency. These symptoms may take time to improve with treatment, and educating the husband helps alleviate concerns.
Correct Answer is A
Explanation
A. Maintain the client on an NPO status: After bariatric surgery, vomiting and the inability to tolerate food and liquids could indicate complications such as gastric outlet obstruction or stenosis. Maintaining NPO status allows the gastrointestinal system to rest while the cause of the symptoms is investigated and treated.
B. Determine if the client is over-hydrating to feel satiated: While over-hydration can cause discomfort, the immediate concern is the client's inability to tolerate food and liquids, which may suggest a more serious issue.
C. Administer daily vitamin supplements: While vitamin supplementation is essential after bariatric surgery to prevent deficiencies, it does not directly address the current issue of vomiting and inability to tolerate food and liquids.
D. Encourage positive self accolades for dietary adherence: Though reinforcing positive behavior is important in long-term weight loss management, it is not the priority at this moment. The immediate focus is addressing the client's symptoms and ensuring they are medically managed.
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