The nurse has reviewed the Graphic Record and Diagnostic Results at 1030.

Select 1 condition and 1 client finding to fill in each blank in the following sentence.

After collecting data from the client, the nurse should identify that the client is experiencing

as evidenced by the client's

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"D"}

Placenta previa: Placenta previa occurs later in pregnancy and is characterized by painless bright red vaginal bleeding without abdominal tenderness. The client is only 6 weeks pregnant, and placenta previa is not a concern this early in gestation.
abruptio placentae: Abruptio placentae involves painful bleeding and a rigid uterus, usually occurring after 20 weeks' gestation. The client’s gestational age and presenting symptoms are more consistent with an early pregnancy complication rather than abruptio placentae.
ectopic pregnancy: This occurs when a fertilized egg implants outside the uterus. The client’s missed period, positive pregnancy test, right lower quadrant tenderness, and dark red vaginal spotting are classic signs of ectopic pregnancy. Ectopic pregnancy is a life-threatening emergency if rupture occurs, requiring prompt identification and management.
acute asthma attack: While the client has a history of asthma and slight inspiratory wheezing, her respiratory status is stable with normal oxygen saturation and no signs of acute respiratory distress. Therefore, an asthma attack is not the primary concern.
pyelonephritis: Pyelonephritis typically presents with fever, chills, flank pain, and urinary symptoms. The client’s presentation of right lower quadrant tenderness and vaginal spotting does not align with the typical findings of pyelonephritis.
respiratory rate: The client’s respiratory rate is normal at 16/min, indicating stable respiratory function. Respiratory rate does not explain the primary concern related to abdominal pain and vaginal bleeding.
history of regular menstrual period: While this supports that the client is late in her cycle, it is not the most direct or critical finding pointing toward the diagnosis. The focus should be on current clinical signs like abdominal tenderness.
temperature: The client’s temperature is within normal range at 37.3°C (99.1°F), making infection less likely and not the primary concern related to her current symptoms.
right lower quadrant abdominal tenderness: Localized tenderness in the right lower quadrant combined with vaginal spotting strongly suggests an ectopic pregnancy. This is a hallmark finding that supports the diagnosis as the growing embryo can cause irritation, stretching, or rupture of the fallopian tube.
hyperactive bowel sounds: Hyperactive bowel sounds are nonspecific and can occur due to anxiety, mild gastrointestinal upset, or pain, but they are not diagnostic for ectopic pregnancy. The abdominal tenderness is the more significant finding.

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Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

Seizures: The client’s symptoms of severe hypertension, persistent headache, hyperreflexia, proteinuria, and low platelet count strongly indicate severe preeclampsia, a condition that can rapidly progress to eclampsia, where seizures occur. This is a critical obstetric emergency requiring immediate intervention to prevent maternal and fetal morbidity.
Hypoglycemia: The client’s blood glucose level is 85 mg/dL, which is within the normal range. There are no signs such as diaphoresis, confusion, or weakness that would suggest hypoglycemia, and this condition is unrelated to the client's primary diagnosis of severe preeclampsia.
Cervical insufficiency: Cervical insufficiency typically causes painless cervical dilation and is associated with second-trimester pregnancy losses. The client is at 31 weeks with no reported cervical changes, contractions, or painless dilation, making this complication unlikely in the current clinical scenario.
Placental abruption: Severe hypertension increases the risk of placental abruption due to damage to the placental blood vessels. Signs of decreased fetal movement and the high-risk profile of preeclampsia support the concern that abruption could occur, leading to serious maternal and fetal compromise.
Heart failure: Although the client has some edema, there are no other clinical signs such as dyspnea, crackles, or orthopnea that would suggest heart failure. The edema seen here is consistent with preeclampsia rather than decompensated cardiac function.

A. Pain radiating down the left arm B. Seizure activity C. Sudden loss of vision in one eye D. Epigastric pain

Correct Answer is C

Explanation

A. Pain radiating down the left arm: Pain radiating to the left arm is more commonly associated with myocardial infarction (heart attack), not a transient ischemic attack (TIA). It indicates cardiac ischemia rather than a temporary disruption in cerebral blood flow.

B. Seizure activity: Seizures are not characteristic of transient ischemic attacks. While seizures can occur after significant brain injury such as a stroke, TIAs typically present with focal neurological deficits that resolve quickly without leading to seizure activity.

C. Sudden loss of vision in one eye: A sudden, temporary loss of vision in one eye (amaurosis fugax) is a classic sign of a TIA. It reflects temporary ischemia in the retinal or cerebral blood vessels and warrants immediate medical evaluation to prevent a full-blown stroke.

D. Epigastric pain: Epigastric pain is usually related to gastrointestinal issues such as gastritis, ulcers, or gallbladder disease. It is not indicative of a transient ischemic attack and would not typically be prioritized in assessing for neurological compromise.

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Naxlex Comprehensive Predictor Exams

The nurse is continuing to assist with the care of the client. Select words from the choices below to fill in each blank in the following sentence. The complications that the client is at greatest risk for developing are ______ and ______

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}

Explanation

A nurse in a long-term care facility is caring for an older adult client who has a history of hypertension. Which of the following findings should the nurse recognize is indicative of transient ischemic attacks?

Correct Answer is C

Explanation

A nurse is assisting with the care of a client who is receiving a continuous IV infusion. Which of the following findings indicates fluid volume overload?

A nurse is assisting with the care of a client. A nurse is reviewing the client's electronic medical record. Which of the following findings on day 7 require further action? Select all that apply.

A nurse is preparing to administer a dose of digoxin to a client who is experiencing heart failure. Which of the following actions should the take prior to administering this medication?

A nurse is collecting data from a client who is experiencing delirium. Which of the following findings should the nurse expect?

A nurse is discussing risk factors for child abuse with members of a parenting group. The nurse should identify which of the following findings as a characteristic of perpetrators of child abuse?

A nurse is assisting in the care of a client who is on isolation for an infection with vancomycin-resistant enterococcus (VRE). Which of the following actions should the nurse take to prevent the spread of infection?

A nurse is assisting with teaching a class about the importance of fire safety. Which of the following hazards should the nurse include as an example of the leading cause of residential fires?

A nurse on a unit is assisting with the care of a group of clients. Which of the following observations by the nurse requires intervention?