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Patient Data

Exhibits

Which assessment findings require follow-up by the nurse? Select all that apply.

Myoclonus

Temperature 102°F (38.8°C)

Blood pressure 168/94 mm Hg

Altered mental status

Heart rate 118 beats/minute

Respirations 16 breaths/minute

Capillary refill

Diaphoresis

Lung sounds.

Answer and Explanation

Correct Answer : A,B,C,D,E,H

Choice A: Myoclonus

Myoclonus refers to sudden, involuntary muscle jerks. In the context of this patient’s presentation, myoclonus is significant because it can be a symptom of serotonin syndrome, a potentially life-threatening condition that can occur with the use of serotonergic medications like paroxetine. Serotonin syndrome is characterized by a triad of cognitive, autonomic, and somatic effects, including altered mental status, autonomic instability, and neuromuscular abnormalities such as myoclonus. Therefore, the presence of myoclonus in this patient warrants immediate follow-up to rule out serotonin syndrome and initiate appropriate treatment if necessary.

Choice B: Temperature 102°F (38.8°C)

A temperature of 102°F (38.8°C) is indicative of a fever, which is an abnormal finding that requires follow-up. Fever can be a sign of infection or other inflammatory processes. In the context of this patient’s symptoms, including altered mental status and myoclonus, a high fever could also be a sign of serotonin syndrome. Normal body temperature ranges from 97.8°F to 99.1°F (36.5°C to 37.3°C). A temperature above this range is concerning and requires further investigation to determine the underlying cause and appropriate intervention.

Choice C: Blood Pressure 168/94 mm Hg

The patient’s blood pressure of 168/94 mm Hg is significantly elevated. Normal blood pressure for adults is typically around 120/80 mm Hg. Hypertension can be a sign of autonomic instability, which is another component of serotonin syndrome. Elevated blood pressure can also increase the risk of cardiovascular events such as stroke or heart attack. Therefore, this finding requires follow-up to manage the patient’s blood pressure and address any underlying causes.

Choice D: Altered Mental Status

Altered mental status is a broad term that encompasses changes in cognitive function, including confusion, disorientation, and altered levels of consciousness. This patient’s altered mental status, combined with other symptoms such as fever and myoclonus, raises concern for serotonin syndrome. Altered mental status can also be caused by other conditions such as infections, metabolic disturbances, or neurological disorders. Immediate follow-up is necessary to determine the cause and provide appropriate treatment.

Choice E: Heart Rate 118 beats/minute

A heart rate of 118 beats per minute is considered tachycardia, which is an abnormally fast heart rate. The normal resting heart rate for adults ranges from 60 to 100 beats per minute. Tachycardia can be a sign of autonomic instability, which is seen in conditions like serotonin syndrome. It can also be caused by fever, dehydration, or other underlying conditions. Follow-up is required to assess the cause of the tachycardia and manage it appropriately.

Choice F: Respirations 16 breaths/minute

A respiratory rate of 16 breaths per minute is within the normal range for adults, which is typically 12 to 20 breaths per minute. Therefore, this finding does not require immediate follow-up. However, it is important to continue monitoring the patient’s respiratory status, especially given the other concerning symptoms.

Choice G: Capillary Refill

Capillary refill time of less than 3 seconds is considered normal. This indicates that the patient’s peripheral perfusion is adequate. Therefore, this finding does not require follow-up. However, it is important to continue monitoring for any changes in perfusion status.

Choice H: Diaphoresis

Diaphoresis, or excessive sweating, is another symptom that requires follow-up. It can be a sign of autonomic instability and is commonly seen in serotonin syndrome. Diaphoresis can also be associated with other conditions such as infections, hyperthyroidism, or anxiety. Given the patient’s other symptoms, it is important to investigate the cause of the diaphoresis and address it as part of the overall management plan.

Choice I: Lung Sounds

Lung sounds are noted to be clear, which is a normal finding. This indicates that there are no immediate respiratory issues such as pneumonia or pulmonary edema. Therefore, this finding does not require follow-up. However, it is important to continue monitoring the patient’s respiratory status, especially given the other concerning symptoms.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Explanation

Choice A: Syncope

Reason: Syncope, or fainting, is a temporary loss of consciousness typically caused by a drop in blood flow to the brain. The client has a history of symptomatic bradycardia, which is a slow heart rate that can lead to insufficient blood flow and oxygen to the brain, causing syncope. The client reported passing out once due to a low heart rate, which aligns with the symptoms of syncope. Bradycardia can cause a significant drop in cardiac output, leading to decreased cerebral perfusion and resulting in fainting episodes.

Choice B: Hypovolemic Shock

Reason: Hypovolemic shock occurs when there is a significant loss of blood or fluids, leading to decreased blood volume and inadequate tissue perfusion. Symptoms include rapid heartbeat, low blood pressure, and confusion. However, the client’s history and current condition do not indicate any significant blood or fluid loss. The primary issue is related to the heart’s electrical activity and rate, not volume loss.

Choice C: Heart Failure

Reason: Heart failure is a condition where the heart cannot pump blood effectively, leading to symptoms like shortness of breath, fatigue, and fluid retention. While the client has a history of atrial fibrillation, which can contribute to heart failure, the immediate concern is the symptomatic bradycardia causing syncope. The client’s symptoms of low heart rate and fainting are more directly related to bradycardia rather than heart failure.

Choice D: Adverse Drug Reaction

Reason: An adverse drug reaction could cause various symptoms, including changes in heart rate and blood pressure. However, the client has not reported any new medications or changes in her current regimen that would suggest an adverse reaction. The symptoms described are consistent with her known condition of bradycardia.

Choice A: Anxiety

Reason: Anxiety can cause various physiological responses, including increased heart rate and blood pressure. However, the client’s primary issue is a low heart rate, which is not typically associated with anxiety. Anxiety might exacerbate symptoms but is not the root cause of the blood pressure changes in this case.

Choice B: Antibiotic

Reason: While antibiotics can cause side effects, they are not typically associated with significant changes in blood pressure. The vancomycin administered was for endocarditis prophylaxis and is unlikely to be the cause of the blood pressure changes observed.

Choice C: IV Infiltration

Reason: IV infiltration occurs when IV fluids leak into the surrounding tissue, causing swelling, pain, and potential tissue damage. While this can cause localized issues, it is not typically associated with systemic blood pressure changes. The client’s symptoms are more consistent with a systemic issue related to her heart condition.

Choice D: Vasodilation

Reason: Vasodilation refers to the widening of blood vessels, which can lead to a drop in blood pressure. This can occur as a response to various factors, including medications, heat, or a physiological response to low blood flow. In the context of bradycardia, the body’s compensatory mechanisms might include vasodilation to improve blood flow, which can result in lower blood pressure.

A. Many of the herbal preparations are helpful primarily because of their placebo effect. B. Topical echinacea is usually used to soothe burns and can cause damage to the skin. C. Echinacea seems to be useful in the treatment of some infections, such as canker sores. D. This product is essentially harmless but also is not very beneficial in treating skin infections.

Correct Answer is C

Explanation

Choice A reason:

While some herbal preparations may have a placebo effect, echinacea has been shown to have active properties that can aid in the treatment of infections. Echinacea contains compounds that boost the immune system and have anti-inflammatory effects, which can help in the healing process of canker sores.

Choice B reason:

Topical echinacea is not typically used to soothe burns, and there is no evidence to suggest it causes damage to the skin. In fact, echinacea is often used in topical preparations to treat skin conditions due to its anti-inflammatory and antimicrobial properties.

Choice C reason:

Echinacea has been found to be useful in treating some infections, including canker sores. Its immune-boosting and wound-healing properties can help reduce the duration and severity of canker sores. This makes it a beneficial herbal remedy for such conditions.

Choice D reason:

While echinacea is generally considered safe and harmless, it is not accurate to say it is not beneficial in treating skin infections. Echinacea has been used traditionally to treat various skin conditions and infections due to its antimicrobial and anti-inflammatory effects.

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Patient Data Exhibits Which assessment findings require follow-up by the nurse? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Explanation

The home health nurse observes that a female client is using a topical preparation that contains echinacea to treat a canker sore. Her husband expresses concern regarding the effectiveness and safety of using herbs. How should the nurse respond?

Correct Answer is C

Explanation

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Patient Data

Exhibits

Which assessment findings require follow-up by the nurse? Select all that apply.