Exhibits
The nurse is reviewing the client's medical record. Which of the following findings indicates the client's condition has improved? Select all that apply.
Echocardiogram results
Blood pressure
Urinary output
Pain level
Respiratory rate
Heart rate
Oxygenation saturation
Correct Answer : B,D,E,F,G
Echocardiogram results would provide information about the structure and function of the heart, particularly regarding any changes in cardiac function or wall motion abnormalities that might have been detected during the acute phase. It does indicate signs of improvement.
B. Blood pressure is an important vital sign that reflects cardiovascular status. In the context of acute coronary syndrome or myocardial infarction, a stable or improving blood pressure indicates adequate perfusion to vital organs, including the heart. A decrease in blood pressure from hypertensive levels seen earlier could indicate stabilization of the client's condition.
C. Urinary output is a critical indicator of renal perfusion and function. During acute illness, including cardiac events, decreased urinary output can indicate poor perfusion due to decreased cardiac output or hypoperfusion. In this scenario the output is still inadequate.
D. Pain level, specifically chest pain in the context of acute coronary syndrome, is a subjective indicator of the client's cardiac status. A reduction in pain intensity, as reported by the client, can indicate that the treatment, such as nitroglycerin for angina, is effective in relieving myocardial ischemia. Therefore, a decrease in pain level suggests improvement in the client's cardiac condition.
E. Respiratory rate is another vital sign that reflects the client's respiratory effort and overall respiratory status. In the context of acute cardiac events, respiratory rate can increase due to pain, anxiety, or respiratory distress. A decrease in respiratory rate suggests improved respiratory comfort and potentially reduced cardiac workload, indicating improvement in the client's condition.
F. Heart rate is a crucial vital sign that reflects cardiac workload and rhythm. In acute coronary syndrome, tachycardia is often present due to sympathetic stimulation and the body's response to myocardial ischemia. A decrease in heart rate suggests that the client's cardiac workload has decreased, possibly indicating improved myocardial perfusion and stability.
G. Oxygen saturation reflects the amount of oxygen bound to hemoglobin in the blood, which is essential for tissue oxygenation. In acute cardiac events, hypoxemia can occur due to impaired cardiac function or respiratory compromise. Improvement in oxygen saturation indicates improved tissue oxygenation, possibly due to effective management of cardiac function or respiratory support.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. An oral airway is a device used to maintain a patent airway by preventing the tongue from obstructing the throat. It can be useful during or after a seizure to ensure the client can breathe effectively and to prevent airway obstruction due to tongue relaxation or loss of muscle tone.
A Wrist restraints are used to immobilize a client's wrists and are not typically indicated for seizure management. Restraining a client during a seizure can increase the risk of injury and hinder appropriate assessment and care
B. Nasogastric (NG) tubes are used for enteral feeding, medication administration, or gastric decompression. They are not directly related to managing seizures and are not typically required during or after a seizure episode. Therefore, an NG tube is not necessary in the client's room for seizure management.
C. Tongue blades are used to depress the tongue for examination of the mouth and throat, but they are not recommended during or immediately after a seizure. There is a common misconception that placing a tongue blade in the mouth prevents the tongue from being bitten during a seizure, but this can actually cause more harm, such as injury to the teeth or gums, during involuntary movements.
Correct Answer is D,B,A,C
Explanation
Step D (Place the client in an upright sitting position): Elevating the client's head and upper body to an upright position helps to reduce blood pressure by promoting venous pooling in the lower extremities.
Step B (Confirm that the client's bladder is empty): Autonomic dysreflexia is often triggered by bladder distention or urinary retention. By confirming and addressing urinary issues promptly, the nurse can remove the triggering stimulus.
Step A (Administer an antihypertensive medication intravenously): In severe cases where blood pressure remains dangerously high despite other interventions, such as positioning and addressing bladder issues, antihypertensive medications may be necessary to lower blood pressure quickly and prevent complications.
Step C (Indicate the risk for autonomic dysreflexia in the client's medical record): Documentation of the occurrence of autonomic dysreflexia, its triggers, and interventions used is essential for continuity of care. It informs other healthcare providers about the client's condition and helps in implementing preventive strategies.
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