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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Taking prescribed cortisone accurately is crucial for managing multiple sclerosis symptoms. Cortisone is a type of steroid that can reduce inflammation and suppress the immune system, helping to manage MS symptoms.
Choice B rationale
Using a walker when weakness occurs can be beneficial for patients with multiple sclerosis as it can help them maintain mobility and independence. However, it is not the most important instruction for the nurse to include in the discharge teaching plan.
Choice C rationale
Increasing daily intake of sodium in the diet is not recommended for patients with multiple sclerosis. High sodium intake can exacerbate symptoms of multiple sclerosis and may increase the risk of relapses.
Choice D rationale
Avoiding extreme environmental temperatures can be beneficial for patients with multiple sclerosis as heat can worsen symptoms. However, it is not the most important instruction for the nurse to include in the discharge teaching plan.
Correct Answer is D
Explanation
Choice A rationale
While it’s true that many contraceptives can help prevent certain sexually transmitted infections (STIs), they are not 100% effective. Condoms, for instance, can reduce the risk of STIs that are spread through bodily fluids, such as gonorrhea and chlamydia. However, they are less effective at protecting against STIs that are transmitted through skin-to-skin contact, such as herpes and human papillomavirus (HPV)1.
Choice B rationale
Not all STIs are transmitted through sexual intercourse. Some STIs, such as herpes and HPV, can be spread through skin-to-skin contact. Others, like HIV and hepatitis B and C, can also be spread through sharing needles or from mother to child during childbirth.
Choice C rationale
Safe sex practices can significantly reduce, but not completely remove, the risk of STIs. These practices include using condoms correctly every time you have sex, getting tested regularly for STIs, and limiting the number of sexual partners.
Choice D rationale
Reinfections can indeed occur from having sex with untreated partners. This is particularly true for bacterial STIs like syphilis. If a person’s partner is not treated, the bacteria can remain in their body and they can pass the infection back to the person after they’ve been treated.
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