A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would the client most likely exhibit?

Bradycardia

Tachycardia

Dysrhythmia

Bigeminal

Answer and Explanation

The Correct Answer is B

Choice A reason: Bradycardia (pulse <60 bpm) is unlikely, as fever, infection, and pain increase sympathetic nervous system activity, elevating heart rate. Infection triggers cytokine release, and pain stimulates adrenaline, both increasing cardiac output to meet metabolic demands. Bradycardia would contradict the physiological stress response, making this incorrect for this scenario.

Choice B reason: Tachycardia (pulse >100 bpm) is likely due to fever, infection, and pain activating the sympathetic nervous system. Fever increases metabolic rate, infection induces inflammatory cytokines, and pain releases adrenaline, all elevating heart rate to enhance oxygen delivery. This physiological response matches the client’s condition, making tachycardia the correct pulse type.

Choice C reason: Dysrhythmia involves irregular heart rhythms, like atrial fibrillation, not directly caused by fever, infection, or pain. These conditions increase heart rate via sympathetic stimulation, not necessarily rhythm irregularity. Dysrhythmias require specific cardiac issues, unlike the expected tachycardia from systemic stress, making this incorrect for the client’s presentation.

Choice D reason: Bigeminal pulse (paired beats) indicates a specific arrhythmia, not typically caused by fever, infection, or pain. These conditions elevate heart rate through sympathetic activation and cytokine release, leading to tachycardia, not patterned beats. Bigeminal rhythms require cardiac-specific issues, making this an unlikely pulse type in this systemic stress scenario.

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Correct Answer is C

Explanation

Choice A reason: Stating the feeding order (cereal, then eggs) dismisses the client’s autonomy, reducing dignity. Offering choice empowers the client, respecting their preferences. This approach lacks patient-centered care, potentially making the client feel controlled, per dignity and psychosocial care principles.

Choice B reason: Assuming the client dislikes being fed is judgmental and undermines dignity, implying resistance. This statement dismisses the client’s feelings, reducing autonomy and respect. A dignified approach involves choice and collaboration, not confrontation, per patient-centered care and ethical nursing standards.

Choice C reason: Asking what part of the meal the client wants first promotes dignity by offering choice and autonomy. It respects the client’s preferences, fostering a sense of control and respect during a dependent task, aligning with patient-centered care and dignity principles in nursing.

Choice D reason: Expressing a wish for more time suggests inadequacy, potentially diminishing the client’s sense of value. This focuses on the nurse’s limitations, not the client’s dignity. Offering choices enhances respect, whereas this statement risks disempowerment, per psychosocial care and dignity standards.

A. Fats are found mostly in animal sources. B. Unsaturated fats are found mostly in animal sources. C. Trans fat should be less than 7% of the total calories. D. Polyunsaturated fats should be less than 7% of the total calories.

Correct Answer is C

Explanation

Choice A reason: Stating fats are mostly from animal sources is inaccurate, as plant sources (e.g., oils, nuts) also provide significant fats. A low-fat diet reduces cardiovascular risk by limiting saturated and trans fats, which raise LDL cholesterol. This statement oversimplifies fat sources, ignoring plant-based fats like olive oil, which are beneficial, making it incorrect.

Choice B reason: Unsaturated fats, including monounsaturated and polyunsaturated, are primarily from plant sources (e.g., avocados, fish), not animal sources. These fats lower LDL cholesterol, benefiting cardiovascular health. The statement is incorrect, as a low-fat diet encourages unsaturated fats over saturated, which are animal-derived, making this misinformation for dietary education.

Choice C reason: Trans fats, found in processed foods, raise LDL and lower HDL cholesterol, increasing cardiovascular risk. Guidelines recommend keeping trans fat below 7% of total calories to minimize atherosclerosis. This is critical for a low-fat diet, as trans fats disrupt lipid metabolism and endothelial function, making this the correct information to share with the patient.

Choice D reason: Polyunsaturated fats, like omega-3s, should not be limited to less than 7% of calories, as they reduce LDL and inflammation, benefiting heart health. A low-fat diet encourages these fats over trans or saturated fats. This statement is incorrect, as polyunsaturated fats support cardiovascular and metabolic health, not requiring such strict limitation.

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A nurse is assessing a client who has a fever, has an infection of a flank incision, and is in severe pain. What type of pulse rate would the client most likely exhibit?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is feeding a client. Which statement would help a person maintain dignity while being fed?

Correct Answer is C

Explanation

In providing diet education for a patient on a low-fat diet, which information is important for the nurse to share?

Correct Answer is C

Explanation

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