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 D
Explanation
A. "Keep your feet together to provide a tight base of support": Incorrect. Keeping feet together reduces stability; a wide base of support is recommended.
B. "Keep objects away from your center of gravity while lifting": Incorrect. Objects should be kept close to the center of gravity to reduce strain.
C. "Bend at the waist when lifting objects from the floor": Incorrect. Bending at the knees, not the waist, is the correct technique to prevent back injury.
D. "Tighten abdominal muscles to improve balance": Tightening the abdominal muscles provides core stability and reduces the risk of injury when lifting.
Correct Answer is A
Explanation
A. Ensuring the client has an alert system addresses immediate safety and the risk of falls, which is a priority for a client with mobility impairments.
B. Support groups are beneficial for emotional support but are secondary to physical safety.
C. Transportation resources are important but do not address the urgent need for fall prevention.
D. Home physical therapy is important for recovery but does not immediately ensure the client's safety.
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