The nurse is collecting data on the client on the morning of day 2.

Exhibits
Which of the following data collection findings indicate an improvement in the client's condition? Select the 4 findings that indicate an improvement.

Orientation

Blood pressure

Temperature

WBC count

Hallucinations

Answer and Explanation

Correct Answer : A,B,C,E

Rationale:

• Orientation: The client was previously disoriented to time and place, thinking it was 1975 and they were at home. On Day 2, they are alert and fully oriented. This improvement shows enhanced neurological and cognitive status.

• Blood pressure: On Day 1, the client’s BP was 88/50 mm Hg, which indicated hypotension. By Day 2, the BP improved to 132/86 mm Hg. This indicates stabilization of cardiovascular function and better perfusion.

• Temperature: The fever rose to 39.1°C on Day 1 but decreased to 37.7°C on Day 2. This drop suggests the client is responding to treatment and the infectious process is being controlled.

• Hallucinations: On Day 1, the client reported spiders crawling on them, indicating delirium. On Day 2, they deny hallucinations. This improvement shows resolving infection or neuroinflammation.

• WBC count: The WBC count of 14,000/mm³ remains elevated above the normal range and was only assessed on Day 1. Without follow-up labs, it does not indicate improvement.

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Correct Answer is A

Explanation

Rationale:

A. Support the extremity above and below each joint during the exercises: Supporting the limb properly prevents strain on the joints and muscles, reduces pain, and helps maintain proper alignment during passive range-of-motion exercises.

B. Repeat each exercise movement 10 times: Repetitions vary depending on the client’s condition and tolerance. A general guideline is 5 to 10 repetitions, but individualized assessment is important to avoid fatigue or injury.

C. Move each joint just past the point of resistance: Moving a joint beyond the point of resistance can cause pain, injury, or dislocation. Movements should be gentle and stop when resistance or discomfort is felt.

D. Position the bed at mid-thigh level: Bed height should be adjusted for caregiver ergonomics to prevent injury, but "mid-thigh level" is not a standard recommendation for performing range-of-motion exercises.

A. "We will keep the number for poison control stored in our phones. B. "We will make sure our hot water heater is set to 54° C (129° F) C. "We will make sure to turn pot handles towards the front of the stove." D. "We will store medications on a high surface that our child can't reach"

Correct Answer is A

Explanation

Rationale:

A. "We will keep the number for poison control stored in our phones.": Having the poison control number readily accessible is a key component of home safety for toddlers, who are at high risk for accidental ingestion. Prompt access supports rapid emergency response and guidance.

B. "We will make sure our hot water heater is set to 54° C (129° F)": This temperature setting is too high and increases the risk of scald burns. Water heaters should be set at or below 49° C (120° F) to reduce the chance of accidental burns during bathing or handwashing.

C. "We will make sure to turn pot handles towards the front of the stove.": Turning pot handles to the front makes them easier for a toddler to grab, increasing burn and injury risk. Handles should always be turned toward the back or center of the stove to keep them out of reach.

D. "We will store medications on a high surface that our child can't reach": High surfaces are not secure enough, as toddlers may climb. Medications should be stored in locked cabinets to ensure they are completely inaccessible to curious children.

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The nurse is collecting data on the client on the morning of day 2. Exhibits Which of the following data collection findings indicate an improvement in the client's condition? Select the 4 findings that indicate an improvement.

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The nurse is collecting data on the client on the morning of day 2.

Exhibits
Which of the following data collection findings indicate an improvement in the client's condition? Select the 4 findings that indicate an improvement.