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 B

Explanation

Choice A rationale

Initiating bilateral intermittent sequential pneumatic compression devices is not the most appropriate immediate intervention for a patient showing signs of a possible stroke. These devices are typically used to prevent deep vein thrombosis in patients who are immobile, not for stroke management.

Choice B rationale

Raising the head of the bed to 30 degrees and keeping the head and neck in neutral alignment is the correct intervention. This position can help reduce intracranial pressure and facilitate venous drainage. In the case of a suspected stroke, it’s crucial to maintain proper cerebral blood flow.

Choice C rationale

Maintaining elevated positioning of the dependent joints on the affected side is not the immediate priority in stroke management. While it’s important to prevent contractures and maintain functional positioning, the immediate concern is to stabilize the patient’s condition.

Choice D rationale

Obtaining a focused history to determine recent bleeding and use of anticoagulants is important, but it’s not the first intervention. While this information will be necessary for the healthcare provider to determine the appropriate course of treatment, the immediate priority is to manage the patient’s acute symptoms.

A. She has mild subcostal retraction B. sitting in an upright position C. Wheezes are noted throughout the lung fields D. The client is pale E. Her heart rate is 122 beats/minute F. Oxygen saturation is 91% on room air G. strong peripheral pulses that are equal bilaterally H. client is admitted to the medical floor I. blood pressure 134/85 mm Hg

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

Explanation

The assessment findings that require immediate follow up by the nurse are: The client has mild subcostal retractions. This could indicate that she is using accessory muscles to breathe, which is a sign of respiratory distress. The client is sitting in an upright position. This is a common position for people who are having difficulty breathing because it allows for maximum expansion of the lungs. Wheezes are noted throughout the lung fields. Wheezing can be a sign of an obstructive process such as asthma. The client is pale. Paleness can be a sign of decreased oxygenation. Her heart rate is 122 beats/minute, which is above the normal range and can indicate that her body is working harder to get oxygen. Her oxygen saturation is 91% on room air. Normal oxygen saturation is generally 95% or higher, so this could indicate that she is not getting enough oxygen.

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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

Correct Answer is B

Explanation

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

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?