A nurse is caring for a client in the emergency department.
Click to highlight the findings that indicate that the client's condition is improving. To deselect a finding, click on the finding again.
Nurses notes:
1400:
Client admitted to the medical-surgical unit at 1200 today. Alert and orientated x4, heart and lung sounds clear. Client urinating 100 mL/hour. Client is tolerating soft diet and oral fluids. Bowel sounds are hyperactive in all 4 quadrants. Bilateral pedal pulses 2+. Blood glucose 310 mg/dL (74 to 106 mg/dL)
Vital signs:
1400:
Temperature 36.8° C (98.2 F)
Pulse rate 84/min
Respiratory rate 16/min
Blood pressure 106/76 mm Hg
Oxygen saturation 96% on room air
Alert and orientated x4, heart and lung sounds clear
Client is tolerating soft diet and oral fluids
Temperature 36.8° C (98.2 F)
The Correct Answer is ["A","B"]
Rationale
Client is alert and oriented x4, heart and lung sounds clear.
This shows that the client is stable and no longer experiencing confusion or respiratory distress, which are signs of improvement.
Client is tolerating soft diet and oral fluids.
The ability to tolerate food and fluids is a sign of recovery and better overall condition
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Decreased blood pressure is a key indicator of dehydration. When a client is dehydrated, there is a reduction in circulating blood volume, which can lead to hypotension. This is a common sign of dehydration, especially in cases of gastroenteritis where fluid loss occurs through vomiting and diarrhea.
B. Pitting, dependent edema is more commonly associated with fluid retention or conditions like heart failure or kidney disease, not dehydration. Dehydration typically results in fluid volume deficit, not excess fluid retention.
C. Distended jugular veins are usually indicative of fluid overload, not dehydration. This is often seen in conditions like heart failure, where the body cannot effectively manage fluid volume.
D. Increased blood pressure is not typically a sign of dehydration. Dehydration tends to lead to decreased blood pressure due to reduced blood volume.
Correct Answer is B
Explanation
A. Calcium levels are not typically elevated in Graves' disease. Calcium levels are more commonly affected by parathyroid disorders or bone-related issues.
B. Triiodothyronine (T3) is one of the thyroid hormones and is typically elevated in Graves' disease. Graves' disease is an autoimmune disorder that causes hyperthyroidism, which leads to an overproduction of thyroid hormones, including T3 and thyroxine (T4).
C. Phosphorus levels are not typically elevated in Graves' disease. Phosphorus imbalances are more commonly associated with kidney disease or parathyroid disorders.
D. Thyroid-stimulating hormone (TSH) levels are usually low in Graves' disease due to the negative feedback mechanism. In hyperthyroidism, the overproduction of thyroid hormones suppresses the release of TSH from the pituitary gland.
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