The nurse is collecting data on the client on the morning of day 2.

Exhibits
Which of the following data collection findings indicate an improvement in the client's condition? Select the 4 findings that indicate an improvement.

Orientation

Blood pressure

Temperature

WBC count

Hallucinations

Answer and Explanation

Correct Answer : A,B,C,E

Rationale:

• Orientation: The client was previously disoriented to time and place, thinking it was 1975 and they were at home. On Day 2, they are alert and fully oriented. This improvement shows enhanced neurological and cognitive status.

• Blood pressure: On Day 1, the client’s BP was 88/50 mm Hg, which indicated hypotension. By Day 2, the BP improved to 132/86 mm Hg. This indicates stabilization of cardiovascular function and better perfusion.

• Temperature: The fever rose to 39.1°C on Day 1 but decreased to 37.7°C on Day 2. This drop suggests the client is responding to treatment and the infectious process is being controlled.

• Hallucinations: On Day 1, the client reported spiders crawling on them, indicating delirium. On Day 2, they deny hallucinations. This improvement shows resolving infection or neuroinflammation.

• WBC count: The WBC count of 14,000/mm³ remains elevated above the normal range and was only assessed on Day 1. Without follow-up labs, it does not indicate improvement.

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Correct Answer is C

Explanation

Rationale:

A. Prescribed epoetin V: Epoetin is used to stimulate red blood cell production, typically for anemia related to chronic kidney disease or chemotherapy. It is not a standard treatment for pernicious anemia and does not directly increase the client’s injury risk in this context.

B. Sleeps 8 to 10 hr per night: Sleeping 8 to 10 hours is within the normal range for many adults, particularly those recovering from fatigue associated with anemia. This finding does not pose any additional risk for injury.

C. Uses a firm-bristled toothbrush: A firm-bristled toothbrush can cause gum irritation or bleeding, especially in clients with anemia who may have fragile oral mucosa or concurrent thrombocytopenia. This increases the risk of oral injury or infection and should be avoided.

D. Prescribed vitamin B IM: Vitamin B12 IM injections are the standard treatment for pernicious anemia due to impaired intrinsic factor and poor absorption. This intervention helps correct the deficiency and prevent neurologic complications, not increase injury risk.

A. Direct questions to the interpreter. B. Ask the client for regular feedback. C. Incorporate acronyms into client teaching D. Ask the client's family member to interpret.

Correct Answer is B

Explanation

Rationale:

A. Direct questions to the interpreter: Communication should be directed to the client, not the interpreter. Speaking directly to the client fosters rapport and respects their autonomy, while the interpreter facilitates understanding.

B. Ask the client for regular feedback: Checking in frequently with the client ensures they understand the information being conveyed. This helps clarify misunderstandings and confirms effective communication through the interpreter.

C. Incorporate acronyms into client teaching: Using acronyms can confuse clients, especially those with limited English proficiency or unfamiliarity with medical terminology. Clear, simple language without jargon is preferred.

D. Ask the client's family member to interpret: Family members may lack medical terminology knowledge, may filter information, or breach confidentiality. Professional interpreters provide more accurate and unbiased communication.

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The nurse is collecting data on the client on the morning of day 2. Exhibits Which of the following data collection findings indicate an improvement in the client's condition? Select the 4 findings that indicate an improvement.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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The nurse is collecting data on the client on the morning of day 2.

Exhibits
Which of the following data collection findings indicate an improvement in the client's condition? Select the 4 findings that indicate an improvement.