A nurse is caring for a client.
Click on the findings that require immediate follow-up. To deselect a finding, click on the finding again.
Nurses' Notes
1500:
Client is alert and oriented to person, place, and time. Client is 4 hr postoperative following abdominal surgery. Surgical site has a small amount of serosanguineous drainage on dressing. Dressing is intact. Client reports pain as 5 on a scale of 0 to 10. Lung sounds are diminished in posterior lobes. Bowel sounds are hypoactive in all 4 quadrants. Last bowel movement was this morning.
1730:
Client is restless and short of breath. Reports pain as 8 on a scale of 0 to 10. Pain medication administered.
Vital Signs
1730:
- Temperature 37.2° C (98.9° F)
- Blood pressure 168/84 mm Hg
- Heart rate 116/min
- Respiratory rate 24/min
- Oxygen saturation 93% on room air
a small amount of serosanguineous drainage
Lung sounds are diminished in posterior lobes
pain as 5 on a scale of 0 to 10
Blood pressure 168/84 mm Hg
Respiratory rate 24/min
Oxygen saturation 93% on room air
Bowel sounds are hypoactive in all 4 quadrants
The Correct Answer is ["A","B","C","D"]
a small amount of serosanguineous drainage,
Lung sounds are diminished in posterior lobes,
pain as 8 on a scale of 0 to 10,
Blood pressure 168/84 mm Hg
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Develop a plan for the client to integrate the change into her lifestyle: Developing a plan for integrating change into one's lifestyle is more appropriate during the preparation stage when the client is actively planning to make a change. During the contemplation stage, the focus is on considering change rather than developing a detailed plan.
B. Assist the client in setting goals to make the change: Setting specific goals is more appropriate during the preparation stage when the client is actively planning to make a change. During the contemplation stage, the client is not yet ready to commit to specific goals.
C. Recommend small changes for the client to make to change her behavior over time: During the contemplation stage of health behavior change, clients are considering making a change but are not yet committed to taking immediate action. This is also more suitable for the preparation or action stages.
D. In the contemplation stage, the client is aware of the problem and is considering making a change but has not yet committed to action. Providing information about the benefits can help the client move toward the next stage of change.
Correct Answer is A
Explanation
Choice A reason:
A. Dilated pupils
During the alarm reaction stage of the general adaptation syndrome (GAS), the body's initial response to stress triggers the "fight or flight" response. This response is characterized by the release of stress hormones, increased sympathetic nervous system activity, and various physiological changes to prepare the body to respond to the stressor. Dilated pupils are one of the manifestations of the fight or flight response, allowing for improved visual acuity and awareness of the environment.
Choice B reason:
Physical exhaustion is inappropriate. This is typically associated with the exhaustion stage of GAS, which follows the alarm reaction stage.
Choice C reason:
Bradycardia is inappropriate. Bradycardia (slow heart rate) is not a typical manifestation during the alarm reaction stage. Increased heart rate (tachycardia) is more common during this stage.
Choice D reason:
Depression is inappropriate. Depression is not a direct manifestation of the alarm reaction stage. It is a psychological response that may occur during or after prolonged stress and may be associated with the later stages of GAS.
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