Nokea
The experienced LPN/LVN reports that a client's blood pressure and heart rate have decreased and that when the face is assessed, one side twitches. What action should you take at this time?
- A. Reassess the client’s blood pressure and heart rate
- B. Review the client's morning calcium level
- C. Request a neurologic consult today
- D. Check the client's pupillary reaction to light
Correct Answer: B
Rationale: Decreased blood pressure and heart rate along with facial twitching could indicate hypocalcemia. Reviewing the morning calcium level will confirm if this is the cause of the symptoms.
You may also like to solve these questions
During an admission assessment of a client with COPD and emphysema complaining of a frequent productive cough and shortness of breath, what assessment finding should the nurse anticipate?
- A. Respiratory alkalosis
- B. Increased anteroposterior diameter of the chest
- C. Oxygen saturation level 96%
- D. Petechiae on chest
Correct Answer: B
Rationale: The correct answer is B: Increased anteroposterior diameter of the chest. In COPD and emphysema, the lungs lose their elasticity, causing the chest to become barrel-shaped with an increased anteroposterior diameter. This occurs due to hyperinflation of the lungs. This finding is known as "barrel chest" and is a classic sign of advanced COPD.
A: Respiratory alkalosis is not typically associated with COPD and emphysema.
C: An oxygen saturation level of 96% is within the normal range and does not specifically relate to the assessment findings in COPD and emphysema.
D: Petechiae on the chest are not typically associated with COPD and emphysema; they may be indicative of other conditions such as bleeding disorders.
Systolic hypertension and stroke are due to:
- A. Increased vascular stiffness related to structural changes
- B. Loss of peripheral vascular tone
- C. Buildup of soft plaque within the veins
- D. Changes within the basement membrane
Correct Answer: A
Rationale: As people age, arteries lose elasticity and become stiffer, leading to increased systolic blood pressure and higher risk of stroke.
The physician tells the patient that there will be an initial course of treatment with continued maintenance treatments and ongoing observation for signs and symptoms over a prolonged period of time. You can help the patient by reinforcing that the primary goal for this type of treatment is:
- A. Cure.
- B. Control.
- C. Palliation.
- D. Permanent remission.
Correct Answer: B
Rationale: The described treatment plan focuses on controlling the disease progression rather than achieving a cure or palliation, given the long-term nature of the intervention.
What is primarily a developmental task of middle age?
- A. Learning and acquiring new skills and information.
- B. Rediscovering or developing satisfaction in one's relationship with a significant other.
- C. Relying strongly upon spiritual beliefs.
- D. Risk-taking and its perceived consequences.
Correct Answer: B
Rationale: Middle age often involves re-evaluating personal relationships.
Which patient is ready for discharge from Phase I PACU care to the clinical unit?
- A. Arouses easily, pulse is 112 bpm, respiratory rate is 24, dressing is saturated, SaO2 is 88%
- B. Difficult to arouse, pulse is 52, respiratory rate is 22, dressing is dry and intact, SaO2 is 91%
- C. Awake, vital signs stable, dressing is dry and intact, no respiratory depression, SaO2 is 92%
- D. Arouses, blood pressure (BP) higher than preoperative and respiratory rate is 10, no excess bleeding, SaO2 is 90%
Correct Answer: C
Rationale: Stable vital signs, intact dressing, and adequate oxygenation indicate readiness for transfer.