Difficulty: Medium
Average Score: 92%
Simulated
Passage / Scenario
Nurses' NotesHistory and Physical
Vital Signs
Physical Examination Results
5 weeks ago:
The client reports experiencing persistent insomnia and anxiety. She has been feeling increasingly restless and has lost weight despite having an increased appetite. Her skin is warm and moist. Speech is rapid, and she seems anxious and fidgety during the assessment. She denies any abdominal discomfort or issues with digestion. Lung sounds are clear to auscultation, and her abdomen is soft with normoactive bowel sounds. The client was instructed to undergo lab work and return for follow-up in 4 weeks.
Today:
The client reports some improvement but still experiences occasional anxiety. She states she has been sleeping better for the past week and her appetite remains unchanged. The nurse notes her skin is warm but now dry. Her lung sounds are clear, and her abdomen remains soft and non-tender with normoactive bowel sounds. The client expresses that she still feels anxious at times but believes her symptoms are improving.
Select the 4 findings that indicate an improvement in the client's condition.
Correct answer
B,C,D,E
Rationale
To determine an improvement in the client's condition, we should look for positive changes in various aspects. Mood is a good indicator as an improved mood often reflects better overall well-being. Weight (C) can indicate positive changes in health status, especially if the client was underweight or overweight previously. A stable or improved sleep pattern (D) is crucial for recovery and indicates progress. Heart rate (E) can show improvements in cardiovascular health. Abdominal findings (F) may not necessarily indicate a general improvement in the client's condition. Temperature (A) can fluctuate for various reasons and is not a reliable indicator of overall improvement. Thus, the correct choices are B, C, D, and E to measure positive changes in the client's condition. [0,1,1,1,1,0]