A nurse is caring for a client who is at 36 weeks of gestation and reports a headache.
Which of the following actions should the nurse take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Graphic Results Temperature 37° C (98.6° F) Heart rate 88/min Respiratory rate 18/min
Blood pressure 144/94 mm Hg
Upper abdominal pain rating 4/10 on a scale from 0 to 10
Perform a contraction stress test.
Prepare for delivery of the fetus.
Increase the client's dietary salt intake to 2 g/day.
Administer ferrous sulfate to the client.
Upper abdominal pain rating 4/10 on a scale from 0 to 10
The Correct Answer is B
Choice A rationale:
A contraction stress test is not appropriate in this context and would not address the potential risks associated with the client's symptoms.
Choice B rationale:
The elevated blood pressure and upper abdominal pain suggest potential preeclampsia, a serious complication of pregnancy that can lead to significant maternal and fetal risks. Delivery may be indicated to prevent further complications.
Choice C rationale:
Increasing dietary salt intake is not recommended for managing elevated blood pressure in pregnancy.
Choice D rationale:
Administering ferrous sulfate is unrelated to the client's symptoms and concerns.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Teaching about manifestations of anxiety might be important, but addressing the immediate needs of the anxious client takes precedence.
Choice B rationale:
Completing the assessment is important, but if the client is becoming increasingly anxious, immediate intervention is needed.
Choice C rationale:
Reassuring the client of their safety is a priority intervention for managing escalating anxiety. This can help to provide a sense of security and prevent the situation from worsening.
Choice D rationale:
Administering an anti-anxiety medication should not be the first step, especially without assessing the client's current condition and considering non-pharmacological interventions first.
Correct Answer is A
Explanation
Choice A rationale:
The client's parent is typically the legal decision-maker for a 19-year-old client who is unable to make decisions due to their condition. Approaching the client's parent about considering organ donation is appropriate.
Choice B rationale:
While family dynamics can vary, the parent is usually the primary decision- maker for a minor or incapacitated individual. The grandparents may be consulted or involved in the decision-making process, but the parent's consent is generally required for organ donation.
Choice C rationale:
The client's older sibling may be consulted or involved in the decision- making process, but the parent's consent is generally required for organ donation.
Choice D rationale:
The client's spouse may be consulted or involved in the decision-making process, but the parent's consent is generally required for organ donation.
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