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 B

Explanation

Rationale:

A. Nifedipine: Nifedipine is a calcium channel blocker that helps reduce myocardial oxygen demand by decreasing afterload and dilating coronary arteries. However, it is not the priority in acute chest pain management because it has a slower onset compared to nitroglycerin.

B. Nitroglycerin: Nitroglycerin is the priority medication for acute angina. It works rapidly by dilating coronary arteries and reducing myocardial oxygen demand, which helps relieve chest pressure and prevent progression to myocardial infarction.

C. Atenolol: Atenolol, a beta-blocker, decreases heart rate and contractility to reduce myocardial oxygen consumption. While useful for long-term angina management, it is not the first-line agent for immediate chest pain relief in acute settings.

D. Clopidogrel: Clopidogrel is an antiplatelet agent that prevents clot formation, often used in long-term management or following stent placement. It does not provide immediate relief from angina and is therefore not the priority medication in this scenario.

A. Recommend the client spend time alone in his room. B. Encourage the client to use positive self-talk C. Offer the client low-protein snacks throughout the day. D. Suggest the client exercise before going to bed.

Correct Answer is B

Explanation

Rationale:

A. Recommend the client spend time alone in his room: Isolation can worsen depressive symptoms by reducing social interaction and support. Clients with major depressive disorder benefit more from structured, supportive environments that encourage engagement.

B. Encourage the client to use positive self-talk: Promoting positive self-talk helps challenge negative thought patterns common in depression. This cognitive-behavioral strategy can improve mood, self-esteem, and overall coping ability.

C. Offer the client low-protein snacks throughout the day: Nutritional support is important, but there is no specific reason to offer low-protein snacks for depression. A balanced diet with adequate protein may better support brain function and mood regulation.

D. Suggest the client exercise before going to bed: Regular exercise is beneficial for managing depression, but exercising before bedtime can disrupt sleep patterns. Physical activity is better scheduled earlier in the day to promote restfulness at night.

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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.

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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.