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 A
Explanation
Rationale:
A. A health care surrogate (also called a durable power of attorney for health care) is a person designated by the client to make health care decisions if the client becomes incapacitated. This is a key component of advance directives.
B. Advance directives can be revised or revoked by the client at any time as long as they remain competent to do so.
C. Legal counsel is not required to assign a surrogate, though the document typically needs to be witnessed and signed according to state regulations.
D. A DNR order is optional and separate from other parts of an advance directive; clients may choose to include or exclude it.
Correct Answer is C
Explanation
Rationale:
A. Asking the client to describe pain involves assessment and evaluation, which require nursing judgment and cannot be delegated to assistive personnel (AP).
B. Observing the position of traction weights requires knowledge of correct traction alignment and setup, which falls under the nurse’s responsibility, not the AP’s. Incorrect traction positioning can lead to misalignment and neurovascular compromise.
C. Measuring urinary catheter output is an appropriate task for delegation. It is a routine, noninvasive, and predictable task that does not require nursing judgment. The nurse remains responsible for analyzing the data.
D. Checking pedal pulses involves assessment of circulation, a task that cannot be delegated since it requires clinical judgment and skill to interpret findings.
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