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","D","F"]
Explanation
Choice A rationale
Assisting the client to the bathroom is appropriate as clonazepam can cause dizziness and unsteadiness, increasing the risk of falls.
Choice B rationale
Having an opioid agonist at the bedside is not necessary for a client starting clonazepam. Clonazepam is a benzodiazepine, not an opioid.
Choice C rationale
Providing oral care at least twice a day is generally good practice for all patients, but it’s not specifically related to clonazepam use.
Choice D rationale
Assessing mental status regularly is crucial as clonazepam can cause changes in mood and behavior.
Choice E rationale
Monitoring calcium levels is not typically required for a client starting clonazepam.
Choice F rationale
Screening for orthostatic hypotension is important as clonazepam can lower blood pressure, leading to dizziness and fainting when the client stands up.
Correct Answer is D
Explanation
Choice D rationale
In a patient with severe ulcerative colitis who has undergone surgery for a fistula repair, replacing fluids IV based on intake and output is the most important intervention to include in the plan of care. This is because patients with ulcerative colitis often experience significant fluid and electrolyte imbalances due to diarrhea and other gastrointestinal losses. Following surgery, these imbalances can be further exacerbated by factors such as fasting, surgical stress, and the use of certain medications. Therefore, careful monitoring of fluid and electrolyte balance, and appropriate IV fluid replacement, is crucial to prevent complications such as dehydration, electrolyte imbalances, and renal dysfunction.
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