Difficulty: Medium
Average Score: 82%
Simulated
Passage / Scenario
NurseÔÇÖs Notes2000:
Client presents to the triage desk accompanied by a friend. The client states, ÔÇ£I need help. I was raped about an hour ago.ÔÇØ The clientÔÇÖs friend states, ÔÇ£I think they may have been drugged.ÔÇØ Allergies: penicillin, doxycycline Physical exam: General: exhibits anxiety Respiratory: breath sounds clear Cardiovascular: S1, S2, no murmur Abdomen: soft, mildly tender Skin: bruising to upper arms bilaterally, broken fingernails
Diagnostic Results
2030:
Urine drug screen: GHB (gamma-hydroxybutyric acid): positive
Vital signs
2015:
Blood pressure: 128/88 mm Hg
Heart rate: 80/min
Respiratory rate: 16/min
Temperature: 37┬░C (98.6┬░F)
Weight: 67.1 kg (147.9 lbs.)
The nurse is continuing to care for the patient in the emergency department.Which findings should the nurse identify as potential complications of the clientÔÇÖs diagnostic results? Select all that apply.
Correct answer
A,B,E,F
Rationale
The correct answer choices (A, B, E, F) are potential complications of the client's diagnostic results in the emergency department. Nausea and vomiting (A) can indicate an adverse reaction to medication or underlying condition. Confusion (B) may result from electrolyte imbalances or neurological issues. Amnesia (E) could be a sign of mental status changes due to the diagnostic results. Respiratory depression (F) might indicate a worsening respiratory condition. Choices C and D are unlikely complications related to diagnostic results, as tachycardia (C) is more likely a physiological response to stress or pain, while hypothermia (D) is not typically associated with diagnostic tests.