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 D
Explanation
A. Assigning tasks is important but comes after understanding family dynamics.
B. Establishing a routine is beneficial but should follow assessment.
C. Referring to a support group is valuable but not the immediate first step.
D. Determining family roles helps the nurse assess coping strategies and dynamics, which is essential before planning interventions.
Correct Answer is A
Explanation
A. Tidaling in the water seal chamber indicates normal fluctuations in pressure as the client inhales and exhales, signifying that the system is functioning properly.
B. Absence of tidaling may indicate that the lung has fully re-expanded.
C. A loop of tubing below the system can cause drainage issues but does not cause tidaling.
D. Clots can partially obstruct the tubing but would not cause regular tidaling.
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