A nurse is attending to a patient who is receiving a unit of packed RBCs. The patient’s vital signs at 0800 and 0815 are given.
Heart rate of 110 bpm
Complete the following sentence using the list of options.
The patient exhibits symptoms of ________
Hypertension
Hypotension
Tachycardia
Bradycardia
The Correct Answer is C
Choice A rationale
Hypertension refers to high blood pressure, which is not directly indicated by the given vital signs.
Choice B rationale
Hypotension, or low blood pressure, is also not directly indicated by the provided vital signs.
Choice C rationale
Tachycardia refers to a fast heart rate. If the patient’s heart rate increased significantly between 0800 and 0815, this could be a sign of tachycardia.
Choice D rationale
Bradycardia, or a slow heart rate, would be indicated by a decrease in heart rate, which is not suggested by the given information.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
The statement “What did I do to deserve this illness?” could indicate spiritual distress. This statement suggests that the patient may be struggling with feelings of guilt, punishment, or existential crisis, which are common manifestations of spiritual distress. The patient may be
questioning their moral or spiritual worth, or trying to find meaning or purpose in their suffering.
Choice B rationale
The statement “I blame medical science for not finding a cure” could indicate frustration or anger, but it does not necessarily indicate spiritual distress. While this statement suggests dissatisfaction with medical progress, it does not directly relate to the patient’s spiritual or existential concerns.
Choice C rationale
The statement “Where is my daughter when I need her most?” could indicate emotional distress related to the patient’s interpersonal relationships, but it does not necessarily indicate spiritual distress. This statement suggests that the patient may feel abandoned or unsupported, but it does not directly relate to the patient’s spiritual or existential concerns.
Choice D rationale
The statement “Will I ever regain control over my life?” could indicate emotional distress related to the patient’s sense of autonomy and control, but it does not necessarily indicate spiritual distress. This statement suggests that the patient may feel helpless or powerless in the face of their illness, but it does not directly relate to the patient’s spiritual or existential concerns.
Correct Answer is D
Explanation
Choice A rationale
Discussing the risk factors for colon cancer may not be helpful or comforting to a client who is expressing anger about their diagnosis. It might lead to feelings of guilt or regret if the client feels they could have done something to prevent the disease.
Choice B rationale
Focusing on future management of the illness may be overwhelming for a client who is currently expressing anger about their diagnosis. It might be more beneficial to address the client’s current emotional state before discussing future plans.
Choice C rationale
Providing written information about the phases of loss and grief may be helpful, but it may not address the client’s immediate emotional needs. The client may not be ready to read and process this information while they are expressing anger.
Choice D rationale
Reassuring the client that anger is an expected response to grief can validate the client’s feelings and help them feel understood. It’s important to acknowledge and validate the client’s emotions during this difficult time.
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