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 C
Explanation
A. Initial assessments require nursing judgment and are performed only by licensed nurses.
B. Interpreting lab results requires critical thinking and is within the RN’s scope, not that of assistive personnel.
C. Changing a nonsterile dressing is a basic, routine task that can be delegated to assistive personnel if the client’s condition is stable and the nurse has assessed the client first.
D. Teaching and evaluating understanding are nursing responsibilities that require professional judgment and cannot be delegated.
Correct Answer is D
Explanation
A. Cheyne-Stokes respirations: This is a common sign of approaching death but not necessarily an indication for pain medication.
B. Constricted pupils: This may indicate opioid use or neurological changes, not pain.
C. Mottled skin: Mottling occurs as circulation declines near the end of life, not specifically due to pain.
D. Restlessness: In palliative care, restlessness is often a sign of pain or discomfort, even if the client cannot verbalize pain. The nurse should administer prescribed pain medication to ensure comfort.
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