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.

Answer and Explanation

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.

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Correct Answer is ["A","B"]

Explanation

Choice A rationale

A boggy fundus refers to an enlarged, soft, and tender uterus identified during physical examination. It is most commonly caused by uterine atony or adenomyosis. A boggy fundus 1 cm above the umbilicus requires immediate follow-up as it indicates that the uterus is not contracting properly after childbirth, which can lead to postpartum hemorrhage.

Choice B rationale

A fundus rotated to the right could indicate a distended bladder. This requires immediate follow-up as it can lead to urinary retention and other complications.

Choice C rationale

Voiding 200 mL of clear yellow urine is a normal finding and does not require immediate follow-up.

Choice D rationale

A blood pressure of 90/62 mm Hg is considered normal according to the American Heart Association. Therefore, it does not require immediate follow-up.

A. I should have taken some allergy medications before going on the hike. B. I have been very stressed out lately and should work on stress management. C. I should have taken an extra dose of fluticasone-salmeterol. D. I should have eaten a snack halfway through the hike. E. My friend smoked cigarettes during the hike.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

I should have taken some allergy medications before going on the hike.- Understanding: Allergens can trigger asthma symptoms, and taking allergy medication can help prevent an asthma attack.
I have been very stressed out lately and should work on stress management.- Understanding: Stress can exacerbate asthma symptoms. Managing stress effectively can help control asthma.
I should have taken an extra dose of fluticasone-salmeterol.- No Understanding: Medication dosage should be as prescribed by the healthcare provider. Taking an extra dose without medical advice can lead to side effects and is not necessarily effective in preventing an asthma attack.
I should have eaten a snack halfway through the hike.- No Understanding: While maintaining good nutrition is important for overall health, eating a snack specifically during a hike is not directly related to preventing an asthma attack.
My friend smoked cigarettes during the hike.- Understanding: Secondhand smoke is a common trigger for asthma. Avoiding exposure to cigarette smoke can help prevent asthma symptoms.

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The patient is resting in bed and cooperative with her mother at her bedside. Which of the following assessments were made?

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Naxlex Comprehensive Predictor Exams

The nurse is reviewing the nurse’s notes and flow chart to identify trends.Which notations require immediate follow-up?

Correct Answer is ["A","B"]

Explanation

Exhibits For each statement, specify if the client has an understanding or no understanding of asthma triggers. Each row must have one option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"}}

Explanation

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The patient is resting in bed and cooperative with her mother at her bedside.
Which of the following assessments were made?