A nurse is caring for a client who is pregnant.

Exhibits

The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.

Blood pressure

Urine ketones

Urine protein Gravida/parity

Report of headache

Respiratory rate

Fetal activity

Answer and Explanation

Correct Answer : A,C,D,F

A. Blood pressure. A blood pressure of 162/112 mm Hg is severely elevated and indicative of preeclampsia, a serious complication during pregnancy. Uncontrolled hypertension can lead to maternal and fetal complications, such as eclampsia, placental abruption, or fetal growth restriction.

B. Urine ketones. The absence of ketones in the urine is normal and does not indicate any prenatal complication. Ketones would typically be seen in cases of starvation, dehydration, or poorly controlled diabetes, which are not evident here.

C. Urine protein. The presence of 3+ protein in the urine is a key diagnostic marker for preeclampsia. This finding, combined with elevated blood pressure, signals potential damage to the kidneys, which is a hallmark of severe preeclampsia.

D. Report of headache. A severe headache unrelieved by acetaminophen is a concerning symptom of preeclampsia. It suggests potential central nervous system involvement, which could lead to complications like seizures if left untreated.

E. Respiratory rate. The client’s respiratory rate of 16/min is within the normal range and does not indicate any immediate concern related to her pregnancy or current condition.

F. Fetal activity. The client’s report of decreased fetal movement is concerning and may indicate fetal distress or compromised placental function. This finding requires prompt evaluation to ensure fetal well-being.

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Correct Answer is B

Explanation

A. Violating others' rights is more characteristic of antisocial personality disorder.

B. Self-centered behavior is a hallmark of histrionic personality disorder. Clients often seek attention, exhibit excessive emotionality, and display dramatic, exaggerated behaviors.

C. Callousness is also seen in antisocial personality disorder rather than histrionic.

D. Suspiciousness is typical of paranoid personality disorder, not histrionic.

A. Encourage the client to drink low-protein supplements. B. Provide the client with cold foods rather than hot foods. C. Serve the client's largest meal in the evening. D. Tell the client to drink two glasses of water with meals.

Correct Answer is B

Explanation

A. Low-protein supplements are not recommended; high-protein, high-calorie foods are encouraged to maintain nutrition.

B. Cold foods are often more tolerable for clients experiencing anorexia, as they are less odorous and may help reduce nausea.

C. Serving the largest meal in the evening is inappropriate as appetite typically decreases later in the day; it’s better to serve meals when the client feels most hungry.

D. Drinking large amounts of fluid with meals can lead to early satiety, reducing overall intake.

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A nurse is caring for a client who is pregnant. Exhibits The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.

Nursing Test Bank

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A nurse is caring for a client who is pregnant.

Exhibits

The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.