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 ["A","B"]
Explanation
A. Weight gain due to fluid retention and increased appetite from corticosteroid use can have psychosocial effects, particularly on body image and self-esteem in children.
B. Irritability is a common side effect of corticosteroids and can affect a child's mood and social interactions, potentially impacting psychosocial development.
C. Osteoporosis is a long-term risk of corticosteroid therapy, but it is not an immediate concern for a child's psychosocial development.
D. Hypertension is a side effect of corticosteroids but is less likely to have an immediate impact on the child's psychosocial development.
E. Nausea is a side effect of corticosteroids but does not typically affect psychosocial development.
Correct Answer is D
Explanation
A. Toddlers often go through phases of decreased appetite and picky eating, so expecting an increased appetite may not be realistic.
B. While vitamins may be useful in some cases, they should not be used to replace a balanced diet. Picky eating should be addressed by offering a variety of foods.
C. A typical toddler's calorie intake is much lower than 3,000 calories; the average is closer to 1,000-1,400 calories per day.
D. The quality of food is more important than the quantity, as toddlers need nutrient-dense foods to support their growth and development.
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