The nurse is continuing to assist with the care of the client.
For each finding, click to specify if the finding indicates that the client's condition has improved or has not changed.
Deep tendon patellar reflex
Blood pressure
Heart rate
Edema
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"}}
- Deep tendon patellar reflex: The client's deep tendon reflexes improved from being hyperreflexive at 4+ to normal at 2+ without clonus on Day 2. This is a positive sign because hyperreflexia increases seizure risk in preeclampsia, and normalization indicates stabilization of neurological irritability.
- Blood pressure: Although still elevated, the blood pressure decreased from 166/110 mm Hg to 152/90 mm Hg by Day 2. While not normal yet, the trend toward lower values represents improvement in controlling the severe hypertension associated with preeclampsia.
- Heart rate: The client's heart rate increased slightly from 72/min to 90/min. While still within normal range, this change reflects a more responsive and stable cardiovascular status, and there are no signs of bradycardia or distress, supporting mild improvement.
- Edema: The client continues to have +3 pitting edema bilaterally, with no reported reduction compared to the initial assessment. Persistent severe edema suggests that fluid balance issues from preeclampsia have not yet improved and still require active management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
- "Use sunglasses if your eyes are sensitive to light.": After thyroid surgery, especially if the client has Graves’ disease and associated exophthalmos, the eyes may remain sensitive to light. Wearing sunglasses helps protect the eyes from irritation and prevents further discomfort while healing progresses.
- "Continue eating foods with protein.": Maintaining adequate protein intake is important for healing after surgery. Protein supports tissue repair, immune function, and recovery, making it an essential part of the client’s postoperative nutrition plan.
- "Remain on bedrest for 3 to 5 days following discharge.": Prolonged bedrest after thyroid surgery is not recommended. Early ambulation helps prevent complications such as blood clots and promotes recovery. Clients are usually encouraged to resume light activities shortly after surgery.
- "You need to support your neck when coughing or moving.": After thyroidectomy, supporting the neck when coughing, sneezing, or repositioning helps protect the surgical site, reduces strain on the incision, and minimizes discomfort, promoting safer healing.
- "You will no longer need to take any medications for your thyroid now that you have had surgery.": This is incorrect because many clients require lifelong thyroid hormone replacement therapy after a thyroidectomy to maintain normal metabolic function, depending on how much thyroid tissue was removed.
Correct Answer is C
Explanation
A. A client who is displaying aggression: Using a gait belt on an aggressive client is unsafe because sudden movements or resistance could lead to injury for both the client and the caregiver. Aggressive behavior requires de-escalation strategies before considering physical assistance or mobility interventions like a gait belt.
B. A client who has had chest trauma: Gait belts should be avoided in clients with chest trauma because the pressure applied around the torso can exacerbate injuries such as rib fractures, pulmonary contusions, or other thoracic complications, posing significant health risks during mobilization.
C. A client who has limited arm strength: A gait belt is appropriate for clients with limited arm strength because it provides secure support around the waist without requiring the client to rely heavily on their upper limbs. It allows for safer ambulation and transfer by offering the caregiver a firm point of control.
D. A client who has a thoracic incision: Applying a gait belt over or near a thoracic incision can interfere with wound healing, cause pain, and increase the risk of wound dehiscence. Alternative methods for assisting mobility should be used for clients with fresh surgical sites in the thoracic region.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.