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 reflex response decreased from 4+ to 2+, demonstrating a reduction in hyperreflexia. This improvement indicates effective magnesium sulfate therapy, showing decreased neuromuscular irritability and a lower risk of progression to eclampsia.
• Blood pressure: The blood pressure declined from 166/110 mm Hg to 152/90 mm Hg, reflecting effective antihypertensive therapy and improved vascular tone. This moderate reduction suggests that labetalol and magnesium sulfate are successfully controlling severe preeclampsia symptoms.
• Heart rate: The heart rate remained within normal parameters (72–90/min) across both days, showing stable cardiac function without significant deviation. This consistency indicates no notable change in hemodynamic status related to treatment.
• Edema: The client continues to exhibit +3 pitting edema in both lower extremities, reflecting persistent fluid retention and endothelial dysfunction. This ongoing finding suggests that intravascular fluid shifts typical of preeclampsia have not yet resolved.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Beneficence: Beneficence involves promoting the well-being of clients. While both clients’ needs are important, the issue here is unequal access to resources, not the nurse’s intent to benefit them.
B. Autonomy: Autonomy relates to the client’s right to make informed decisions about their own care. The situation does not interfere with either client’s ability to make choices.
C. Nonmaleficence: Nonmaleficence means avoiding harm. Although delayed access to supplies could indirectly cause harm, the primary ethical concern is the fairness in distribution, not direct harm by action.
D. Justice: Justice involves fairness and equitable treatment. Providing supplies to one client based on insurance status while requiring the other to obtain them elsewhere reflects unequal treatment and a breach of the principle of justice.
Correct Answer is D
Explanation
Rationale:
A. "Your child can return to school 24 hours after beginning antibiotics.": Varicella (chickenpox) is a viral infection, so antibiotics are not effective unless there is a secondary bacterial infection.
B. "Your child can return to school once the fever has subsided.": Although the fever may resolve, the child remains contagious until all lesions have crusted over, so returning at this stage risks spreading infection.
C. "Your child can return to school after a negative titer result.": Titer testing is used to assess immunity, not for determining when an active infection is no longer contagious.
D. "Your child can return to school once the lesions have crusted over.": This is the correct statement because a child with varicella is contagious until all vesicular lesions have dried and crusted, usually about 5–7 days after onset.
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