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. Ibuprofen is not recommended during pregnancy, particularly in the third trimester, due to potential risks to the fetus.
B. Testing the baby’s cord blood is not a standard method to detect HSV transmission.
C. Cortisone cream is not typically used to treat HSV lesions.
D. Cesarean birth is recommended if there are active lesions at the time of labor to prevent neonatal transmission.
Correct Answer is C
Explanation
A. Widened pulse pressure (not narrowed) is associated with increased ICP.
B. Bradycardia (not tachycardia) is commonly seen in increased ICP due to Cushing’s triad.
C. An increasingly severe headache is a key sign of rising ICP due to increased pressure on pain-sensitive structures.
D. Hypertension, not hypotension, is a characteristic of increased ICP.
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