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 D
Explanation
Rationale:
A. "Why did this happen to me?": This statement reflects the anger stage of grief, where the client questions fairness and expresses frustration about their situation. It does not involve negotiating or making promises in exchange for a desired outcome.
B. "I never did anything bad to hurt anyone": This reflects the guilt or depression stage, as the client may be feeling remorse or self-blame related to their illness. It is an emotional expression rather than an attempt to bargain.
C. "I hope my family can accept what's happening": This reflects the acceptance stage, where the client begins to come to terms with their prognosis and focuses on reconciliation or emotional resolution.
D. "If I get better I will study to become a priest.": This is an example of the bargaining stage, where the client attempts to negotiate or make promises in exchange for a desired outcome, such as improved health or extended life. It demonstrates the “what if” reasoning characteristic of this stage of grief.
Correct Answer is []
Explanation
Rationale for correct choices
• Deep vein thrombosis: The client presents with unilateral right lower extremity swelling, warmth, and pain below the knee, all of which are hallmark signs of deep vein thrombosis (DVT). Postoperative immobility, recent hysterectomy, obesity, age, and history of smoking significantly increase the risk of venous thromboembolism.
• Check for pedal pulses and signs of ischemia: Assessing pedal pulses and ischemic changes ensures that arterial circulation remains intact while monitoring for potential complications. This evaluation is essential prior to initiating interventions, including anticoagulation or mechanical therapies, to prevent tissue damage or further vascular compromise.
• Request a prescription for a lower-extremity Doppler flow study: A Doppler ultrasound is the standard diagnostic test to confirm DVT. Timely imaging guides the initiation of anticoagulation therapy and helps prevent clot propagation or embolization. Confirming the diagnosis is crucial for implementing safe and effective treatment strategies.
• Signs of bleeding after anticoagulation initiation: Monitoring for bleeding is essential because anticoagulants are the mainstay of DVT treatment. The client is at risk for hemorrhage due to medication or underlying surgical recovery, and early recognition of bleeding complications prevents serious morbidity.
• PT/INR and platelet count: These laboratory parameters are critical to monitor coagulation status and platelet function, particularly if anticoagulation therapy (e.g., heparin or warfarin) is prescribed. Tracking these values ensures therapeutic effectiveness while minimizing the risk of bleeding complications.
Rationale for incorrect choices
• Cellulitis: Cellulitis typically presents with diffuse erythema, tenderness, and possible fever. While the client has warmth and swelling, the unilateral presentation and postoperative risk factors point toward a thrombotic event rather than a bacterial infection. WBC is only slightly elevated, and systemic signs of infection are minimal.
• Muscle strain: Muscle strains usually occur after acute trauma or overuse and often involve localized pain without significant swelling or warmth. The client’s symptoms developed postoperatively without recent exertion, making a strain unlikely.
• Heart failure: Heart failure often presents with bilateral edema, pulmonary congestion, dyspnea, and elevated BNP. The client’s edema is unilateral and below the knee, with clear lungs and normal oxygen saturation, which does not support a diagnosis of heart failure.
• Implement rest, ice, elevation, compression (RICE): RICE is appropriate for musculoskeletal injuries such as strains or sprains but is not recommended for DVT, as compression and manipulation of the affected extremity could dislodge the clot and precipitate a pulmonary embolism.
• Assess for Homan's sign: Homan’s sign (pain on dorsiflexion of the foot) is not a reliable or specific indicator of DVT and is generally discouraged as a primary assessment tool. Clinical observation and Doppler imaging are preferred.
• Request a prescription for IV furosemide: Furosemide is used to treat fluid overload in conditions like heart failure, not DVT. The client’s symptoms are localized, and there is no evidence of systemic fluid retention requiring diuretics.
• Brain natriuretic peptide (BNP) levels: BNP is used to assess for heart failure. This client has no signs of pulmonary congestion or systemic fluid overload, so BNP monitoring is not indicated in this scenario.
• ECG changes: While ECG is useful for detecting cardiac arrhythmias, it does not provide information regarding lower-extremity venous thrombosis. The client’s cardiac history does not suggest arrhythmia as the primary concern at this time.
• Temperature: The client’s temperature is normal, and there is no indication of systemic infection, so monitoring temperature does not directly assess the progression of DVT.
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