A nurse is assisting with the care of a client who has pneumonia.

Exhibits

For each potential nursing action, click to specify if the potential action is. anticipated or contraindicated for the client.

The data collection findings are consistent with the following disease processes: Abdominal cramping: This finding can indicate ulcerative colitis, diverticulitis, or Crohn’s disease.

Abdominal cramping is a common symptom of inflammation and infection in the digestive tract. Weight loss: This finding can indicate ulcerative colitis or Crohn’s disease. Weight loss can result from malabsorption, reduced appetite, inflammation, or complications of the disease. Diarrhea: This finding can indicate ulcerative colitis or Crohn’s disease. Diarrhea is caused by increased intestinal motility, inflammation, and ulceration of the mucosa. Anemia: This finding can indicate ulcerative colitis or Crohn’s disease. Anemia can result from chronic blood loss, iron deficiency, vitamin B12 deficiency, or inflammation. The finding of fatty appearance and foul odor of the stool is also consistent with Crohn’s disease, as it suggests steatorrhea (excess fat in the stool) due to malabsorption. The finding of a positive fecal occult blood test is consistent with ulcerative colitis or Crohn’s disease, as it indicates bleeding in the digestive tract.

Choice A rationale:

Performing a vaginal examination every 12 hours is not necessary in this case. The client is not in labor and there are no indications of any complications that would require frequent vaginal examinations.

Choice B rationale:

The client’s symptoms of severe headache, +3 pitting edema in bilateral lower extremities, and a patellar reflex of 4+ without the presence of clonus are indicative of severe preeclampsia. Antihypertensive medications are often used to manage high blood pressure in preeclampsia.

Choice C rationale:

Betamethasone is a corticosteroid that is given to pregnant women who are at risk of delivering prematurely to help mature the baby’s lungs. Given that the client is at 31 weeks of gestation and has had a previous preterm birth, administering betamethasone would be appropriate.

Choice D rationale:

A low-stimulation environment can help reduce blood pressure and prevent seizures in clients with preeclampsia.

Choice E rationale:

Bed rest can help lower blood pressure and improve blood flow to the placenta, which can be beneficial for the baby.

Choice F rationale:

Monitoring intake and output every hour can help assess kidney function, which can be affected by preeclampsia.

Choice G rationale:

A 24-hour urine specimen can provide information about protein levels in the urine, which can indicate the severity of preeclampsia. It’s important to note that normal ranges for lab parameters can vary slightly depending on the lab, but generally, protein levels in a 24-hour urine specimen should be less than 300 mg. Pitting edema is usually graded on a scale of 1+ (mild) to 4+ (severe), and a patellar reflex of 4+ is considered hyperactive and may indicate nervous system hyperexcitability seen in severe preeclampsia or eclampsia.