The nurse is reviewing the patient's record. Select to highlight the findings that demonstrate that the patient is improving.
1430: Nurses' Note: Urine output 50 mL/hr dark amber color. Continues to be lethargic.
1430: Vital Signs: Temp 100.4°F (37.8°C) HR 110 bpm: regular RR 24 breaths/min: rapid, deep SpO2 98% on room air BP 94/56 mm Hg
1430: Labs: Glucose 460 mg/dl
HR 110 bpm
regular RR 24 breaths/min
BP 94/56 mm Hg
Glucose 460 mg/dl
The Correct Answer is ["A","B","C","D"]
HR: 110 bpm; regular - The heart rate has decreased from 115 bpm and is now regular, suggesting improved cardiac rhythm stability.
RR: 24 breaths/min; rapid, deep - The respiratory rate has decreased from 26 breaths/min, indicating less rapid breathing.
BP: 94/56 mm Hg - While the blood pressure remains relatively low, there is a slight improvement compared to the previous reading.
Glucose 460 mg/dl - The glucose level has decreased from 525 mg/dL and 530 mg/dL in previous readings. While still elevated, this indicates some improvement in hyperglycemia.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B. Severe upper abdominal pain is a hallmark symptom of gastrointestinal perforation. Perforation can lead to the leakage of gastric contents into the peritoneal cavity, causing intense, sharp pain in the upper abdomen. The pain may be sudden and severe and can radiate to the back or shoulders.
A. Bradycardia, or a slow heart rate, is not typically associated with gastrointestinal perforation. Instead, tachycardia (rapid heart rate) is more commonly observed due to the body's response to shock or inflammation caused by perforation.
C. Hyperactive bowel sounds are more commonly associated with conditions such as gastroenteritis or bowel obstruction. In the case of gastrointestinal perforation, bowel sounds may initially be normal but can eventually become absent due to peritoneal irritation and subsequent paralytic ileus.
D. Epigastric fullness may be present in peptic ulcer disease but is not a specific manifestation of gastrointestinal perforation. Perforation is more likely to present with severe, acute pain rather than a sensation of fullness.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"},"F":{"answers":"A"},"G":{"answers":"B"},"H":{"answers":"A"}}
Explanation
Hypoglycemia
Tremor is a common symptom of hypoglycemia, as low blood sugar levels can lead to shaky hands and trembling.
Seizures can occur in severe cases of hypoglycemia when the brain is deprived of glucose, leading to abnormal electrical activity and convulsions.
Sweating, particularly cold and clammy skin, is a common symptom of hypoglycemia as the body responds to low blood sugar levels.
Hunger or sudden feelings of extreme hunger are common symptoms of hypoglycemia as the body seeks additional fuel to raise blood sugar levels.
Hyperglycemia
Lethargy, or extreme fatigue and drowsiness, is more commonly associated with hyperglycemia, as elevated blood sugar levels can affect energy levels and lead to feelings of sluggishness.
Polydipsia is a classic symptom of hyperglycemia, as high blood sugar levels can cause dehydration and trigger the body's thirst response.
Abdominal pain is more commonly associated with hyperglycemia, particularly in conditions like diabetic ketoacidosis (DKA), where abdominal discomfort can be a sign of metabolic disturbances.
Polyuria is a classic symptom of hyperglycemia, as high blood sugar levels can lead to increased urine production as the kidneys work to remove excess glucose from the bloodstream.
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