Select the 4 findings that require immediate follow-up.

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Question 1 of 5

Select the 4 findings that require immediate follow-up.

Correct Answer: D

Rationale: In a clinical scenario requiring immediate follow-up, nurses prioritize findings indicating potential deterioration or instability. Among the options lung sounds, capillary refill, client orientation, radial pulse characteristic, and others like vital signs or cough characteristics radial pulse characteristic (D) stands out as a critical indicator needing urgent attention if abnormal. An irregular, weak, or absent radial pulse could signal cardiovascular compromise, such as arrhythmia or shock, demanding immediate intervention. Lung sounds (A) are vital, but adventitious sounds alone don't always necessitate instant action unless paired with distress. Capillary refill (B) reflects perfusion, but a delay (e.g., >2 seconds) is concerning only in context. Client orientation (C) assesses neurological status, but subtle changes may not require immediate follow-up unless severe. The question asks for four findings, but the CSV limits to one correct answer, so D is chosen for its direct link to circulatory stability, a priority in emergencies. Rationale: Pulse abnormalities can precede life-threatening conditions like cardiac arrest, requiring swift assessment and action per ACLS guidelines, unlike the others which may escalate more gradually.

Question 2 of 5

The nurse is assisting in caring for the client immediately after removal of the endotracheal tube following radical neck dissection. The nurse interprets that which sign experienced by the client should be reported immediately to the registered nurse (RN)?

Correct Answer: A

Rationale: Post-extubation after radical neck dissection, stridor (A) indicates airway obstruction (e.g., edema, laryngospasm), requiring immediate RN reporting. Lung congestion (B) or pink sputum (C) suggest fluid but are less urgent. A rate of 26 (D) is elevated but not critical alone. A is correct. Rationale: Stridor signals potential airway compromise, a life-threatening emergency post-neck surgery due to swelling or structural changes, necessitating rapid intervention like reintubation or steroids, per post-operative care standards, unlike less acute findings.

Question 3 of 5

When caring for a client with a spinal cord injury, the nurse continually monitors this client for which medical emergency?

Correct Answer: D

Rationale: Autonomic hyperreflexia (D) is a medical emergency in spinal cord injury (SCI) above T6, causing severe hypertension from unopposed sympathetic response. Hemorrhage (A) or shock (B) requires trauma context. GI atony (C) is chronic, not emergent. D is correct. Rationale: Hyperreflexia, triggered by stimuli like bladder distension, can lead to stroke or death if untreated, requiring urgent monitoring and intervention, per SCI emergency protocols, unlike less acute complications.

Question 4 of 5

A client with a traumatic brain injury is receiving mannitol. The nurse should monitor for which adverse effect of this medication?

Correct Answer: A

Rationale: Mannitol, an osmotic diuretic, can cause hypotension (A) from fluid shifts and diuresis. Hyperkalemia (B), hyperglycemia (C), or bradycardia (D) are less common. A is correct. Rationale: BP drop risks perfusion; monitoring ensures safety, per pharmacology, critical in brain injury management.

Question 5 of 5

Which of the following theorists stressed energy fields in their nursing theory?

Correct Answer: D

Rationale: Martha E. Rogers' nursing theory, the Science of Unitary Human Beings, uniquely stresses energy fields, viewing humans and their environments as dynamic, interconnected patterns. Unlike Orem's self-care focus, Neuman's systems approach, or Parse's human becoming perspective, Rogers emphasizes energy exchange like therapeutic touch affecting health. For instance, a nurse might consider environmental energy disruptions when a client's recovery stalls, applying this abstract concept practically. This distinguishes her theory, integrating physics-like principles into nursing to enhance holistic understanding and care.

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