The nurse has reviewed the nurses’ notes, medication administration record, and vital signs at 1400.

Exhibits

Based on the findings, which of the following client findings indicate an improvement in the client’s condition? (Select all that apply.)

Temperature

Hallucinations

Oxygen saturation

Heart rate

Orientation

Blood pressure

Answer and Explanation

Correct Answer : A,B,D,E,F

Choice A: Temperature
Reason: The client’s temperature decreased from 38.6°C (101.5°F) at 0200 and 0415 to 37.2°C (98.9°F) at 1400. This indicates a reduction in fever, which is a sign of improvement in the client’s condition.
Choice B: Hallucinations
Reason: Initially, the client was experiencing hallucinations, as evidenced by the statement about seeing someone in an empty chair. By 1400, no hallucinations were observed, indicating an improvement in the client’s mental status.
Choice C: Oxygen Saturation
Reason: The client’s oxygen saturation remained stable at 98% on room air throughout the observations. While this is within the normal range (95-100%), it does not indicate a change or improvement in the client’s condition.
Choice D: Heart Rate
Reason: The client’s heart rate decreased from 104/min at 0200 and 108/min at 0415 to 78/min at 1400. This reduction to within the normal range (60-100 beats per minute) indicates an improvement in the client’s condition.
Choice E: Orientation
Reason: Initially, the client was confused and disoriented. By 1400, the client was awake, oriented to person and place, and watching television, indicating an improvement in cognitive function.
Choice F: Blood Pressure
Reason: The client’s blood pressure decreased from 158/96 mm Hg at 0200 and 148/94 mm Hg at 0415 to 128/84 mm Hg at 1400. This reduction to within the normal range (90/60 mm Hg to 120/80 mm Hg) indicates an improvement in the client’s condition.

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Correct Answer is C

Explanation

Choice A Reason:
Eating a meal just before bedtime is generally not recommended for promoting sleep. Consuming food late at night can lead to indigestion and discomfort, which can interfere with the ability to fall asleep and stay asleep. Additionally, certain foods may cause an increase in energy levels, making it harder to wind down. The body’s digestive process can also disrupt the natural sleep cycle, leading to poorer sleep quality.

Choice B Reason:
Drinking a glass of wine or any alcoholic beverage before bed is not advisable for promoting healthy sleep. While alcohol might initially make you feel drowsy, it can disrupt the sleep cycle later in the night. Alcohol can interfere with the REM (Rapid Eye Movement) stage of sleep, which is crucial for restorative sleep. It can also lead to fragmented sleep and frequent awakenings, reducing overall sleep quality.

Choice C Reason:
Limiting caffeine intake is a well-known strategy for improving sleep quality. Caffeine is a stimulant that can interfere with the ability to fall asleep and stay asleep. By limiting yourself to two caffeinated beverages per day, preferably consumed earlier in the day, you reduce the likelihood of caffeine affecting your sleep. This recommendation aligns with sleep hygiene practices that promote better sleep patterns and overall sleep quality.

Choice D Reason:
Taking a nap after lunch can be beneficial for some people, but it can also interfere with nighttime sleep if not managed properly. Long or late naps can reduce the body’s sleep drive, making it harder to fall asleep at night. For individuals with sleep difficulties, it is often recommended to avoid napping or to limit naps to short durations (20-30 minutes) and to take them earlier in the day to prevent interference with nighttime sleep.

A. Excessively anxious B. Exploitive of others C. Blunted affect D. Withdrawn behaviors

Correct Answer is B

Explanation

Choice A: Excessively anxious
Antisocial personality disorder (ASPD) is characterized by a pervasive pattern of disregard for, and violation of, the rights of others. Individuals with ASPD often exhibit behaviors that are manipulative, deceitful, and exploitative. Excessive anxiety is not typically associated with ASPD. Instead, anxiety disorders are more commonly linked with conditions such as generalized anxiety disorder (GAD), panic disorder, and social anxiety disorder. While individuals with ASPD may experience anxiety, it is not a defining characteristic of the disorder.

Choice B: Exploitive of others
Exploitive behavior is a hallmark of antisocial personality disorder. Individuals with ASPD often manipulate and take advantage of others for personal gain or pleasure. This behavior stems from a lack of empathy and a disregard for the feelings and rights of others. Exploitation can manifest in various ways, including deceit, coercion, and manipulation. This trait is central to the diagnosis of ASPD and is one of the key features that differentiate it from other personality disorders.

Choice C: Blunted affect
Blunted affect refers to a significant reduction in the intensity of emotional expression. While this can be seen in various mental health conditions, it is more commonly associated with schizophrenia and other psychotic disorders. In the context of ASPD, individuals may display a superficial charm and a lack of genuine emotional depth, but blunted affect is not a primary characteristic. Instead, their emotional responses may be more calculated and manipulative rather than genuinely blunted.

Choice D: Withdrawn behaviors
Withdrawn behaviors are more characteristic of avoidant personality disorder or social anxiety disorder, where individuals may avoid social interactions due to fear of rejection or criticism. In contrast, individuals with ASPD are often socially engaging, but in a manipulative and deceitful manner. They may seek out social interactions to exploit others rather than to avoid them. Therefore, withdrawn behavior is not typically associated with ASPD.

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The nurse has reviewed the nurses’ notes, medication administration record, and vital signs at 1400. Exhibits Based on the findings, which of the following client findings indicate an improvement in the client’s condition? (Select all that apply.)

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The nurse has reviewed the nurses’ notes, medication administration record, and vital signs at 1400.

Exhibits

Based on the findings, which of the following client findings indicate an improvement in the client’s condition? (Select all that apply.)