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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 D

Explanation

Choice A reason:

Assessing for hypoglycemia between meals is important, but it is not the most critical intervention. Insulin lispro is a rapid-acting insulin that peaks quickly, so timing meals with insulin administration is crucial to prevent hypoglycemia.

Choice B reason:

Checking blood glucose levels every six hours is a good practice for monitoring overall glucose control, but it does not address the immediate need to coordinate insulin administration with meals to prevent hypoglycemia.

Choice C reason:

Keeping an oral liquid or glucose source available is essential for treating hypoglycemia if it occurs. However, the primary focus should be on preventing hypoglycemia by ensuring that meals are timed appropriately with insulin administration.

Choice D reason:

Providing meals at the same time insulin is given is the most important intervention. Insulin lispro acts rapidly, and if meals are not timed correctly, there is a high risk of hypoglycemia. Ensuring that the client eats at the same time as the insulin injection helps maintain stable blood glucose levels.

A. If severe hypoglycemia occurs. B. Before meals to prevent hyperglycemia. C. When unable to eat during sick days. D. At the onset of signs of diabetic ketoacidosis.

Correct Answer is A

Explanation

Choice A Reason:

Glucagon is a hormone used to treat severe hypoglycemia (low blood sugar) in individuals with diabetes. Severe hypoglycemia can be life-threatening and requires immediate treatment to raise blood sugar levels. Glucagon works by stimulating the liver to release stored glucose into the bloodstream. It is crucial for clients and their families to recognize the signs of severe hypoglycemia, such as confusion, unconsciousness, or seizures, and to administer glucagon promptly.

Choice B Reason:

Administering glucagon before meals to prevent hyperglycemia is incorrect. Glucagon is not used to prevent high blood sugar levels; it is specifically used to treat low blood sugar levels. Preventing hyperglycemia typically involves insulin administration and dietary management, not glucagon.

Choice C Reason:

While managing blood sugar levels during sick days is important, glucagon is not used for this purpose. Clients are usually advised to monitor their blood sugar levels more frequently and adjust their insulin doses as needed during illness. Glucagon is reserved for emergency situations involving severe hypoglycemia.

Choice D Reason:

Glucagon is not used to treat diabetic ketoacidosis (DKA). DKA is a serious complication of diabetes that requires immediate medical attention and is treated with insulin, fluids, and electrolytes. Administering glucagon would not address the underlying issues of DKA and could potentially worsen the condition.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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

Patient Data

Exhibits

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