Question

The nurse in the outpatient clinic is assessing a 22-year-old patient who needs a physical exam before starting a new job. The patient reports a history of a splenectomy several years previously after an accident but has otherwise been healthy. Which information obtained during the assessment will be of most immediate concern to the nurse?

A) The patient engages in unprotected sex.
B) The oral temperature is 100°F (37.8°C).
C) The blood pressure is 148/76 mm Hg.
D) The patient admits to daily marijuana use.

Answer 1

The most immediate concern for the nurse should be the patient's elevated temperature, which indicates a potential infection, especially concerning due to the patient's history of splenectomy.

Step-by-step explanation:

The most immediate concern for the nurse assessing a 22-year-old patient who had a splenectomy is the oral temperature of 100°F (37.8°C). This is the most significant finding because the patient is at increased risk for infections due to the absence of the spleen, which plays a significant role in filtering bacteria from the blood and aiding in the immune response. The other findings, such as unprotected sex, elevated blood pressure, and daily marijuana use, present long-term health risks, but these are not as immediately concerning as the potential for infection indicated by the fever.