Select the 3 findings on day 3 that require immediate follow-up.

Exhibits

PICC line insertion site

Breath sounds

Temperature

Heart rate

Answer and Explanation

Correct Answer : A,C,D

A. PICC line insertion site: The client reports pain, redness, and edema at the PICC line insertion site, which are signs of a possible infection. This finding requires immediate follow-up to prevent complications like bloodstream infection or sepsis.

B. Breath sounds: The client’s breath sounds are clear and unchanged from Day 1, so this finding does not require immediate follow-up.

C. Temperature: The client's temperature has risen to 39 °C (102.2 °F) from 37.2 °C (99 °F) on Day 1. Such a significant increase in temperature indicates a possible infection and needs prompt intervention.

D. Heart rate: The client’s heart rate has increased to 108/min from 66/min, suggesting tachycardia. This could be a response to infection, potentially linked to sepsis, and warrants immediate follow-up.

E. Albumin level: The albumin level has increased to within the normal range, which is a positive trend and does not require urgent intervention.

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Correct Answer is B

Explanation

A. Gynecomastia refers to breast tissue enlargement in males and does not typically relate to the menstrual cycle.

B. Cyclic pain refers to breast pain that is linked to the menstrual cycle, commonly occurring before menstruation and subsiding during or after menstruation.

C. Mammary pain is a broader term that may refer to any breast pain, but it does not specify the cyclical nature related to menstruation.

D. Noncyclic pain refers to breast pain not related to the menstrual cycle and does not follow the described pattern.

A. The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred. B. The nurse will briefly touch the client, and the client will need to identify where the touch occurred. C. Client will close their eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object. D. The client is to identify the numbers of points felt when the nurse touches the client with the ends of two applicators at the same time.

Correct Answer is C

Explanation

A. This description relates more to a sensory discrimination test, not graphesthesia.

B. This option does not accurately describe the graphesthesia test, which involves identifying shapes or numbers rather than just touch location.

C. In the graphesthesia test, the client closes their eyes while the nurse uses a blunt object to write a number or shape in the client's palm, and the client must identify what was written. This assesses the ability to recognize letters or numbers drawn on the skin.

D. This option describes a two-point discrimination test rather than graphesthesia, which focuses on identifying drawn shapes or numbers.

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Select the 3 findings on day 3 that require immediate follow-up. Exhibits

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which reproductive health issue causes breast pain beginning a few days before menstruation and subsides when menstruation begins?

Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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Select the 3 findings on day 3 that require immediate follow-up.

Exhibits