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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.

A.

Heart rate

B.

Blood pressure

C.

Edema

D.

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

  1. Heart rate: Not changed
    • The heart rate increased from 72/min to 90/min, indicating no improvement.
  2. Blood pressure: Improved
    • The blood pressure decreased from 166/110 mm Hg to 152/90 mm Hg, indicating improvement.
  3. Edema: Improved
    • The edema decreased from +3 pitting to +2 pitting, indicating improvement.
  4. Deep tendon reflexes: Improved
    • The patellar reflex decreased from 4+ to 2+, indicating improvement.


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Related Questions

Correct Answer is D

Explanation

A. The catheter should be picked up carefully, but the length from the tip is less important than maintaining sterility.

B. Cleansing the area is typically done with a single clean swab in a circular motion from the urethral meatus outward.

C. The correct technique for cleaning the penis is a circular motion from the urethra outward, not side-to-side.

D. Lifting the penis perpendicular to the body helps straighten the urethra, making catheter insertion easier and reducing the risk of injury.

Correct Answer is ["C","E","G"]

Explanation

  1. Difficulty sleeping: This can be a side effect of fluoxetine, which can cause insomnia in some individuals.
  2. Frequent headaches: Headaches are a common side effect of many antidepressants, including fluoxetine.
  3. BP 169/91 mm Hg: Elevated blood pressure can be an adverse effect of fluoxetine, especially if the client has a history of hyperlipidemia.

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