Patient Data

The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis.
Select the 3 findings consistent with a therapeutic response to interventions.

Temperature 98.8° F (37.1° C)

Capillary refill greater than 3 seconds bilateral lower extremities

Serum blood glucose 185 mg/dL (10.2 mmol/L)

Pain 2 on a 0 to 10 scale, bilateral lower legs described as neuropathic

White blood cell count 11.2 x 10/μL (11.2 x 109/L)

Bilateral lower extremities skin warm, dry, and pink

Answer and Explanation

Correct Answer : A,E,F

Rationale:
A. Temperature 98.8° F (37.1° C): A return to normal body temperature indicates resolution of the febrile response associated with infection. This demonstrates that the antibiotic therapy is effectively controlling the cellulitis.

B. Capillary refill greater than 3 seconds bilateral lower extremities: Delayed capillary refill reflects poor peripheral perfusion, which is a chronic finding related to peripheral vascular disease and not an indicator of cellulitis resolution. This does not demonstrate therapeutic response.

C. Serum blood glucose 185 mg/dL (10.2 mmol/L): Although lower than the initial 252 mg/dL, this glucose level remains above the normal range. While improved glycemic control supports healing, it is not a direct indicator of resolution of the cellulitis.

D. Pain 2 on a 0 to 10 scale, bilateral lower legs described as neuropathic: This is the client's chronic baseline pain due to diabetic neuropathy. The "tightness" and acute pain from the cellulitis would ideally decrease, but this specific neuropathic pain is a chronic condition and not an indicator of antibiotic success.

E. White blood cell count 11.2 x 10/μL (11.2 x 10⁹/L): Reduction of WBC toward the normal range demonstrates that the systemic inflammatory response to infection is resolving. This is consistent with a positive response to antibiotic therapy.

F. Bilateral lower extremities skin warm, dry, and pink: Restoration of normal skin color, temperature, and texture in the affected leg indicates resolution of local inflammation and edema from cellulitis. This is a clear sign of therapeutic effectiveness.

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Correct Answer is B

Explanation

Rationale:
A. Explain that living wills cannot be followed by emergency personnel: Living wills are legally recognized documents that guide care preferences, but their applicability depends on the patient’s current clinical situation. Blanket statements dismissing the document are inappropriate and may cause mistrust.

B. Seek clarification of the type of advance directive the client has: Different advance directives, such as a living will or a DNR order, provide varying levels of guidance regarding resuscitation. Confirming the specific directive ensures that care aligns with the client’s legally documented wishes. This is the most accurate and patient-centered response.

C. Schedule a client and family conference to review the plan of care: While a conference may be useful for ongoing care planning, it does not immediately address the family’s question about why resuscitation was performed. Immediate clarification is the priority.

D. Check the client's arm for a "Do Not Resuscitate" (DNR) bracelet: DNR bracelets may indicate resuscitation preferences but are not universally used. Verification should include reviewing the medical record and legal documentation, not solely relying on a bracelet.

A. Initiate peripheral IV (PIV) access. B. Obtain a complete set of vital signs. C. Access laboratory results to confirm a thyroid crisis. D. Encourage relaxation and slow deep breathing.

Correct Answer is B

Explanation

Rationale:
A. Initiate peripheral IV (PIV) access: IV access is important for management of a thyroid crisis, but assessment takes priority before initiating interventions. The client’s sudden apprehension, restlessness, and heat intolerance suggest acute physiologic instability. Vital signs are needed to determine the severity of the condition and guide urgent treatment.

B. Obtain a complete set of vital signs: Thyroid crisis (thyroid storm) is characterized by hyperthermia, tachycardia, hypertension, and possible dysrhythmias. Rapid assessment of temperature, heart rate, blood pressure, and respiratory status is critical to identify life-threatening instability. This action establishes the urgency and directs immediate interventions.

C. Access laboratory results to confirm a thyroid crisis: Thyroid storm is a clinical diagnosis based on symptoms and vital signs rather than laboratory confirmation. Waiting for lab results delays urgent care. Immediate assessment and stabilization take precedence over diagnostic confirmation.

D. Encourage relaxation and slow deep breathing: Anxiety and restlessness are physiologic manifestations of excess thyroid hormone, not primarily psychogenic. Relaxation techniques do not address the underlying hypermetabolic state. This approach risks delaying recognition of a medical emergency.

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Patient Data The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.

Nursing Test Bank

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Correct Answer is B

Explanation

Correct Answer is B

Explanation

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Patient Data

The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis.
Select the 3 findings consistent with a therapeutic response to interventions.