Exhibits
The nurse reviews the client’s medical record from admission to 1930 hrs. Click to indicate whether the assessment finding has improved or not changed.
Dyspnea
Heart rate
Blood pressure
Oxygen saturation
Respiratory rate
Oral intake
Lung sounds
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}
Assessment Finding |
Improved |
No change |
Dyspnea |
|
✅ |
Heart rate |
✅ |
|
Blood pressure |
✅ |
|
Oxygen saturation |
✅ |
|
Respiratory rate |
✅ |
|
Oral intake |
✅ |
|
Lung sounds |
|
✅ |
Rationale:
Improved:
Heart rate and blood pressure are slightly improved by 1930, likely due to the medications (furosemide, enalapril) helping manage fluid retention and blood pressure.
Oral intake has improved, but monitoring of this is critical given the recent lack of eating for several days.
No change:
Dyspnea remains unchanged, since the adolescent is still dyspneic with activity.
Lung sounds remain unchanged, indicating that there may still be some wheezing or fluid buildup in the lungs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. The CRIES scale is used for neonates and infants, not toddlers.
B. The FACES pain rating scale is appropriate for children aged 3 years and older, allowing them to express their pain visually through faces showing different expressions.
C. The Noncommunicating children's pain checklist is used for older children with communication impairments.
D. The Numeric pain rating scale is more suitable for older children and adults who can understand and use numbers to rate pain.
Correct Answer is A
Explanation
A. The toddler’s behavior—sitting quietly and turning away from the nurse—suggests anxiety due to separation from the mother. This is typical of toddlers who experience distress when separated from caregivers.
B. Developing autonomy is a developmental task of toddlers, but the behavior described (turning away from the nurse and seeking comfort through thumb-sucking) indicates distress rather than an expression of independence.
C. Regression can occur in toddlers when they experience stress, but the behavior here seems more related to anxiety than a return to earlier developmental behaviors.
D. Resentment toward the mother is unlikely in this situation; the behavior is more indicative of separation anxiety.
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