For documenting vital signs, the following documentation made by the nurse indicates an understanding of the teaching:
Pulse 82/min, client sitting in a chair
Temperature 36.9°C (98.4°F)
Respirations auscultated, even at 22/min, client supine
Blood pressure 108/68 mm Hg
The Correct Answer is A
Choice A reason: This documentation is correct as it includes the pulse rate and the client's position when the measurement was taken, which can affect the reading.
Choice B reason: The temperature is documented with the correct unit of measurement, but it does not specify the method of measurement (oral, axillary, tympanic, etc.), which is important for accurate interpretation.
Choice C reason: Respirations should be observed, not auscultated, and the documentation should include the client's position. The term 'even' is unnecessary and could be confusing.
Choice D reason: The blood pressure reading is correctly documented with both systolic and diastolic values. However, it should also include the client's position and the arm in which the measurement was taken for clarity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Going to bed and waking up at the same times each day is a recommended practice for good sleep hygiene. It helps to regulate the body's internal clock and can improve sleep quality.
Choice B reason: Watching television until falling asleep is not recommended for healthful sleep habits. The light emitted from screens can interfere with the body's production of melatonin, the hormone that regulates sleep, and can make it more difficult to fall asleep.
Choice C reason: Avoiding naps, especially in the afternoon or evening, can help ensure that a person is sufficiently tired at bedtime, which can improve the ability to fall asleep and maintain sleep throughout the night.
Choice D reason: Having a small snack and taking a bath before bed can be part of a relaxing bedtime routine. A light snack can prevent hunger from disrupting sleep, and a warm bath can help to relax the body and signal that it's time to wind down.
Correct Answer is A
Explanation
Choice A reason: This response demonstrates empathy and active listening. It acknowledges the client's feelings without judgment and opens the door for further discussion about their concerns. It is a therapeutic communication technique that helps build rapport and trust between the nurse and the client. When a client feels understood, it can reduce their anxiety and promote a sense of safety, which may improve their ability to sleep and concentrate.
Choice B reason: While it is important for clients to communicate with their healthcare providers, this response might make the client feel dismissed or that their immediate concerns are not being addressed by the nurse. It could be perceived as deflecting the responsibility to someone else, rather than the nurse providing support at that moment.
Choice C reason: Asking the client to self-reflect on the reasons for their anxiety could be helpful, but it might also be overwhelming for them if they are already in a heightened state of anxiety. This question should be asked with caution and at an appropriate time when the client is more likely to engage in productive self-reflection.
Choice D reason: This statement minimizes the client's experience by suggesting that their problem is common and insignificant. It fails to acknowledge the severity of the client's distress and does not offer any comfort or assistance. It is not a therapeutic response because it does not validate the client's feelings or encourage further communication.
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