Which 3 findings require immediate follow-up?

The nurse is caring for a 68-year-old client in the emergency department.
History Physical Vital Signs
Admission: The client comes to the emergency department with progressively worsening back pain that began 3 weeks ago. The pain has become significantly worse over the past 12 hours. Pain level is rated as 8 on a scale of 0-10. The client was recently diagnosed with prostate cancer and has had a poor response to treatment. This morning, the client had trouble walking and reports decreased sensation in the feet. The client also reports mild nausea, difficulty urinating, decreased urinary sensation, and no bowel movement in the past 3 days

A. Cardiovascular findings
B. Genitourinary symptoms
C. Musculoskeletal symptoms
D. Neurologic symptoms
E. Vital signs

Correct Answer: B,C,D

Rationale: Urinary retention , trouble walking , and decreased sensation suggest spinal cord compression, requiring urgent intervention.

The nurse is caring for a 12-year-old client.
History and Physical Vital Signs Body System Findings
General- The client has a 2-day history of decreased appetite, nausea, fatigue, and headaches, the client had a "sore throat" 2 weeks ago that resolved without treatment; BMl is in the 65th percentile
Eye, Ears, Nose, and Throat (EENT)- Periorbital edema; no changes in vision
Pulmonary- Lung sounds clear bilaterally; no increased work of breathing; no cough Cardiovascular- S1 and S2 heard on auscultation; no murmur auscultated; 3+ bilateral lower extremity edema is noted
Gastrointestinal- Bowel sounds present, no masses or tenderness felt Musculoskeletal No joint pain or swelling
Genitourinary- Decreased urination; dark, cola-colored urine

Which finding requires priority follow-up?

A. Dark, cola-colored urine
B. Decreased appetite
C. Hypertension
D. Periorbital edema

Correct Answer: A

Rationale: Cola-colored urine suggests hematuria, a hallmark of acute postinfectious glomerulonephritis, requiring urgent evaluation.

The nurse is caring for a 75-year-old female client. Nurses' Notes Laboratory Results Diagnostic Results Emergency Department
The client is transferred to the emergency department from a skilled nursing facility for a 3-day history of left lower quadrant abdominal pain rated 8 on a scale of 0-10, loss of appetite, and nausea. Although the client has a history of chronic constipation, she has had 2 or 3 loose stools daily for 1 week. The client reports tenderness on deep palpation of the left lower quadrant. There is an area of blanchable redness on the coccyx. The stool is positive for occult blood.
The client has residual left-sided weakness from an ischemic stroke 2 years ago and ambulates with a walker. The client reports falling several times in the past 6 months; the last fall was 3 weeks ago No ecchymosis or injuries are noted. The client had a hysterectomy and salpingo-oophorectomy for uterine fibroids 20 years ago. Vital signs are T 100 F (37.8 C), P 98, RR 17, BP 126/68, and SpOz 97% on room air.
Medical-Surgical Unit: 4 Days Later
The client continues to experience left lower quadrant pain, decreased appetite, and nausea. Today, she developed chills. Stool frequency has not increased. Severe tenderness is noted in the left lower quadrant, and a mass is palpable. Vital signs are T 101.3 F (38.5 C), P 112, RR 17, BP 110/80, SpO, 97% on room air.

Click to highlight below the findings that are most concerning at this time.

A. The client is transferred to the emergency department from a skilled nursing facility for a 3-day history of left lower quadrant abdominal pain rated 8 on a scale of 0-10, loss of appetite, and nausea.
B. Although the client has a history of chronic constipation, she has had 2 or 3 loose stools daily for 1 week.
C. The client reports tenderness on deep palpation of the left lower quadrant. There is an area of blanchable redness on the coccyx. The stool is positive for occult blood.
D. The client has residual left-sided weakness from an ischemic stroke 2 years ago and ambulates with a walker.
E. The client reports falling several times in the past 6 months; the last fall was 3 weeks ago. No ecchymosis or injuries are noted.
F. The client had a hysterectomy and salpingo-oophorectomy for uterine fibroids 20 years ago. Vital signs are T 100 F (37.8 C), P 98, RR 17, BP 126/68, and SpO2 97% on room air.

Correct Answer: A,C

Rationale: Severe abdominal pain with nausea and tenderness with occult blood suggest acute diverticulitis, requiring urgent evaluation.

The nurse is caring for a 43-year-old client.
Nurses' Notes Vital Signs
Emergency Department
0800: A 43-year-old client comes to the emergency department due to lower back pain and bilateral leg weakness. The client reports that the weakness began 3 days ago in the feet and has gradually worsened. The client sought treatment today after becoming "so weak that I fell while walking" and noticing new hand weakness and difficulty swallowing. Back pain radiates down both legs and is rated as 5 on a scale of 0-10. The client recently recovered from an illness with flu-like symptoms. The client reports a history of hypertension and takes no medications. Assessment of the lower extremities reveals muscle strength of 2/5 and decreased sensation to pinprick. Achilles tendon and patellar reflexes are decreased

Which finding is the most concerning to the nurse at this time?

A. Bilateral leg weakness
B. Difficulty swallowing
C. Elevated blood pressure
D. Radiating lower back pain

Correct Answer: B

Rationale: Difficulty swallowing indicates bulbar involvement in Guillain-BarrÃ© syndrome, risking aspiration and requiring urgent intervention.

The nurse is caring for a 23-year-old client. Nurses' Notes Vital Signs Medication Administration Record
Inpatient Unit Admission:
The client was found alone in a public park shouting at people who were not present. The client told the staff, "There's nothing wrong with me. It's just the effects of the microchip that was implanted in my head." The client is not oriented to place or time. Day 7: The client has developed confusion, fever, and diaphoresis. Speech is slurred Muscular rigidity is observed in all extremities. Deep tendon reflexes are 2+; no clonus is noted

The nurse recognizes that the client is most likely experiencing which is a complication of

A. Diabetes insipidus
B. Serotonin syndrome
C. Neuroleptic malignant syndrome
D. Lithium
E. Fluoxetine
F. Olanzapine

Correct Answer: C,F

Rationale: Neuroleptic malignant syndrome is a complication of antipsychotics like olanzapine , presenting with fever, rigidity, and confusion.

The newborn nurse is attending births in the labor and delivery unit.
Nurses' Notes
Labor and Delivery Unit
0000: A 39-year-old client, gravida 4 para 3, at 38 weeks gestation arrives at the labor and delivery unit reporting contractions every 2-3 min. During this pregnancy, the client was diagnosed with gestational diabetes mellitus and prescribed insulin, but she reports not taking the insulin. The client reports cigarette smoking (3-5 cigarettes/day) but denies alcohol or recreational drug use. The client received treatment for bacterial vaginosis during the second trimester. The client has gained 55 lb (25 kg) during the pregnancy. Group B Streptococcus result is negative. 1400: The newborn is delivered via forceps-assisted vaginal birth at
1400. The newborn was immediately placed in skin-to-skin contact with the mother, dried, and stimulated. Apgar scores are 7 at 1 minute and 9 at 5 minutes
1405: Newborn vital signs are T 97.3 F (36.3 C), P 156, and RR 52.
1415: Newborn weight is obtained. The newborn is 9 lb 15 oz (4500 g). The maternal client is assisted to latch the newborn onto the breast.
1430: Slight bruising to the scalp is noted where forceps were applied. Newborn vital signs are T 97.2 F (36.2 C), P 160, RR 55, and SpO 95% on room air.

For each nursing action, click to specify if the action is indicated or not indicated for the care of the newborn during a heel stick.

A. Warm the heel prior to initiating the procedure
B. Collect the first drop of blood for blood glucose testing
C. Draw blood by pricking the skin with a small-gauge needle
D. Obtain the blood specimen from the lateral aspect of the heel
E. Clean the heel with an alcohol pad prior to obtaining the blood specimen

Correct Answer: A,C,D,E

Rationale: Warming the heel , using a needle , lateral heel site , and cleaning are standard. The first drop is discarded to avoid contamination.