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. Heat can exacerbate MS symptoms (Uhthoff’s phenomenon) by worsening muscle weakness and fatigue.
B. MS causes fatigue due to demyelination, so rest periods help conserve energy and prevent symptom flare-ups.
C. Clients should remain as independent as possible to preserve mobility and self-esteem.
D. Intense aerobic exercise can worsen fatigue; mild stretching and range-of-motion exercises are preferred.
Correct Answer is D
Explanation
A. Atomoxetine is a norepinephrine reuptake inhibitor used for attention-deficit/hyperactivity disorder (ADHD), not anxiety or panic attacks. It does not have immediate anxiolytic effects and is not indicated for acute panic management.
B. Watching television is a distraction strategy, but during a panic attack, the client’s anxiety level is too high to focus on such activities. Cognitive interventions are ineffective until acute symptoms subside.
C. Teaching new coping skills like meditation should occur after the panic attack resolves. During a panic attack, the client cannot process new information effectively.
D. The priority is to stay with the client and maintain a calm, reassuring presence. Sitting quietly conveys safety, helps ground the client, and prevents escalation. The nurse should speak calmly, use simple, brief statements, and reduce environmental stimuli. Once the client’s anxiety lessens, teaching relaxation techniques can begin.
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