A nurse is collecting data on client who has a heart rate of 56/min. Which of the following findings should the nurse expect?
Hypoglycemia
Report of dizziness
Temperature of 39° C (102.2° F).
History of cigarette smoking
The Correct Answer is B
A: Hypoglycemia does not directly correlate with a lower heart rate.
B: A heart rate of 56/min may indicate bradycardia, which can lead to symptoms like dizziness due to decreased cardiac output and subsequently reduced cerebral perfusion.
C: A fever would typically increase the heart rate, not decrease it.
D: Cigarette smoking is more commonly associated with an increased heart rate due to stimulants like nicotine.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A: Subjective information refers to what the patient experiences and reports, not what is sensed by the observer.
B: Objective signs are those that can be observed and measured by someone other than the patient, such as visual inspections, palpations, and auditory cues.
C: Reported by the patient would be subjective data, opposite of what is sensed and recorded by healthcare providers.
D: Hidden signs would imply they are not readily observable, which contradicts the use of senses to identify them.
Correct Answer is ["A","B","C","D","E"]
Explanation
A. The site where the blood pressure was obtained is important to document because blood pressure measurements can differ significantly between different parts of the body (e.g., arm versus thigh). Documenting the site ensures that future measurements can be compared appropriately.
B. Interventions implemented in response to a client's blood pressure need documentation to track what actions were taken and whether these actions had the intended effect on the patient's health status. This helps in assessing the efficacy of interventions.
C. A client's position when the blood pressure was obtained affects the readings; measurements might differ when taken in positions such as lying, sitting, or
standing. Accurate documentation of position helps in ensuring that readings are interpreted correctly.
D. The frequency in which a blood pressure is taken provides context for understanding how the patient’s blood pressure is trending over time, which is critical for ongoing management and therapeutic decisions, especially in unstable or critical patients.
E. A client's response to interventions implemented should be documented to evaluate whether the treatment plan needs adjustments and to understand how the patient is coping with the treatment. This documentation is crucial for patient safety and care continuity.
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