A nurse is caring for a client who is pregnant.
A nurse is evaluating the client's response to therapy. Which of the following recent assessment findings indicate the client's condition has improved or not changed?
For each recent assessment finding. click to specify if the finding indicates the client’s condition has improved or has not changed. Each finding may support more than 1 disease process or none at all. There must be at least 1 selection in every column. There does not need to be a selection in every row.
Deep tendon patellar reflex
Blood pressure
Edema
Heart rate
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"}}
Deep tendon patellar reflex (DTR): The client’s reflexes decreased from 4+ on Day 1 to 2+ on Day 2. Hyperactive reflexes are a hallmark of preeclampsia with severe features, so the reduction indicates an improvement in neuromuscular excitability.
Blood pressure: While slightly decreased from 166/110 mm Hg (Day 1, 0930) to 152/90 mm Hg (Day 2, 0900), indicating partial improvement with antihypertensive therapy. However, the BP remains elevated above normal range requiring further management.
Heart rate: The heart rate changed from 84–90/min (Day 1–Day 2), which is stable and within normal limits, suggesting no acute cardiovascular compromise.
Edema: The client continues to have +3 pitting edema in bilateral lower extremities on both Day 1 and Day 2, showing no change in fluid retention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. While family support is important, the client’s autonomy and emotional state must be addressed first.
B. Offering a referral for counseling or to a support person (e.g., social worker, mental health professional, chaplain) acknowledges the client’s feelings and provides a pathway for discussing goals of care and coping strategies. This response is therapeutic and supports informed decision-making.
C. Dismissing the statement as anxiety minimizes the client’s distress.
D. Deferring the conversation can leave the client feeling unheard and unsupported at a critical time.
Correct Answer is ["B","D"]
Explanation
A. Flossing is not typically required for toddlers until teeth touch each other closely (around 3 years old).
B. A toothbrush with soft nylon bristles is recommended for toddlers to clean teeth effectively without damaging gums.
C. Drinking milk at bedtime exposes teeth to sugars overnight, increasing the risk for dental caries (early childhood caries or “baby bottle tooth decay”).
D. A pea-sized amount of fluoride toothpaste helps strengthen enamel and prevent decay; supervise to avoid swallowing.
E. Toddlers’ teeth should be brushed twice daily, especially before bedtime.
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