A nurse is caring for a client at an outpatient clinic.

Complete the following sentence by using the lists of options. The nurse should first address the client's
_____

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C"}

Rationale for correct choice

• Fall risk: The client experiences sudden episodes of leg weakness, intermittent muscle spasms, and gait changes, all of which significantly increase the risk of falls. Falls in clients with multiple sclerosis can lead to serious injury and further functional decline. Addressing safety and fall prevention is the most immediate priority to prevent harm while other concerns, such as memory or employment, are addressed.

Rationale for incorrect choices

• Memory: Although the client reports struggling to remember things, cognitive issues are not immediately life-threatening. Memory deficits should be addressed through ongoing assessment and cognitive support interventions, but they are not the first priority compared with safety risks.

• Blood pressure: Vital signs are within normal limits, and there is no evidence of hypertensive crisis or acute cardiovascular instability. Blood pressure monitoring remains part of routine care but does not require immediate intervention.

• BMI: The client’s BMI indicates overweight status but does not pose an immediate safety threat. Weight management is important for long-term health but is not the first priority in the context of neurological deficits and fall risk.

• Employment: Reduced work hours due to exacerbation episodes reflect functional limitations and psychosocial impact. Employment concerns are important for quality of life but are secondary to preventing physical injury from falls.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","E","F","G"]

Explanation

A. Administer betamethasone: Betamethasone is indicated to promote fetal lung maturity in a client at 31 weeks gestation at risk for preterm delivery. Administering corticosteroids reduces neonatal complications and is appropriate for this high-risk pregnancy.

B. Give antihypertensive medication: The client’s blood pressure readings (162/112 mm Hg and 166/110 mm Hg) indicate severe hypertension, which requires prompt management to prevent maternal complications such as stroke, eclampsia, or organ damage. Administering antihypertensives is a priority in controlling blood pressure.

C. Monitor intake and output hourly: Frequent monitoring of fluid balance is essential due to the risk of renal impairment from preeclampsia. Hourly intake and output helps detect oliguria or fluid retention, which can indicate worsening maternal status or impending complications.

D. Perform a vaginal examination every 12 hr: Routine vaginal examinations are avoided in clients with preeclampsia or severe hypertension due to the risk of inducing labor or causing trauma. Vaginal exams should be performed only when medically indicated.

E. Obtain a 24-hr urine specimen: Measuring proteinuria via a 24-hour urine collection helps evaluate the severity of preeclampsia and guides clinical management. This client has 3+ protein on urinalysis, confirming significant proteinuria.

F. Provide a low-stimulation environment: Reducing stimuli helps prevent exacerbation of headache, hypertension, and risk for seizures. A calm, quiet environment is a standard intervention for clients with severe preeclampsia.

G. Maintain bed rest: Bed rest with lateral positioning promotes uteroplacental perfusion, reduces blood pressure, and helps prevent complications such as eclampsia. The intervention supports maternal and fetal stability in the acute phase of severe preeclampsia.

A. Beneficence B. Autonomy C. Nonmaleficence D. Justice

Correct Answer is B

Explanation

A. Beneficence: Beneficence refers to the ethical principle of promoting good and acting in the best interest of the client. While this guides nursing actions to provide beneficial care, it does not directly involve respecting a client’s decision to refuse treatment.

B. Autonomy: Autonomy is the ethical principle that recognizes the client’s right to make independent decisions about their own healthcare. Respecting the client’s decision to refuse treatment honors their personal values, beliefs, and right to self-determination, even if the nurse disagrees with the choice.

C. Nonmaleficence: Nonmaleficence involves the obligation to avoid causing harm to the client. While important in all nursing actions, it focuses on preventing harm rather than specifically supporting a client’s right to make healthcare decisions.

D. Justice: Justice refers to fairness in the distribution of healthcare resources and treatment. It ensures equitable care for all clients but is not directly related to respecting an individual client’s choice to accept or refuse treatment.

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A nurse is caring for a client at an outpatient clinic. Complete the following sentence by using the lists of options. The nurse should first address the client's _____

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is continuing to care for the client. The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.

Correct Answer is ["A","B","C","E","F","G"]

Explanation

A nurse is caring for a client who has made the decision to refuse treatment. Which of the following ethical principles is demonstrated when the nurse respects the client's decision?

Correct Answer is B

Explanation

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A nurse is caring for a client at an outpatient clinic.

Complete the following sentence by using the lists of options. The nurse should first address the client's
_____