When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?
When the client has ankle edema.
If the client has an elevated blood pressure.
During admission to labor and delivery.
Within the first trimester of pregnancy.
The Correct Answer is B
Choice A reason: When the client has ankle edema, it is important for the nurse to assess for other signs of fluid retention, such as weight gain, jugular venous distension, and crackles in the lungs. However, ankle edema alone is not a specific indicator of preeclampsia or eclampsia, which are conditions that can cause hyperreflexia or increased DTRs.
Choice B reason: This is the correct answer because if the client has an elevated blood pressure, it is important for the nurse to assess for other signs of preeclampsia or eclampsia, such as proteinuria, headache, blurred vision, epigastric pain, and hyperreflexia or increased DTRs. These conditions can cause seizures and other complications that can endanger the mother and fetus.
Choice C reason: During admission to labor and delivery, it is important for the nurse to assess various aspects of the client's health status, such as vital signs, fetal heart rate, contractions, cervical dilation, and pain level. However, assessing DTRs is not a routine part of labor and delivery assessment unless there are signs of preeclampsia or eclampsia.
Choice D reason: Within the first trimester of pregnancy, it is important for the nurse to assess for signs of pregnancy-related nausea and vomiting, bleeding, infection, and ectopic pregnancy. However, assessing DTRs is not a routine part of first trimester assessment unless there are signs of neurological disorders or spinal cord injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Creatinine is not a relevant laboratory test for the nurse to monitor, as this reflects renal function and is not affected by naproxen or arthritis. This is a distractor choice.
Choice B reason: Serum calcium is not a pertinent laboratory test for the nurse to monitor, as this indicates bone metabolism and is not related to naproxen or arthritis. This is another distractor choice.
Choice C reason: Erythrocyte sedimentation rate is not an important laboratory test for the nurse to monitor, as this measures inflammation and is not influenced by naproxen or stomach pain. This is another distractor choice.
Choice D reason: Hemoglobin is an essential laboratory test for the nurse to monitor, as this shows blood oxygen-carrying capacity and can be reduced by naproxen-induced gastrointestinal bleeding, which can cause stomach pain, weakness, and fatigue. Therefore, this is the correct choice.
Correct Answer is A
Explanation
Choice A reason: This is the correct answer because getting an eye examination with an ophthalmologist annually is an important point for disease and symptom management for a client with type 2 diabetes mellitus. Diabetes mellitus can cause damage to the blood vessels and nerves in the eyes, leading to vision problems and eye diseases such as diabetic retinopathy, cataracts, and glaucoma. Regular eye check-ups can help detect and treat these conditions early and prevent blindness.
Choice B reason: Arranging diet schedule around three regular meals a day is not a sufficient point for disease and symptom management for a client with type 2 diabetes mellitus. Diabetes mellitus is a condition that affects the body's ability to produce or use insulin, a hormone that regulates blood glucose levels. Eating three regular meals a day may not be enough to control blood glucose levels and prevent complications such as hypoglycemia or hyperglycemia. The nurse should teach the client to follow a balanced diet that includes carbohydrates, proteins, fats, vitamins, minerals, and fiber, and to eat smaller portions more frequently throughout the day.
Choice C reason: Using garlic, herbs, and spices will improve the flavor of food is not a specific point for disease and symptom management for a client with type 2 diabetes mellitus. Garlic, herbs, and spices are natural ingredients that can enhance the taste and aroma of food, but they do not have a direct impact on blood glucose levels or diabetes complications. The nurse should teach the client to limit the intake of salt, sugar, and saturated fats, and to choose foods that are low in glycemic index and high in antioxidants.
Choice D reason: Inspecting feet every month for ingrown nails, cuts, and calluses is not a frequent enough point for disease and symptom management for a client with type 2 diabetes mellitus. Diabetes mellitus can cause damage to the blood vessels and nerves in the feet, leading to reduced sensation, poor circulation, infection, ulceration, and amputation. The nurse should teach the client to inspect feet every day for any signs of injury or infection, and to wash, dry, moisturize, and protect them properly. The nurse should also advise the client to wear comfortable shoes and socks, avoid walking barefoot, and seek medical attention for any foot problems.
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