A nurse is caring for a client who is pregnant.
Exhibits
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

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"}}

Rationale:

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.

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Free Nursing Study Resources

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 {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

The nurse recommends the adolescent notify the provider immediately if a change in moodor engagement in sexual activityoccurs during therapy.

Rationale:

A change in mood: Isotretinoin carries a risk of depression, mood swings, or suicidal ideation. Adolescents should report any sudden mood changes immediately.

Engagement in sexual activity: Isotretinoin is highly teratogenic. Although the adolescent currently has a negative pregnancy test, any sexual activity could increase the risk of pregnancy, which requires strict precautions and provider notification.

Nausea, dry mouth, dry eyes, sunburn, decreased night vision, worsening acne: These are common side effects of isotretinoin and should be monitored, but they do not require immediate notification unless severe or persistent.

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Naxlex Comprehensive Predictor Exams

A nurse is teaching participants at a community center about advance directives. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

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