A nurse in an antepartum clinic is caring for four clients. Which of the following clients should the nurse assess first?
A client who is at 34 weeks of getation and reports double vision
A client who is at 38 weeks of gestation and reports leg cramps
A client who is at 8 weeks of gestation and reports excessive salivation
A client who is at 24 weeks of gestation and reports periodic finger numbness
The Correct Answer is A
A. Double vision at 34 weeks of gestation is a potential sign of preeclampsia, which can lead to severe complications such as seizures (eclampsia), stroke, or organ damage. This client requires immediate assessment.
B. Leg cramps are common in late pregnancy due to pressure on nerves and changes in circulation. This is not an urgent concern.
C. Excessive salivation (ptyalism) is benign and can occur in early pregnancy due to hormonal changes. It does not require immediate assessment.
D. Periodic finger numbness is often due to carpal tunnel syndrome, a common non-urgent condition in pregnancy caused by fluid retention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A child with cystic fibrosis and difficulty clearing secretions is the priority because airway clearance is critical in cystic fibrosis. Mucus buildup can lead to respiratory distress and infection, requiring immediate intervention.
B. A child with an atrial septal defect and a heart rate of 120/min is not the priority because a heart rate of 120/min is within the expected range for a 3-year-old and does not indicate immediate distress.
C. A child with type 1 diabetes and a blood sugar of 150 mg/dL is not the priority because this blood glucose level is slightly elevated but not critical.
D. A child with diarrhea and abdominal pain requires assessment, but dehydration or electrolyte imbalance develops over time. Airway issues take priority over gastrointestinal symptoms.
Correct Answer is C
Explanation
A. Decaffeinated coffee is not recommended for clients with GERD because it can still increase gastric acid secretion, which may worsen symptoms.
B. Tomato soup is acidic and can trigger acid reflux, making it an unsuitable choice for clients with GERD.
C. White fish is a low-fat, non-acidic protein source that is unlikely to trigger GERD symptoms, making it an appropriate dietary choice.
D. Hot cocoa contains chocolate and caffeine, both of which can relax the lower esophageal sphincter (LES) and increase acid reflux.
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