The nurse is continuing to care for the client.
A nurse is evaluating the client's response to therapy. Which of the following recent findings indicate the client's condition has improved or not changed? For each assessment finding, click to specify if the finding indicates that the client's condition has improved or has not changed.
Heart rate
Blood pressure
Edema
Deep tendon reflexes
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
|
Finding |
Improved |
Not changed |
|
Heart rate |
|
✓ |
|
Blood pressure |
✓ |
|
|
Edema |
✓ |
|
|
Deep tendon reflexes |
✓ |
|
Rationale
- Heart rate: Not changed
- The heart rate increased from 72/min to 90/min, indicating no improvement.
- Blood pressure: Improved
- The blood pressure decreased from 166/110 mm Hg to 152/90 mm Hg, indicating improvement.
- Edema: Improved
- The edema decreased from +3 pitting to +2 pitting, indicating improvement.
- Deep tendon reflexes: Improved
- The patellar reflex decreased from 4+ to 2+, indicating improvement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
- Transient tachypnea of the newborn: The newborn's elevated respiratory rate and mild grunting are indicative of transient tachypnea, a condition where the baby breathes too fast due to retained lung fluid.
- Hypoglycemia: Newborns, especially those with higher birth weights, are at risk for hypoglycemia, which can be exacerbated by stress and increased energy expenditure due to rapid breathing.
Correct Answer is C
Explanation
A. The risk of overdose is minimized by the device's programming.
B. The medication is limited based on a preset dose and frequency.
C. PCA pumps deliver a controlled dose of medication, preventing overdose by limiting the amount dispensed.
D. Only the client should press the button to ensure safety.
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