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The nurse continues to care for the client who is at 30 weeks of gestation.

Exhibits

Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.

Initiate contact precautions.

Check urinary output.

Decrease lighting in the client's room.

Monitor blood pressure.

Prepare for amniocentesis.

Apply Internal fetal monitor.

Assess DTR.

Encourage bed rest.

Answer and Explanation

Correct Answer : B,C,D,G,H

A. Contact precautions are not indicated based on the assessment findings provided. Preeclampsia is primarily a hypertensive disorder of pregnancy characterized by systemic manifestations such as elevated blood pressure, proteinuria, and multiorgan involvement. It is not transmitted through direct contact, so contact precautions are unnecessary.

B. The client is exhibiting signs and symptoms consistent with preeclampsia, including right upper abdominal pain, headache, nausea, vomiting, facial edema, weight gain, and elevated blood pressure. Monitoring urinary output is essential for assessing renal function and detecting oliguria, which is a potential complication of preeclampsia.

C. Reducing stimuli, such as bright lights and loud noises, can lower the risk of seizures in clients with preeclampsia.

D. The client's blood pressure readings are elevated, indicating hypertension, which is a hallmark sign of preeclampsia. Monitoring blood pressure regularly is crucial for assessing the severity of hypertension and guiding management.

E. Amniocentesis is not indicated based on the assessment findings provided. Amniocentesis is a diagnostic procedure typically performed to obtain amniotic fluid for various purposes, such as fetal lung maturity assessment or genetic testing. In the context of preeclampsia, it is not a standard intervention.

F. Internal fetal monitoring is typically used during labor to provide a more accurate reading of the baby's heart rate. It involves guiding a thin wire through the cervix and attaching it to the baby's scalp. At 30 weeks gestation, internal monitoring would not be standard practice as it is invasive and labor has not yet commenced.

G. Deep tendon reflexes (DTRs) are assessed to monitor for signs of neurological involvement in preeclampsia. Hyperreflexia, as indicated by a 3+ DTR bilaterally, is a characteristic finding in severe preeclampsia and may indicate central nervous system irritability.

H. Bed rest is often recommended for clients with preeclampsia to reduce physical activity and minimize the risk of complications such as eclampsia or stroke. It can help lower blood pressure and reduce the risk of placental abruption.

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Correct Answer is D

Explanation

A. Primary glaucoma is not typically considered a contraindication to kidney donation.
B. Amputation, unless associated with significant underlying medical conditions, is not necessarily a contraindication to kidney donation.
C. Osteoarthritis, a degenerative joint disease, is unlikely to be a contraindication to kidney donation unless it significantly affects the donor's overall health.
D. Hypertension is a significant risk factor for kidney disease and can increase the risk of complications for both the donor and the recipient. It is typically considered a contraindication to kidney donation.

A. Provocative behavior B. Lack of empathy C. Goal-oriented D. Lability

Correct Answer is C

Explanation

A. This is not characteristic of OCPD; such behavior is more associated with personality disorders that involve issues with impulse control and attention-seeking, such as histrionic personality disorder.
B. While people with OCPD might appear rigid or stubborn, a lack of empathy is more characteristic of antisocial or narcissistic personality disorders.
C. Individuals with obsessive-compulsive personality disorder (OCPD) are often highly focused on orderliness, perfectionism, and control, making them very goal- oriented and preoccupied with productivity.
D. Emotional lability is not a feature of OCPD; it is more often associated with borderline personality disorder, which includes rapid and intense emotional swings.

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The nurse continues to care for the client who is at 30 weeks of gestation. Exhibits Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.

Nursing Test Bank

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A nurse is caring for a client who has end-stage kidney disease. The client's adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the child's medical history should the nurse Identify as a contraindication to the procedure?

Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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The nurse continues to care for the client who is at 30 weeks of gestation.

Exhibits

Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.