Which four patient assessment findings require follow-up by the nurse? Select all four that apply.
The patient is alert and oriented x4.
The patient reports nausea.
The abdomen is tender to palpation.
The patient is 60 years old.
The patient has dark amber urine.
The patient's oral temperature is 102.4°F.
The patient is voiding without difficulty.
Correct Answer : B,C,E,F
Choice A reason: The patient is alert and oriented x4. This indicates that the patient is fully aware of their surroundings and does not require follow-up for this finding.
Choice B reason: The patient reports nausea. Nausea can be a symptom of many underlying conditions, including gastrointestinal issues or medication side effects, and requires follow-up to determine the cause and provide appropriate treatment.
Choice C reason: The abdomen is tender to palpation. Abdominal tenderness can indicate inflammation, infection, or other abdominal pathology, which requires follow-up to identify the underlying cause and provide appropriate management.
Choice D reason: The patient is 60 years old. This is a demographic detail and does not indicate a medical condition requiring follow-up.
Choice E reason: The patient has dark amber urine. Dark amber urine can be an indication of dehydration or other underlying conditions that require follow-up to identify and address the cause.
Choice F reason: The patient's oral temperature is 102.4°F. A fever indicates the presence of an infection or other health issue that needs to be investigated and managed.
Choice G reason: The patient is voiding without difficulty. This indicates that there are no issues with urinary function, so no follow-up is required for this finding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A reason: Hypotension is not typically associated with hyperthyroidism. In fact, hyperthyroidism usually leads to an increase in metabolic rate, which can cause an increase in blood pressure rather than a decrease. Therefore, hypotension is not a consistent finding in patients with hyperthyroidism.
Choice B reason: Diaphoresis, or excessive sweating, is a common symptom of hyperthyroidism. The increased metabolic rate associated with hyperthyroidism causes the body to generate more heat, leading to excessive sweating as the body attempts to cool down. This symptom is frequently observed in patients with this condition.
Choice C reason: Heat intolerance is a hallmark symptom of hyperthyroidism. Due to the increased metabolic activity, patients with hyperthyroidism often feel excessively warm and have difficulty tolerating heat. They may seek cooler environments and prefer lighter clothing, even in colder weather, to manage their discomfort.
Choice D reason: Tachycardia, or an abnormally rapid heart rate, is a common finding in hyperthyroidism. The excess thyroid hormones stimulate the heart, leading to an increased heart rate and palpitations. This symptom is a significant indicator of hyperthyroidism and is often one of the first signs noticed by patients and healthcare providers.
Choice E reason: Insomnia is frequently seen in patients with hyperthyroidism. The increased metabolic rate and heightened nervous system activity can lead to difficulty sleeping and restlessness. Patients may report trouble falling asleep, staying asleep, or feeling rested after sleep, contributing to overall fatigue and irritability.
Correct Answer is ["A","C","E","F","G"]
Explanation
Choice A reason: Weight loss is indicative of hypermetabolism caused by excessive thyroid hormone production. The increased metabolic rate leads to higher energy consumption, resulting in unintentional weight loss even if the patient maintains or increases their food intake.
Choice B reason: Begins to cry when he tells you he recently lost his wife. Emotional responses, such as crying, can be associated with personal loss and grief but are not directly linked to hypermetabolism or excess thyroid hormone. This statement reflects the patient's emotional state rather than a physiological manifestation of hyperthyroidism.
Choice C reason: Hyperactive bowel sounds are a common manifestation of hypermetabolism due to hyperthyroidism. The increased metabolic rate accelerates gastrointestinal motility, resulting in hyperactive bowel sounds and sometimes diarrhea.
Choice D reason: 1+ pitting edema noted in bilateral lower extremities is related to fluid retention and heart failure rather than hypermetabolism. Edema is not a typical manifestation of hyperthyroidism and is more indicative of cardiovascular or renal issues.
Choice E reason: A heart rate of 124 (tachycardia) is a common finding in patients with hyperthyroidism. Excess thyroid hormones increase the heart rate and cardiac output, leading to symptoms such as palpitations and tachycardia.
Choice F reason: Bounding radial pulses are indicative of increased cardiac output and stroke volume, which are common in hyperthyroidism due to the hypermetabolic state induced by excess thyroid hormones. This leads to strong and forceful pulses.
Choice G reason: Anxious and restless behavior is a manifestation of the increased adrenergic activity associated with hyperthyroidism. Excess thyroid hormones stimulate the nervous system, leading to symptoms such as anxiety, restlessness, and irritability.
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