A nurse is caring for a client at the clinic.
Complete the following sentence by using the lists of options.
The client is at risk for
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A"}
Rationale for correct choices
• Spontaneous abortion: The client is presenting at 10 weeks gestation with moderate, bright red vaginal bleeding and a history of risk factors including type 1 diabetes mellitus and recurrent infections. The open cervix on examination indicates that the pregnancy may not be viable and suggests impending or ongoing miscarriage.
• Cervical dilation: Cervical dilation is a key clinical sign of spontaneous abortion, as it indicates that the body is preparing to expel the pregnancy. The presence of an open cervix in conjunction with vaginal bleeding and cramping directly supports the risk for miscarriage. Monitoring cervical changes helps the healthcare team assess the progression and urgency of intervention.
Rationale for incorrect choices
• Molar pregnancy: Molar pregnancy typically presents with markedly elevated hCG levels, larger-than-expected uterine size, and absence of a viable embryo. Although the client has an elevated hCG, the level is not excessively high, and there is no indication of vesicular tissue or characteristic ultrasound findings, making molar pregnancy unlikely.
• Ectopic pregnancy: Ectopic pregnancy generally presents with unilateral abdominal pain, shoulder pain, and sometimes hypotension or signs of internal bleeding. The client’s bleeding is bright red, moderate, and accompanied by cervical dilation, which is not typical for an ectopic pregnancy. No abdominal mass or unilateral tenderness is reported, reducing the likelihood of this diagnosis.
• Lower abdominal cramping: While cramping is a symptom associated with miscarriage, it alone is not sufficient evidence to determine the risk for spontaneous abortion. Cervical dilation is a more definitive clinical sign indicating that the miscarriage may be occurring or imminent.
• hCG levels: The client’s hCG level of 30,000 IU/L is within the expected range for 10 weeks gestation and does not specifically indicate miscarriage. Unlike cervical dilation, hCG levels alone cannot confirm the risk for spontaneous abortion.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. “I should advise a client about what I feel to be his best health care decision.": Advocacy involves supporting the client’s choices and rights, not imposing the nurse’s personal opinions. Advising based on personal beliefs undermines the client’s autonomy and is not consistent with professional advocacy.
B. "I should not advocate for a client unless he is able to ask me himself.": Client advocacy includes speaking up on behalf of clients who cannot voice their own needs, such as those who are incapacitated or vulnerable. Waiting for the client to ask would neglect the nurse’s responsibility to protect and support the client.
C. “I will intervene if there is a conflict between a client and his provider.": Advocacy involves intervening when a client’s rights, preferences, or safety are at risk, including resolving conflicts with providers. This demonstrates understanding of the nurse’s role in ensuring the client’s voice is heard and needs are met.
D. “I will inform a client that his family should help make his health care decisions.": While family input can be important, the client’s autonomy takes priority. Encouraging family decision-making over the client’s choices does not reflect proper advocacy and may compromise the client’s rights.
Correct Answer is A
Explanation
Rationale:
A. Stair carpeting is attached with carpet tacks: Loose or improperly secured carpeting on stairs creates a significant tripping hazard, especially for clients with mobility limitations such as a hip fracture. Carpet tacks can cause the edges of the carpet to lift, increasing the risk of falls and further injury.
B. Nonessential items are stored in drawers: Storing nonessential items in drawers does not create an immediate fall risk or safety hazard. Keeping items organized in drawers can actually reduce clutter in walking areas, making the environment safer.
C. Magazines are stacked neatly on the stairs: Even neatly stacked magazines on stairs are a potential tripping hazard. However, the option specifies “neatly stacked,” which implies some order, though ideally items should not be on stairs at all. Carpet tacks pose a more immediate and hidden danger than visible items.
D. End tables are secured to the wall: Securing furniture prevents tipping and provides stability, which enhances safety for clients with mobility limitations. This measure decreases the risk of falls and does not pose a hazard.
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