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Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require follow-up.
- A. Smoking marijuana to clear their mind
- B. Attends school regularly
- C. Heart rate 99/min
- D. Client experiences nightmares
- E. BP 122/80 mm Hg
- F. Caregiver reporting client acting differently than usual
- G. Witnessing their family's death
Correct Answer: A,D,F,G
Rationale: These findings suggest unresolved trauma and substance use, requiring intervention.
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Which of the following information should the nurse include in the teaching?
- A. Take mineral oil at bedtime
- B. Decrease insoluble fiber intake
- C. Drink 1,5 L of fluids each day.
- D. Increase exercise activity.
Correct Answer: D
Rationale: The correct answer is D: Increase exercise activity. This is important for promoting regular bowel movements and overall gastrointestinal health. Exercise helps stimulate the digestive system and aids in relieving constipation. Taking mineral oil (choice A) can interfere with nutrient absorption and is not recommended for long-term use. Decreasing insoluble fiber intake (choice B) can worsen constipation as fiber helps promote bowel regularity. Drinking 1.5 L of fluids each day (choice C) is important for hydration but alone may not be sufficient to improve bowel function. Increasing exercise activity (choice D) is the most effective way to promote healthy digestion and prevent constipation.
Which of the following information should the nurse include?
- A. This type of seizure lasts 30 to 60 seconds.
- B. This type of seizure can be mistaken for daydreaming.
- C. This type of seizure has a gradual onset.
- D. The child usually has an aura prior to onset.
Correct Answer: B
Rationale: Absence seizures are often brief and can easily be mistaken for daydreaming.
Which of the following findings require follow up? Select all that apply.
- A. WBC count
- B. Temperature
- C. Potassium level
- D. Breath sounds
- E. Blood pressure
Correct Answer: A,B,D,E
Rationale: These findings suggest infection and respiratory distress, requiring immediate follow-up.
Which of the following statements should the nurse make?
- A. Do you need a prescription for an antianxiety medication?
- B. Do you need information on hospice care?
- C. Would you like to talk to a counselor about advance directives?
- D. Would you like to speak to a spiritual advisor?
Correct Answer: D
Rationale: Spiritual support can help address emotional and existential concerns in terminally ill clients.
Which of the following actions should the nurse take?
- A. Administer dextrose 10% in water.
- B. Give 500 mL of lactated Ringers solution.
- C. Slow the TPN infusion rate.
- D. Temporarily discontinue the infusion
Correct Answer: A
Rationale: The correct answer is A: Administer dextrose 10% in water. This action is appropriate for treating hypoglycemia, which can be a potential complication of TPN (Total Parenteral Nutrition) therapy. Administering dextrose 10% in water can help raise the patient's blood sugar levels quickly and effectively. Choice B is incorrect as lactated Ringers solution does not directly address hypoglycemia. Choice C is not the best option as slowing the TPN infusion rate may further decrease the patient's blood sugar levels. Choice D is also incorrect as temporarily discontinuing the TPN infusion may exacerbate the hypoglycemia.