A nurse is assisting with the care of a client.

Exhibits

The nurse is reinforcing teaching for the client and their family about potential adverse effects of the client's prescribed medications.

For each potential adverse effect, click to specify if the effect is. consistent with agranulocytosis, neuroleptic malignant syndrome, or. serotonin syndrome.

Each finding may support more than 1 disease process.

The correct answer is choice B and C.

Choice A rationale:

Cervical insufficiency is a condition where the cervix begins to shorten and open too early during pregnancy, leading to premature birth or loss of an otherwise healthy pregnancy. However, the client’s symptoms do not indicate cervical insufficiency. There are no reports of lower abdominal pressure, mild pelvic cramps, or a change in vaginal discharge, which are common symptoms of cervical insufficiency.

Choice B rationale:

The client’s severe headache unrelieved by acetaminophen, +3 pitting edema in bilateral lower extremities, and hyperactive reflexes (patellar reflex 4+) are indicative of severe preeclampsia. One of the complications of severe preeclampsia is seizures, also known as eclampsia. Therefore, the client is at risk for developing seizures.

Choice C rationale:

Placental abruption is a serious pregnancy complication in which the placenta detaches from the uterus prematurely. The client’s report of decreased fetal movement could be a sign of placental abruption. In addition, severe preeclampsia can increase the risk of placental abruption. Therefore, the client is at risk for developing placental abruption.

Choice D rationale:

Heart failure occurs when the heart can’t pump enough blood to meet the body’s needs. While preeclampsia can eventually affect many organ systems including the cardiovascular system, there are no immediate signs of heart failure in the client’s symptoms.

Choice E rationale:

Hypoglycemia refers to low blood sugar levels. The client’s symptoms do not suggest hypoglycemia. Symptoms of hypoglycemia typically include confusion, dizziness, feeling shaky, hunger, headaches, irritability, pounding heart or irregular heartbeat, sweating, trembling or tremors, and weakness. In conclusion, based on the client’s symptoms and clinical presentation, she is at greatest risk for developing seizures (Choice B) and placental abruption (Choice C) due to severe preeclampsia.

Choice A rationale:

Encourage the client to have continual bed rest. Rationale: Continual bed rest is not the appropriate intervention for a client experiencing chronic fatigue due to leukemia. Prolonged bed rest can lead to further weakness and deconditioning. Encouraging some level of physical activity, such as gentle exercise, can help improve strength and reduce fatigue.

Choice B rationale:

Encourage strength-training exercise. Rationale: This is the correct intervention for a client with leukemia experiencing chronic fatigue. Strength-training exercises, when appropriate and under the guidance of healthcare professionals, can help improve muscle strength and overall endurance. It can combat the fatigue commonly associated with leukemia and its treatment.

Choice C rationale:

Increase the client's fluids to 4 L per day. Rationale: While adequate hydration is essential, increasing fluids to 4 liters per day may not be appropriate for every client. The optimal fluid intake for a client should be determined based on their individual needs and medical condition. Excessive fluid intake without medical indication can lead to complications like fluid overload.

Choice D rationale:

Increase protein in the diet. Rationale: Increasing protein intake can be beneficial for clients with leukemia as it helps in tissue repair and supports the immune system. However, it should be done in consultation with a registered dietitian to ensure that the client's specific dietary needs are met.