The nurse continues to care for the client.
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. FHR baseline 138, minimal variability. No further reports of burning with urination. |
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Laboratory Results |
WBC 12,000/mm3 (5000 to 10000/mm3) Platelet count 188000/mm3 (150000 to 400000/mm3) |
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Vital Signs |
Temperature 37.1oC (98.7 oF) Blood pressure 120/78 mmHg |
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
FHR baseline 138, minimal variability
No further reports of burning with urination
WBC 12,000/mm3 (5000 to 10000/mm3)
Platelet count 188000/mm3 (150000 to 400000/mm3)
Temperature 37.1oC (98.7 oF)
Blood pressure 120/78 mmHg
The Correct Answer is ["A","C","E","F","H","I"]
Nurses' Notes:
Client rates lower back pain a 0 on a scale from 0 to 10: Indicates pain resolution, suggesting improvement.
No reports of vaginal discharge: Suggests stabilization and no signs of labor progression.
No uterine contractions noted: Indicates that preterm labor is resolving.
No further reports of burning with urination: Suggests that the urinary tract infection (UTI) is improving.
Vital Signs:
Temperature 37.1°C (98.7°F): Fever has resolved, indicating response to antibiotics.
Blood pressure 120/78 mmHg: Remains stable within normal limits.
Laboratory Results:
WBC 12,000/mm³ (previously 16,000/mm³): Decreasing WBC count suggests resolution of infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Incorrect – A 24-hour fluid deficit of 30 mL is mild and does not require immediate intervention.
B. Incorrect – Decreased appetite and irritability are common with gastroenteritis but not as concerning as dehydration.
C. Incorrect – A temperature of 38°C (100.4°F) and pulse of 124/min are mild and expected with infection.
D. Correct – Sunken fontanels and dry mucous membranes are signs of dehydration, which is a major concern in gastroenteritis. Severe dehydration can lead to hypovolemic shock.
Correct Answer is C
Explanation
A. Simply stating that caring for a terminally ill person is difficult does not offer support or a solution.
B. Reassuring the son that he is doing a great job does not address his exhaustion or offer assistance.
C. Offering respite care helps relieve caregiver burden by providing temporary relief, allowing the son to rest.
D. Recommending a sleeping pill does not address the underlying caregiver fatigue and might not be appropriate without medical evaluation.
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