The patient is resting in bed and cooperative with her mother at her bedside.
Which of the following assessments were made?

Neurological: Agitation. Oriented x. Dizziness. Pupils equal and reactive to light.

Cardiovascular: Bradycardia. Bilateral radial pulses weak. Capillary refill 2 seconds. No lower leg edema noted.

Respiratory: Clear breath sounds.

Gastrointestinal: Last reported bowel movement 4 days ago.

Answer and Explanation

Correct Answer : C

Choice A rationale

The patient is resting and cooperative, which indicates a calm and alert state, not agitation. Orientation x means the patient is aware of person, place, time, and situation, which is a normal finding. Dizziness is not mentioned in the patient’s condition. Pupils being equal and reactive to light is a normal finding and does not indicate a neurological issue.

Choice B rationale

Bradycardia refers to a slower than normal heart rate, which is not mentioned in the patient’s condition. Weak bilateral radial pulses could indicate poor blood circulation, but this is not mentioned in the patient’s condition. Capillary refill of 2 seconds is a normal finding. The absence of lower leg edema is a normal finding and does not indicate a cardiovascular issue.

Choice C rationale

Clear breath sounds are a normal finding and indicate that the patient’s lungs are free of obstructions or fluid.

Choice D rationale

The last reported bowel movement being 4 days ago could indicate constipation, but this is not mentioned in the patient’s condition.

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Correct Answer is ["A","B","C","D","F"]

Explanation

A.Bone misalignment- The nurse’s notes mention that the collarbone appears out of alignment on the left side. This could indicate a fracture or dislocation and should be investigated further.

B.Decreased range of motion- The client reports an inability to move his left arm. This could be due to the pain or a result of the injury and should be investigated further.

C.Left arm that is cool to touch- Decreased temperature in a limb can indicate poor circulation, which could be a result of the injury. This should be investigated further.

D.Swelling at the site of injury- Swelling and bruising are present on the client’s shoulder. This is a common sign of injury and should be investigated further.

E.Blood pressure of 136/90 mm Hg- While this blood pressure is not extremely high, it is on the higher end of normal. Given the client’s age and the stress of the situation, it would be worth monitoring.

F.Intense pain reported by client- The client reports a pain rating of 10 on a 0 to 10 scale in the left arm. This level of pain is concerning and should be addressed.

G.Oxygen saturation 95% on room air- While an oxygen saturation of 95% is within the normal range, given the client’s recent trauma and reported nausea, it would be prudent to monitor this closely.

A. Remember exercise will not affect blood glucose levels. B. Include no more than 1-2 alcoholic beverages in diet per day. C. Keep any wounds covered with an antibiotic ointment. D. Soak feet daily in hot water no longer than 10 minutes.

Correct Answer is B

Explanation

Choice A rationale

Exercise is an important part of managing type 2 diabetes as it helps regulate blood glucose levels. When you exercise, your muscles use sugar (glucose) for energy. Regular physical activity also helps your body use insulin more efficiently. Therefore, the statement “Remember exercise will not affect blood glucose levels” is incorrect.

Choice B rationale

Moderate alcohol consumption is generally safe for most people with diabetes. A moderate amount of alcohol is up to one drink a day for women of all ages and men older than age 65, and up to two drinks a day for men age 65 and younger. Too much alcohol can cause blood sugar levels to drop too low and can also increase the risk of other health problems.

Choice C rationale

While it’s important to keep wounds clean and covered, using antibiotic ointment on every wound isn’t always necessary. Overuse of antibiotics can lead to antibiotic resistance. It’s best to consult with a healthcare provider for wound care advice.

Choice D rationale

Soaking feet in hot water can lead to burns or infections, especially if the person has neuropathy. It’s recommended to wash feet with warm — not hot — water and dry them gently, especially between the toes.

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The patient is resting in bed and cooperative with her mother at her bedside. Which of the following assessments were made?

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Naxlex Comprehensive Predictor Exams

Exhibits The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

Correct Answer is ["A","B","C","D","F"]

Explanation

The nurse is providing teaching to a client with type 2 diabetes mellitus about important points for disease and symptom management.Which response by the client indicates understanding?

Correct Answer is B

Explanation

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The patient is resting in bed and cooperative with her mother at her bedside.
Which of the following assessments were made?