The nurse is continuing to care for the client.

Exhibits

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

Answer and Explanation

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.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

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.

A. Plan to monitor the client every 30 min while restrained. B. Request a provider to evaluate the client in person every 36 hr. C. Ensure that the prescription for restraints be renewed every 6 hr. D. Document the client's behavior every 15 min.

Correct Answer is D

Explanation

A. Monitoring every 30 minutes is insufficient; it should be more frequent.

B. Providers must evaluate the client within 1 hour of restraint initiation, not 36 hours.

C. Restraint prescriptions for adults must be renewed every 4 hours, not 6.

D. Documenting the client’s behavior every 15 minutes ensures continuous assessment and compliance with safety protocols.

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}

Explanation

A nurse in an acute care mental health facility is placing a client in seclusion and restraints. Which of the following actions should the nurse plan to take?

Correct Answer is D

Explanation

A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications?

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A nurse is caring for a client. Exhibits Select the 2 actions that the nurse should take.

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The nurse is continuing to care for the client. Exhibits The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.