The nurse is reviewing 24-hour Holter monitor diaries of various patients. Which of the following entries is the MOST complete?
VS at 0900: T-37.3, P-102, R-20
1400: Basketball practice, dizzy, no loss of consciousness, no caffeine today.
Electrodes on upper left and right chest and lower left rib area.
Breakfast: Eggs and Toast, Lunch: Chicken Noodle Soup, Dinner: Chicken nuggets and fries.
The Correct Answer is B
A. This entry only provides vital signs and lacks context regarding the patient's activities or symptoms.
B. This entry is the most complete as it includes the time, activity (basketball practice), symptom (dizziness), absence of loss of consciousness, and relevant detail (no caffeine intake), giving a comprehensive picture of the patient's experience.
C. This entry describes the electrode placement but does not provide any information on activities or symptoms.
D. This entry details the patient's meals but does not include any information on activities or symptoms related to the Holter monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A blood pressure of 100/56 and a small weight gain may indicate fluid retention, but they are not immediately life-threatening.
B. A heart rate of 150 beats/minute with crying can be normal for a child of this age, especially during emotional distress.
C. An apical pulse of 70 beats/minute and vomiting are concerning because they may indicate digoxin toxicity. A low heart rate (bradycardia) in a child on digoxin requires immediate attention.
D. An hourly urine output of 45 mL/hour is adequate and not concerning in this context.
Correct Answer is C
Explanation
A. While appropriate clothing is important, it is not the priority for reducing child abuse.
B. Skin and nail care are necessary for infant hygiene but are not directly related to preventing child abuse.
C. Recognizing that increased crying is normal during the first month and ensuring parents have emotional support can significantly reduce the risk of frustration that may lead to child abuse.
D. Understanding normal feeding patterns is important but less critical for the immediate goal of preventing child abuse.
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