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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

Answer and Explanation

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.

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Correct Answer is B,A,D,C

Explanation

1. B. Verify the insulin prescription: The first step is to verify the prescription to ensure the correct type and dose of insulin before administering it. This ensures one is following the appropriate instructions.

2. A. Obtain blood glucose level: The next step is to check the client's blood glucose level to determine the amount of insulin needed based on the sliding scale.

3. D. Cleanse the selected site: After obtaining the blood glucose level, the next step is to prepare the injection site by cleaning it properly to prevent infection.

4. C. Draw insulin into insulin syringe: Finally, drawing the appropriate amount of insulin into the syringe, based on the sliding scale and the blood glucose level, to administer the injection.

A. Her fourth child weighed 9 pounds (4.08 kg) at 41 weeks gestation B. Client is at 28 weeks. She has been receiving prenatal care since 8 weeks gestation C. Her fasting 1-hour glucose screening level, which was done 1 week prior, is 164 mg/dL (9.1 mmol/L) D. Her 3-hour oral glucose tolerance test results reveal a fasting blood sugar of 168 (9.3 mmol/L) and a two-hour postprandial of 220 mg/dL (12.2 mmol/L)

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

Explanation

Rationale for correct findings:

Fasting 1-hour glucose screen: 164 mg/dL (9.1 mmol/L): The fasting glucose of 164 mg/dL is elevated, indicating impaired glucose metabolism, which suggests the possibility of gestational diabetes.
3-hour glucose tolerance test: Fasting blood sugar 168 mg/dL (9.3 mmol/L): The fasting blood sugar of 168 mg/dL is above the normal threshold of 140 mg/dL, reinforcing the suspicion of gestational diabetes.
2-hour postprandial glucose: 220 mg/dL (12.2 mmol/L): A postprandial glucose level of 220 mg/dL is significantly above the normal limit of 140 mg/dL, further indicating gestational diabetes.
Fourth child with macrosomia: 9 pounds (4.08 kg) at 41 weeks gestation: Macrosomia is often associated with gestational diabetes. The fourth child weighing 9 pounds suggests the possibility of undiagnosed gestational diabetes during the previous pregnancy, which could be recurring in the current pregnancy.

Rationale for incorrect Findings:

Client is at 28 weeks and has been receiving prenatal care since 8 weeks gestation: The client’s consistent prenatal care since 8 weeks indicates early and regular monitoring, reducing the likelihood of other major complications.

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Exhibits Which information from the history and physical, nurses' note, and flow sheet requires further evaluation? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B,A,D,C

Explanation

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

Explanation

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Exhibits

Which information from the history and physical, nurses' note, and flow sheet requires further evaluation? Select all that apply.