Exhibits
Click to highlight the findings that indicate improvement in the client's condition. To deselect a finding, click on the finding again.
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Assessment |
Findings |
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Nurses' Notes |
Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge. Membranes intact No uterine contractions noted. |
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FHR baseline 138, minimal variability. No further reports of burning with urination. |
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Laboratory Results |
WBC 12,000/mm2 (5,000 to 10,000/mm3) Platelet count 188,000/mm3 (150,000 to 400,000/mm3) |
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Vital Signs |
Temperature 37.1° C (98.7° F) Blood pressure 120/78 mm Hg |
Client rates lower back pain a 0 on a scale from 0 to 10. No reports of vaginal discharge.
No uterine contractions noted.
No further reports of burning with urination.
WBC 12,000/mm2 (5,000 to 10,000/mm3)
Temperature 37.1° C (98.7° F)
Membranes intact
FHR baseline 138, minimal variability.
Platelet count 188,000/mm3 (150,000 to 400,000/mm3)
Blood pressure 120/78 mm Hg
The Correct Answer is ["A","B","C","D","E"]
Client rates lower back pain as 0 on a scale from 0 to 10:
On Day 1, the client reported lower back pain, which could be associated with uterine contractions or other complications. By Day 2, the pain has resolved completely, with the client reporting a pain level of 0/10. This is a clear sign of improvement in her condition, especially since pain is often a key indicator of progress in antepartum care.
No reports of vaginal discharge:
On Day 1, the client reported pinkish vaginal discharge, which can be indicative of preterm labor or other complications. By Day 2, the absence of vaginal discharge suggests that the situation has improved, and the risk of preterm labor may be decreasing.
No uterine contractions noted:
On Day 1, the client had uterine contractions occurring every 8 minutes, which could be indicative of early labor or preterm labor. By Day 2, the absence of uterine contractions is a positive sign that the client is no longer experiencing early labor signs. This indicates that the situation is improving.
No further reports of burning with urination:
On Day 1, the client reported burning with urination, which was indicative of a urinary tract infection (UTI). On Day 2, the client no longer reports this symptom, suggesting that the urinary symptoms have resolved, and the infection may be improving, especially in light of ongoing treatment (e.g., antibiotics).
Laboratory Results Indicating Improvement:
WBC count 12,000/mm³ (Day 2) vs. 16,000/mm³ (Day 1):
The WBC count has decreased from 16,000/mm³ on Day 1 (which indicated infection or inflammation) to 12,000/mm³ on Day 2. Although the WBC count is still slightly elevated above the normal range (5,000-10,000/mm³), the decrease in WBC count suggests that the client's body is responding to treatment, and the infection or inflammation may be resolving.
Vital Signs Indicating Improvement:
Temperature 37.1° C (98.7°F) (Day 2) vs. 38.4° C (101.1°F) (Day 1):
The client’s fever has resolved, with a temperature decrease from 38.4°C (101.1°F) on Day 1 to 37.1°C (98.7°F) on Day 2. Fever is a common sign of infection, and the reduction in temperature suggests that the infection (likely a urinary tract infection) is being controlled and is improving.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Engaging the panic alarm should only be done if there is an immediate threat of violence.
B. Acknowledging the client's feelings is an appropriate de-escalation technique that shows empathy and may help calm the situation.
C. A face shield and mask are not routinely necessary unless there is a risk of bodily fluids.
D. Seclusion should be considered only when the client poses a significant threat to themselves or others.
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Explanation
The client is at risk for developing serotonin syndrome due to adverse effects of paroxetine.
Rationale
Serotonin syndrome is a potentially life-threatening condition that occurs when there is an excess of serotonin in the central nervous system, often as a result of taking certain medications, particularly selective serotonin reuptake inhibitors (SSRIs) like paroxetine.
Adverse effects of paroxetine:
The client was recently switched from fluoxetine (another SSRI) to paroxetine, and has had their dose increased from 10 mg to 30 mg. This may lead to an increase in serotonin levels, which, if excessive, could trigger serotonin syndrome. The client’s current symptoms, including restlessness, abdominal pain, disorientation, and fever, are indicative of potential serotonin syndrome, which is often accompanied by agitation, hyperreflexia, tremors, and autonomic dysregulation (e.g., fever, tachycardia, hypertension).
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