A nurse is caring for a client who is at 34 weeks of gestation. Which of the following statements by the client is the nurse’s priority to report to the provider?

"My heart feels like it skips a beat."

"I have nosebleeds once per week."

"The palms of my hands are red and blotchy."

"I’m experiencing persistent headaches."

Answer and Explanation

The Correct Answer is A

Choice A reason: Palpitations at 34 weeks may signal arrhythmia or preeclampsia-related cardiac strain. This urgent symptom in pregnancy requires immediate provider evaluation.

Choice B reason: Weekly nosebleeds are common in pregnancy from vascular changes, less critical. Without severity, they’re not the priority over cardiac concerns.

Choice C reason: Red, blotchy palms (palmar erythema) are normal in pregnancy from estrogen. It’s benign, not urgent compared to potential heart issues.

Choice D reason: Persistent headaches suggest preeclampsia, but palpitations pose a more immediate cardiac risk. At 34 weeks, this takes reporting precedence.

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Correct Answer is C

Explanation

Choice A reason: Threatening health consequences may escalate resistance in diabetes care. It dismisses feelings, reducing trust, and isn’t therapeutic for addressing refusal effectively.

Choice B reason: Guilt via family impact pressures the client, not exploring reasons. This approach hinders open dialogue, critical for diabetes self-management acceptance.

Choice C reason: Inviting thoughts fosters therapeutic communication, exploring barriers to insulin use. It respects autonomy, building trust essential for diabetes education and compliance.

Choice D reason: "Why" questions can feel confrontational, shutting down discussion. Open-ended inquiry better uncovers motivations in diabetes refusal, avoiding defensiveness.

A. Release the client’s restraints every 4 hr. B. Check the client’s status every hour. C. Obtain written consent by the client for the placement of the restraints. D. Document the client’s behavior leading to the initiation of the restraints.

Correct Answer is D

Explanation

Choice A reason: Releasing restraints every 4 hours lacks context; policy requires 2-hour checks with release if safe. Scientifically, this risks neglect, as frequent assessment ensures circulation and safety, making it less precise than behavior documentation.

Choice B reason: Hourly checks are good but not the action specified; 15-minute intervals are standard for restraints. Scientifically, this underestimates risk monitoring needs, as behavior justification is a legal and clinical priority over timing alone.

Choice C reason: Client consent isn’t required for restraints in emergencies; provider orders suffice. Scientifically, imminent harm overrides autonomy, and consent isn’t feasible mid-crisis, making this impractical and misaligned with restraint protocols.

Choice D reason: Documenting behavior justifies restraints, ensuring legal and ethical use for safety. Scientifically, this aligns with standards, as specific actions (e.g., aggression) validate intervention, providing a clinical basis critical for care continuity and review.

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A nurse is caring for a client who is at 34 weeks of gestation. Which of the following statements by the client is the nurse’s priority to report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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