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 C

Explanation

Choice A rationale

While a headache with sudden onset can be a symptom of various conditions, it is not the most critical finding to report in a client with atrial fibrillation and a rapid ventricular rate.

Choice B rationale

Flat jugular vein distention (JVD) at 45 degrees is not the most critical finding to report in a client with atrial fibrillation and a rapid ventricular rate.

Choice C rationale

An abnormal level of consciousness can be a sign of decreased cerebral perfusion, which can occur in a client with atrial fibrillation and a rapid ventricular rate. This is a critical finding that should be reported to the healthcare provider immediately.

Choice D rationale

Nausea with vomiting is not the most critical finding to report in a client with atrial fibrillation and a rapid ventricular rate.

A. Resume normal physical activity. B. Administer a dose of regular insulin as prescribed. C. Consume electrolyte fluid replacements. D. Monitor urine output over the next 24 hours.

Correct Answer is B

Explanation

Choice A rationale

Resuming normal physical activity is not the appropriate action when a patient with type 1 diabetes mellitus experiences increased thirst, an early sign of Diabetic Ketoacidosis (DKA). Physical activity can increase blood glucose levels, which could exacerbate the condition.

Choice B rationale

Administering a dose of regular insulin as prescribed is the most appropriate action to address increased thirst in a patient with type 1 diabetes and early signs of DKA. Elevated blood sugar levels are the cause of the increased thirst, and insulin helps lower blood sugar levels.

Choice C rationale

Consuming electrolyte fluid replacements is not the appropriate action when a patient with type 1 diabetes mellitus experiences increased thirst, an early sign of DKA. While hydration is important, it does not address the underlying issue of high blood sugar levels.

Choice D rationale

Monitoring urine output over the next 24 hours is not the appropriate action when a patient with type 1 diabetes mellitus experiences increased thirst, an early sign of DKA. While it is important to monitor urine output in patients with diabetes, it does not address the underlying issue of high blood sugar levels.

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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

A client has developed atrial fibrillation with a ventricular rate of 150 beats/minute observed via telemetry.The client’s blood pressure is 80/40 mm Hg. Which finding is most important for the nurse to report to the healthcare provider?

Correct Answer is C

Explanation

When educating a patient newly diagnosed with type 1 diabetes mellitus, the nurse explains that increased thirst is an early sign of Diabetic Ketoacidosis (DKA). What action should the nurse advise the patient to take if this sign of DKA appears?

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?