The nurse is continuing to care for the client.
A nurse is evaluating the client's response to therapy. Which of the following recent findings indicate the client's condition has improved or not changed?
For each assessment finding, click to specify if the finding indicates that the client's condition has improved or has not changed.
Deep tendon patellar reflex
Heart rate
Blood pressure
Edema
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"}}
Rationale:
• Deep tendon patellar reflex: The client’s patellar reflex decreased from 4+ on day 1 to 2+ on day 2, indicating reduced hyperreflexia. This suggests a positive response to antihypertensive and preeclampsia management, lowering the risk for complications such as eclampsia or seizures.
• Heart rate: The client’s heart rate increased slightly from 84/min on day 1 to 90/min on day 2, which falls within a normal physiologic range and does not indicate significant improvement or deterioration. This shows that cardiovascular status has remained relatively stable.
• Blood pressure: Blood pressure decreased from severely elevated readings (162/112 mm Hg and 166/110 mm Hg) to 152/90 mm Hg, reflecting a partial response to antihypertensive therapy. Although still above normal, the downward trend indicates some improvement in maternal hemodynamic status.
• Edema: The client continues to have +3 pitting edema in bilateral lower extremities, which has not improved since the previous day. Persistent edema suggests that fluid balance and vascular permeability issues related to preeclampsia remain a concern and require ongoing monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Check the medication label twice before administering it: Verifying the label is an essential safety step, but it does not provide the nurse with information about the medication’s purpose, dosage, administration route, or potential side effects. This action alone is insufficient when unfamiliar with a drug.
B. Review the client's medication reconciliation record: Reviewing the reconciliation ensures the medication aligns with the client’s current prescriptions, but it does not provide information about how to safely administer a medication the nurse does not know.
C. Draw up the medication dose and ask the charge nurse to administer it: Delegating administration without first understanding the medication compromises client safety and violates the nurse’s responsibility to ensure safe administration. The nurse must gain knowledge before handling the medication.
D. Use a medication reference book to look up the medication: Consulting a reputable medication reference allows the nurse to obtain critical information about indications, dosage, side effects, contraindications, and administration guidelines. This step ensures safe and informed medication administration.
Correct Answer is D
Explanation
A. Heart rate 98/min: A heart rate of 98 beats per minute is within normal limits (60–100/min) for adults. While it is at the upper end of normal, it does not typically require urgent reporting or intervention.
B. Widened P wave: A widened P wave may indicate atrial enlargement or conduction delay, which is important to note, but it is not immediately life-threatening. It should be documented and monitored, but it does not necessitate urgent notification.
C. 2 PVCs/min: Occasional premature ventricular contractions (PVCs) can occur in healthy individuals or as a response to stress, caffeine, or electrolyte imbalances. Two PVCs per minute is usually not critical unless associated with symptoms or patterns like couplets or runs of ventricular tachycardia.
D. S-T segment elevations: ST-segment elevation is a significant finding that can indicate acute myocardial injury or infarction. This is a medical emergency requiring immediate notification of the provider for rapid assessment, intervention, and potential reperfusion therapy.
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