The patient is resting in bed and cooperative with her mother at her bedside.
Which of the following assessments were made?
Neurological: Agitation. Oriented x. Dizziness. Pupils equal and reactive to light.
Cardiovascular: Bradycardia. Bilateral radial pulses weak. Capillary refill 2 seconds. No lower leg edema noted.
Respiratory: Clear breath sounds.
Gastrointestinal: Last reported bowel movement 4 days ago.
Correct Answer : C
Choice A rationale
The patient is resting and cooperative, which indicates a calm and alert state, not agitation. Orientation x means the patient is aware of person, place, time, and situation, which is a normal finding. Dizziness is not mentioned in the patient’s condition. Pupils being equal and reactive to light is a normal finding and does not indicate a neurological issue.
Choice B rationale
Bradycardia refers to a slower than normal heart rate, which is not mentioned in the patient’s condition. Weak bilateral radial pulses could indicate poor blood circulation, but this is not mentioned in the patient’s condition. Capillary refill of 2 seconds is a normal finding. The absence of lower leg edema is a normal finding and does not indicate a cardiovascular issue.
Choice C rationale
Clear breath sounds are a normal finding and indicate that the patient’s lungs are free of obstructions or fluid.
Choice D rationale
The last reported bowel movement being 4 days ago could indicate constipation, but this is not mentioned in the patient’s condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
D.
Choice A rationale
Checking capillary refill on bilateral upper extremities can help assess peripheral circulation and identify any potential vascular injuries.
Choice B rationale
Administering morphine 2 mg IV as ordered would help manage the patient’s pain.
Choice C rationale
Performing range of motion exercises may not be appropriate immediately after the fall and before the extent of the patient’s injuries are fully assessed.
Choice D rationale
Administering ondansetron 4 mg IV as ordered can help manage any nausea or vomiting that the patient may experience, which can be a side effect of the morphine or a result of the fall itself. TemazepamTemazepam Explore
Correct Answer is B
Explanation
Choice A rationale
Noting the presence of an auscultatory gap, which is a period of abnormal silence in Korotkoff sounds during blood pressure measurement, is important. However, in this case, the silence followed by a Korotkoff sound is a normal finding and does not indicate an auscultatory gap.
Choice B rationale
After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. This is a normal finding and indicates that the nurse should continue with the blood pressure assessment.
Choice C rationale
Re-inflating the cuff to a higher number is not necessary in this case as the initial silence followed by a Korotkoff sound is a normal finding.
Choice D rationale
Repositioning the stethoscope over the brachial artery may not resolve the issue of hearing silence followed by a Korotkoff sound. It is important to assess the situation further before making adjustments.
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