A nurse in a clinic is caring for an adolescent client who is at 24 weeks of gestation and showing signs of preeclampsia. Which of the following findings should the nurse expect?
Decreased BUN
Increased protein in urine
Increased platelet count
Decreased serum uric acid
The Correct Answer is B
Choice A reason: Decreased BUN is not typical in preeclampsia, where renal impairment often elevates BUN due to reduced glomerular filtration. Normal or increased BUN is expected, so this finding does not align with preeclampsia’s pathophysiology, making it an incorrect expectation.
Choice B reason: Increased protein in urine (proteinuria) is a hallmark of preeclampsia, resulting from glomerular damage due to hypertension and endothelial dysfunction. This diagnostic criterion, often >300 mg/24 hours, is critical for identifying preeclampsia, making it the correct finding the nurse should expect.
Choice C reason: Increased platelet count is not associated with preeclampsia, which often causes thrombocytopenia due to endothelial activation and platelet consumption. A decreased count (<100,000/mm³) is more likely, making this finding incorrect for preeclampsia’s clinical presentation.
Choice D reason: Decreased serum uric acid is not expected in preeclampsia, where elevated uric acid occurs due to reduced renal clearance from glomerular dysfunction. Increased levels are a marker, so this finding is opposite to preeclampsia’s effects, making it incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Decreasing fluid intake to firm stools is incorrect, as adequate hydration (2-3 L/day) is essential to prevent constipation, especially with opioids like oxycodone, which slow intestinal motility. Low fluid intake hardens stools, exacerbating constipation risk by reducing water content in the colon, indicating a misunderstanding of prevention strategies.
Choice B reason: Increasing dietary fiber intake (25-35 g/day) adds bulk to stools, stimulating peristalsis and counteracting opioid-induced slowed motility. Soluble and insoluble fiber, found in fruits, vegetables, and whole grains, promotes regular bowel movements. This statement reflects correct understanding of dietary measures to prevent constipation during opioid therapy.
Choice C reason: Taking a laxative only when constipated is reactive, not preventive. Opioids like oxycodone commonly cause constipation by reducing peristalsis via mu-opioid receptors in the gut. Prophylactic use of stool softeners or laxatives is recommended to maintain regular bowel movements, making this statement incorrect as it lacks a preventive approach.
Choice D reason: Exercising less to conserve energy worsens constipation, as physical activity stimulates intestinal motility, countering opioid-induced slowing. Regular movement, like walking, promotes bowel function by enhancing peristalsis and blood flow to the gut. This statement indicates a misunderstanding, as reduced activity increases constipation risk.
Correct Answer is B
Explanation
Choice A reason: A single light fixture along the sidewalk provides limited illumination, insufficient for comprehensive safety. Multiple, evenly spaced lights are needed to prevent falls, especially for older adults. Inadequate lighting increases risks of trips or assaults, indicating the client’s understanding of outdoor safety is incomplete and does not fully address home safety needs.
Choice B reason: Changing smoke alarm batteries annually ensures functional alarms, reducing fire-related mortality by 50%. Regular maintenance supports early smoke detection, enabling timely evacuation or response. This action reflects a strong understanding of fire safety, a critical home safety component, making it the best indicator of the client’s safety awareness.
Choice C reason: A small area rug at the front door poses a tripping hazard, particularly for those with mobility issues. Loose rugs can lead to falls, causing injuries like fractures. This finding suggests the client does not fully understand fall prevention, a key aspect of home safety, making it an incorrect indicator of safety awareness.
Choice D reason: Securing electrical cords under furniture risks fire hazards if cords are damaged or pinched, potentially causing electrical shorts. Cords should be secured along walls or with covers to prevent tripping without compromising safety. This indicates a misunderstanding of electrical safety, increasing fire or injury risks, and is not a correct safety measure.
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