A nurse caring for a client who is at home on hospice care.
At the end of the visit, the nurse reevaluates the client. Indicate if the assessment findings are improved, show no change, or show that the client has declined.
Client calm not agitated. Grimaces with movement.
Oral mucous membranes dry.
Axillary temp 102 F (38.9 C), client shivering.
Productive cough.
Coarse rhonchi bilaterally. Crackles in bases.
Respirations irregular with periods of apnea
Client resting in recliner. RR 12, regular
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"B"},"E":{"answers":"C"},"F":{"answers":"A"},"G":{"answers":"A"}}
Client calm not agitated. Grimaces with movement.
No change: While the client is calm and not agitated, grimacing with movement indicates continued discomfort or pain, which remains unchanged.
Oral mucous membranes dry.
No change: Dry oral mucous membranes persist, suggesting ongoing dehydration or inadequate oral hydration.
Axillary temp 102 F (38.9 C), client shivering.
Declined: The axillary temperature has increased from 100.8 F (38.22 C) to 102 F (38.9 C), indicating a worsening of the client's fever. Shivering suggests the body's attempt to generate heat in response to the fever.
Productive cough.
No change: The client continues to have a productive cough, indicating ongoing respiratory congestion or infection.
Coarse rhonchi bilaterally. Crackles in bases.
Declined: The presence of coarse rhonchi bilaterally and crackles in the bases suggests worsening respiratory status, possibly indicating progression of underlying lung disease or development of complications such as pneumonia.
Respirations irregular with periods of apnea.
Improved: The client's respirations, previously irregular with periods of apnea, are now regular, indicating an improvement in respiratory function.
Client resting in recliner. RR 12, regular.
Improved: The client's respiratory rate has decreased from 18 to 12 breaths per minute, and respirations are now regular, suggesting improved respiratory status and possibly reduced distress.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. People mistakenly think they are experiencing seasonal allergies: While seasonal allergies may share some symptoms with the common cold, such as nasal congestion and sneezing, they are caused by allergens rather than viruses. This factor does not directly contribute to the high communicability of the common cold.
B. The virus is spread by individuals who don't have symptoms: The common cold is highly communicable because individuals infected with the virus can spread it to others even before they develop symptoms or when they have mild symptoms. This makes it challenging to prevent the spread of the virus, as infected individuals may not realize they are contagious.
C. Hand washing is not effective against the cold virus: Hand washing is an effective measure for preventing the spread of the common cold virus. Proper hand hygiene can help reduce the transmission of the virus from contaminated surfaces to the nose and mouth.
D. Use of over-the-counter cold products reduces immune resistance: Over-the-counter cold products may help relieve symptoms of the common cold but do not directly affect immune resistance. However, reliance on symptomatic relief without taking precautions to prevent the spread of the virus can contribute to its communicability.
Correct Answer is ["A","D","E"]
Explanation
A. Confusion and restlessness: Confusion and restlessness can indicate changes in cerebral perfusion as the body begins to shut down. These signs may occur as death approaches.
B. Increased appetite and thirst: Increased appetite and thirst are less likely as death approaches.
In fact, clients often have decreased appetite and thirst as the body's systems slow down.
C. Increase in urinary and bowel output: As death approaches, urinary and bowel output typically decrease as the body's metabolic processes slow down.
D. Increased fatigue and sleep: Increased fatigue and sleepiness are common as death approaches. The body's energy levels decrease, leading to increased periods of sleep and rest.
E. Excess secretions in the throat and decrease swallow reflex: Excess secretions in the throat and a decrease in the swallow reflex can occur as the body's ability to manage secretions diminishes. This can lead to a gurgling sound in the throat known as the death rattle.
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