A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority?

Social relationship with peers

Plans for attending school while pregnant

Understanding of infant care

Current nutritional status

Answer and Explanation

The Correct Answer is D

Rationale:

A. Social relationship with peers: Evaluating peer relationships helps determine the client’s emotional support system, which can influence stress levels and coping during pregnancy. However, this assessment does not pose an immediate impact on the physiologic wellbeing of the mother or fetus. It becomes more relevant after ensuring that no urgent health concerns are present.

B. Plans for attending school while pregnant: Exploring educational plans is important for long-term stability and preventing adverse socioeconomic outcomes. Although valuable for overall wellbeing, it is not an immediate safety concern. Educational planning should be addressed after assessing the pregnancy for factors that directly affect maternal–fetal health.

C. Understanding of infant care: Assessing knowledge of infant care helps identify educational needs before delivery and supports better neonatal outcomes. However, this is a future-oriented consideration and does not address the adolescent’s immediate health status. It becomes appropriate once urgent physiologic needs are evaluated.

D. Current nutritional status: Adolescents already have increased nutritional requirements for their own growth, and pregnancy further elevates these demands. Poor nutrition can lead to anemia, low birth weight, preterm birth, and delayed fetal growth, making it a priority assessment. Ensuring adequate maternal nutrition directly influences fetal development and reduces preventable complications.

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Correct Answer is ["B","D","E"]

Explanation

Rationale:

A. Magnesium sulfate: Magnesium sulfate does not have significant interactions with warfarin and is not contraindicated. It can be safely administered with appropriate monitoring, making it safe in this context.

B. Ibuprofen: Ibuprofen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding when taken with warfarin. It inhibits platelet function and can potentiate anticoagulation, making it contraindicated.

C. Cetirizine: Cetirizine is an antihistamine that does not significantly affect coagulation or interact with warfarin. It can be safely used with warfarin under normal circumstances.

D. Gingko biloba: Gingko biloba can increase the risk of bleeding by inhibiting platelet aggregation. Clients on warfarin should avoid herbal supplements like gingko that can potentiate anticoagulation effects.

E. Aspirin: Aspirin has antiplatelet effects and can significantly increase the risk of bleeding when combined with warfarin. Concurrent use is generally contraindicated unless specifically approved and closely monitored by the provider.

A. Suction the client every 2 hr. B. Maintain ICP at 20 mm Hg C. Avoid overstimulation of the client. D. Keep the client in a supine position.

Correct Answer is C

Explanation

Rationale:

A. Suction the client every 2 hr: Frequent suctioning can increase intracranial pressure due to stimulation of the airway and coughing reflex. Suctioning should be performed only when necessary and with careful monitoring of ICP, rather than routinely every 2 hours.

B. Maintain ICP at 20 mm Hg: Normal ICP ranges from 5 to 15 mm Hg. An ICP of 20 mm Hg or higher indicates increased intracranial pressure and requires intervention. Planning to maintain ICP at this elevated level is unsafe and not appropriate for care planning.

C. Avoid overstimulation of the client: Minimizing noise, unnecessary procedures, and environmental stimuli helps prevent spikes in ICP. Overstimulation can increase cerebral metabolic demand and worsen intracranial hypertension, so this intervention supports ICP management and neurologic stability.

D. Keep the client in a supine position: Supine positioning can impair venous drainage from the brain, potentially increasing ICP. Elevating the head of the bed to 30 degrees while maintaining spinal precautions is preferred to promote venous outflow and reduce intracranial pressure.

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A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new prescription for warfarin. When reviewing the client's current medications, which of the following medications should the nurse identify as contraindicated for use with warfarin? (Select all that apply)

Correct Answer is ["B","D","E"]

Explanation

A nurse in the intensive care unit is planning care for a client who has a closed head injury. The client's intracranial pressure (ICP) is being monitored via an intraventricular catheter. Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

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