Nokea
A nurse is reviewing the medical record of a client. Click to highlight below the findings that require immediate follow-up.
- A. Neurological: Alert and oriented to person, place, and time; deep tendon reflexes 4+
- B. Musculoskeletal: Generalized weakness with equal bilateral muscle strength and mild leg cramping
- C. Respiratory: Lungs clear
- D. Cardiovascular: Heart rate irregular, Heart rate 95/min
- E. Gastrointestinal: Bowel sounds hyperactive x 4 quadrants
Correct Answer: D
Rationale: An irregular heart rate (D) requires immediate follow-up due to potential arrhythmia risks.
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Nurses' Notes
Diagnostic Results
Day 1:
1000:
A peripherally inserted central catheter (PICC) is inserted into left arm. Dressing dry and intact. Bilateral breath sounds clear and present throughout.
1200:
Parenteral nutrition started through PICC line infusing at 75 mL/hr.
Day 3:
0800:
Client is lethargic and reports thirst and frequent urination. Bilateral breath sounds clear and present throughout.
A nurse is reviewing the medical record of a client who has a paralytic ileus.
Select words from the choices below to fill in each blank in the following sentence:
The findings in the client's medical record indicate----and----.
- A. Dehydration
- B. Pneumothorax
- C. Hyperglycemia
- D. Infection
- E. Electrolyte Imbalance
- F. Hypoglycemia
Correct Answer: A, C
Rationale: A: Thirst and urination suggest dehydration. C: Lethargy and polyuria indicate hyperglycemia from parenteral nutrition.
A nurse is reinforcing teaching with a client about the use of a quad cane. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should move my stronger leg forward before moving my weaker leg.
- B. I will hold the cane on my stronger side.
- C. I will move the cane forward 18 inches.
- D. I should wear shoes with smooth soles to help slide my weak leg forward.
Correct Answer: B
Rationale: Holding the cane on the stronger side provides optimal support.
A nurse is observing an assistive personnel (AP) apply a belt restraint to a client. Which of the following actions by the AP requires intervention by the nurse?
- A. Placing the restraint across the client's chest
- B. Applying the restraint over the client's gown
- C. Using a quick-release tie to secure the restraint
- D. Tying the restraint to the bed frame
Correct Answer: A
Rationale: Placing the restraint across the chest restricts breathing; it should be at the waist.
A nurse is participating in a group discussion about complicated grief associated with loss. Which of the following should the nurse identify as an example of exaggerated grief?
- A. A client whose grief response begins following a terminal diagnosis
- B. A client whose grief response is repressed
- C. A client whose grief response is triggered by a secondary loss
- D. A client whose grief response leads to self-destructive behaviors
Correct Answer: D
Rationale: Exaggerated grief involves extreme, self-destructive reactions beyond normal grieving.
A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer. The employer asks the nurse about the client's condition. Which of the following is an appropriate response by the nurse?
- A. He is here in the hospital, but I cannot tell you anything else.
- B. I cannot confirm or deny that we have a client by that name.
- C. The client's condition is stable right now.
- D. I will tell him you called.
Correct Answer: B
Rationale: Protecting confidentiality under HIPAA requires not confirming client presence.