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.
Heart rate
Blood pressure
Edema
Deep tendon reflexes
The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"}}
|
Finding |
Improved |
Not changed |
|
Heart rate |
|
✓ |
|
Blood pressure |
✓ |
|
|
Edema |
✓ |
|
|
Deep tendon reflexes |
✓ |
|
Rationale
- Heart rate: Not changed
- The heart rate increased from 72/min to 90/min, indicating no improvement.
- Blood pressure: Improved
- The blood pressure decreased from 166/110 mm Hg to 152/90 mm Hg, indicating improvement.
- Edema: Improved
- The edema decreased from +3 pitting to +2 pitting, indicating improvement.
- Deep tendon reflexes: Improved
- The patellar reflex decreased from 4+ to 2+, indicating improvement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Hypotension is a concern but may occur for various reasons and is not as immediately life-threatening as dyspnea.
B. Tachycardia can indicate a problem but is less urgent than respiratory distress.
C. Dyspnea is the priority as it may indicate a recurrence of pulmonary embolism or another life-threatening respiratory issue.
D. A dry cough is a less urgent symptom and does not require immediate reporting.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"D"}
Explanation
Rheumatoid arthritis: The client's symptoms of bilateral wrist and shoulder stiffness, fatigue, and loss of appetite, along with a positive ANA test and elevated ESR, are indicative of rheumatoid arthritis.
ESR level: The elevated ESR levels (21 mm/hr and 22 mm/hr) suggest inflammation, which is a common marker for rheumatoid arthritis.
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