The home health nurse is assessing a 17-year-old pregnant client at 34 weeks of gestation who has been diagnosed with preeclampsia. Upon assessment, the nurse finds that the client has gained 2 pounds in the past week and her blood pressure is 144/92 mmHg. Which assessment finding would require further action by the nurse?
Visual disturbances
Frequent voiding in large amounts
1+ pedal edema
One headache in the past week
The Correct Answer is A
Visual disturbances would require further action by the nurse as they can be a sign of worsening preeclampsia and a potential indication for immediate medical attention. The client's recent weight gain and elevated blood pressure are also concerning findings, but visual disturbances are a more urgent symptom. Frequent voiding in large amounts and 1+ pedal edema are common in pregnancy, while one headache in the past week may or may not be significant depending on the context.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
In the case of a bioterrorism attack involving anthrax, the main priority for the nurse is to administer antibiotics within 48 hours of exposure using the Strategic National Stockpile. Anthrax is a serious bacterial infection that can be used as a bioterrorism weapon. Antibiotics, such as ciprofloxacin, doxycycline, and penicillin, can be used to prevent anthrax from developing in people who have been exposed.
There is currently no vaccine available for anthrax exposure. Also, symptom support alone is not enough in cases of anthrax exposure, as anthrax can progress rapidly and lead to serious complications. Placing everyone who was exposed in quarantine may not be necessary in all situations, and should be determined on a case-by-case basis depending on the extent and severity of the exposure.
Correct Answer is B
Explanation
In DIC, there is widespread clotting that can lead to depletion of clotting factors and platelets, resulting in bleeding. The priority in the care of DIC is to correct the underlying cause and to replace lost blood products to prevent hypovolemia and hemorrhage. Therefore, the nurse should anticipate an order for the administration of blood products such as packed red blood cells, fresh frozen plasma, and platelets. Administration of steroids may also be ordered to reduce inflammation and stabilize cell membranes. Restriction of intravascular fluids may be necessary to prevent further bleeding, but it is not the first priority. Invasive hemodynamic monitoring may be used to assess the client's fluid and electrolyte status, but it is not typically the first intervention.
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