Which client assessment should a nurse immediately report to the health care provider?
Report of joint pain by a client who recently started taking arthritis medication.
Report of decreased appetite and difficulty sleeping in a recently widowed client.
Weight loss of two pounds in a client admitted in congestive heart failure.
Diminished breath sounds in a client admitted with pneumonia.
The Correct Answer is D
This is because diminished breath sounds indicate poor oxygenation and ventilation, which can lead to respiratory failure and hypoxia. The healthcare provider should be notified immediately to assess the client and provide appropriate interventions.
Choice A is wrong because joint pain is a common side effect of some arthritis medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs). It does not require immediate attention unless it is severe or accompanied by other symptoms, such as swelling, redness, or fever.
Choice B is wrong because decreased appetite and difficulty sleeping are normal responses to grief and loss. They do not indicate a medical emergency, but rather a need for emotional support and counseling.
Choice C is wrong because a weight loss of two pounds in a client admitted with congestive heart failure is a positive sign that indicates fluid removal and improved cardiac function. It does not require immediate reporting, but rather ongoing monitoring and evaluation.
Normal ranges for vital signs are as follows :
- Blood pressure: 90/60 mm Hg to 120/80 mm Hg
- Breathing: 12 to 18 breaths per minute
- Pulse: 60 to 100 beats per minute
- Temperature: 97.8°F to 99.1°F (36.5°C to 37.3°C); average 98.6°F (37°C)
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
This is because renal calculi can cause renal colic, which is a sudden and intense pain in the flank area that radiates to the groin or testicles.
The pain is caused by the stone obstructing the ureter and triggering spasms.
Choice A is wrong because a feeling of pressure in the bladder is more likely to indicate a lower urinary tract infection or an overactive bladder.
Choice B is wrong because a mild, burning pain when urinating is more likely to indicate a urinary tract infection or a urethral injury.
Choice D is wrong because a constant, dull, aching pain in the right upper quadrant is more likely to indicate a liver or gallbladder problem.
Normal ranges for urine pH are 4.5 to 8.0, and for specific gravity are 1.005 to 1.030.
Correct Answer is ["B","C","E"]
Explanation
These interventions are based on the principles of sleep hygiene and cognitive behavioral therapy for insomnia (CBT-I), which are evidence-based strategies to promote better sleep.
Choice A is wrong because alcohol can disrupt sleep quality and cause frequent awakenings during the night. It can also interfere with the normal sleep cycle and reduce REM sleep.
Choice D is wrong because reading a book 30 minutes before bedtime can be stimulating and make it harder to fall asleep. It can also violate the stimulus control therapy, which aims to associate the bed only with sleep and sex and avoid any other activities that may keep the mind alert.
Some additional sentences are:
- Normal ranges for sleep vary depending on age, lifestyle, and individual factors, but generally adul,ts need about 7 to 9 hours of sleep per night.
- Insomnia is a common sleep disorder that affects about 10% to 30% of adults and can have negative impacts on physical and mental health, as well as quality of life.
- If insomnia persists despite following these interventions, it is advisable to consult a doctor or a sleep specialist for further evaluation and treatment options.
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