The nurse knows the importance of assessing vital signs is to:

Evaluate the client's responses to treatment.

Carry out orders from the healthcare provider.

Monitor risks for alterations in health.

Establish a baseline.

Answer and Explanation

Correct Answer : A,C,D

Choice A Reason:
Assessing vital signs is crucial for evaluating the client's responses to treatment. Changes in vital signs can indicate whether the body is responding positively or negatively to a treatment, allowing healthcare providers to adjust care plans accordingly. For example, a decrease in fever after administering antipyretics would suggest the treatment is effective.

Choice B Reason:
While carrying out orders from the healthcare provider is a responsibility of the nurse, it is not the primary reason for assessing vital signs. Vital signs are assessed to inform clinical decisions, not solely to fulfill orders. Therefore, this choice is not correct in the context of the importance of vital sign assessment.

Choice C Reason:
Monitoring risks for alterations in health is another key reason for assessing vital signs. Vital signs can serve as early indicators of health issues, such as the onset of an infection indicated by a rising temperature or cardiovascular problems suggested by changes in blood pressure or heart rate.

Choice D Reason:
Establishing a baseline is essential when assessing vital signs. It provides a reference point for future comparisons, which is important for detecting any deviations from the client's normal range. This helps in identifying potential health issues early and monitoring the progression of known conditions.

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Correct Answer is B

Explanation

Choice a reason:
Educational Prevention is not a recognized level of prevention in healthcare. While education is a key component in all levels of prevention, it is not a standalone category. Education is typically included in primary prevention as it involves informing the public about health practices to prevent the onset of disease.

Choice b reason:
Tertiary Prevention is the level of prevention that aims to manage and treat an existing disease to prevent further complications or deterioration. In the case of immobile stroke patients, tertiary prevention would involve measures to prevent skin breakdown and other complications associated with immobility and the stroke's long-term effects.

Choice c reason:
Secondary Prevention involves early detection and prompt intervention to prevent the progression of a disease. For stroke patients, secondary prevention might include monitoring for signs of skin breakdown so that early treatment can be initiated. However, the scenario described focuses on managing an existing condition rather than early detection.

Choice d reason:
Primary Prevention aims to prevent the disease or injury before it occurs. This would involve strategies to prevent strokes in the first place, such as controlling high blood pressure or encouraging healthy lifestyle changes. It does not directly relate to the prevention of skin breakdown in patients who have already had a stroke.

A. Tachycardia. B. Diarrhea. C. Facial edema. D. Heat intolerance. E. The correct answer is c) Facial edema.

Correct Answer is C

Explanation

Choice A reason:
Tachycardia, or an abnormally rapid heart rate, is not a typical finding in myxedema. Myxedema is associated with hypothyroidism, which usually presents with bradycardia, or a slower than normal heart rate, due to the decreased metabolic demands on the body.
Choice B reason:
Diarrhea is not commonly associated with myxedema. Instead, patients with hypothyroidism and myxedema often experience constipation due to slowed gastrointestinal motility.
Choice C reason:
Facial edema, particularly around the eyes, is a classic sign of myxedema. Myxedema is a severe form of hypothyroidism that can cause mucopolysaccharide deposition in the skin, leading to non-pitting edema. This can be particularly noticeable in the face and periorbital area.
Choice D reason:
Heat intolerance is more commonly associated with hyperthyroidism, not hypothyroidism. Patients with myxedema typically have cold intolerance due to a decrease in basal metabolic rate and reduced heat production.

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The nurse knows the importance of assessing vital signs is to:

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Naxlex Comprehensive Predictor Exams

A nurse educator is presenting at a continuing education seminar for nurses. As part of his presentation, he is emphasizing the prevention of skin breakdown in immobile patients who have suffered from a stroke. The level of prevention being discussed by the nurse educator is:

Correct Answer is B

Explanation

A nurse is assessing a client who has myxedema. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

A client describes a 3-week history of hoarseness. The client also reports feeling fatigue and noticeable weight gain over the past month. Which cause should the nurse consider as most likely?

In which disease process should a nurse expect to see a patient with the presence of pitting edema?

The clinical nurse is precepting a group of students, and one student questions the nurse, "What is the primary purpose of health assessment?" What is the most appropriate response by the clinical nurse?

A client with a history of COPD is being assessed. When the nurse percusses the client's chest, which characteristic sound is expected?

A 45-year-old African-American client comes to the clinic complaining of fatigue, thirst, and frequent urination. During the physical exam, the nurse notices areas of linear hyperpigmentation around the neck and in the axillae (Acanthosis Nigricans). What would the nurse do next?

The nurse knows the importance of assessing vital signs is to:

While auscultating a client's 1st and 2nd intercostal spaces, close to the sternal body, the nurse would document these normal breath sounds as which of the following?