The nurse is continuing to assist with the care of the client.
Drag 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
The Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"E"}
The client presents with severe hypertension, proteinuria, hyperreflexia, edema, and elevated liver enzymes, all consistent with worsening preeclampsia with risk for end-organ involvement. Severe preeclampsia can rapidly progress to eclampsia (seizures) and placental abruption due to poor placental perfusion and vascular instability. Early recognition of these complications is critical for maternal and fetal safety.
Rationale for correct choices:
• Seizures are the defining feature of eclampsia, which is a severe complication of preeclampsia. The client already demonstrates severe hypertension, hyperreflexia (4+ reflexes), and proteinuria, indicating significant central nervous system irritability. These findings increase the risk of cerebral edema and seizure activity. Without prompt management, preeclampsia can progress to eclampsia, which is life-threatening for both mother and fetus.
• Placental abruption is a serious complication of preeclampsia caused by vasospasm and impaired placental perfusion leading to premature separation of the placenta from the uterine wall. Severe hypertension and endothelial damage increase this risk. Although fetal status is currently stable, the underlying vascular instability places the client at high risk. Abruptions can lead to fetal distress, hemorrhage, and maternal instability.
Rationale for incorrect choices:
• Cervical insufficiency is a structural problem of the cervix that leads to painless cervical dilation and preterm birth, typically unrelated to hypertensive disorders of pregnancy. This client’s condition is driven by vascular and systemic endothelial dysfunction rather than cervical weakness. There ae no cervical changes or painless dilation in the assessment. Therefore, it is not a likely complication.
• Although preeclampsia can cause fluid shifts and increased vascular resistance, this client does not show clinical signs of cardiac failure such as pulmonary edema, crackles, or decreased oxygenation. Oxygen saturation is normal, and lung sounds are normal. Although edema is present, it is more consistent with preeclampsia-related fluid retention.
• Hypoglycemia is not associated with preeclampsia or hypertensive disorders of pregnancy. The client’s blood glucose is within normal limits, and there is no evidence of insulin use or fasting state contributing to low blood sugar. The symptoms and laboratory findings are unrelated to glucose metabolism. Therefore, hypoglycemia is not a relevant complication.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Clients receiving chemotherapy for Hodgkin’s lymphoma are highly immunocompromised due to bone marrow suppression, particularly neutropenia, which places them at high risk for infection. When a private room is unavailable, infection control principles guide appropriate roommate selection to minimize exposure to infectious pathogens. The safest roommate is one who does not have an infectious disease or transmissible condition. This reduces the risk of opportunistic infections in the immunosuppressed client.
Rationale:
A. Community-acquired pneumonia is an active respiratory infection that can be transmitted via droplets, making it unsafe for a severely immunocompromised client. Exposure could lead to severe or even life-threatening infection due to reduced immune defenses from chemotherapy. Therefore, this client should not be placed in the same room.
B. Paget’s disease is a noninfectious chronic bone disorder characterized by abnormal bone remodeling. It is not caused by pathogens and poses no risk of transmission to others. This is the safest option for roommate placement with an immunocompromised oncology client.
C. Herpes zoster is caused by reactivation of the varicella-zoster virus and is highly contagious through direct contact with lesions and airborne transmission in disseminated cases. Immunocompromised clients are at high risk for severe infection if exposed. This condition requires isolation precautions, making it inappropriate for shared room placement.
D. Clostridioides difficile colitis is a highly contagious gastrointestinal infection transmitted via spores through the fecal-oral route and contaminated surfaces. Immunocompromised clients are especially vulnerable to severe complications. Strict contact precautions are required, so sharing a room is contraindicated.
Correct Answer is A
Explanation
Evisceration is a surgical emergency in which abdominal organs protrude through a dehisced incision. It most commonly occurs after abdominal surgery due to increased intra-abdominal pressure or wound failure. Immediate nursing actions focus on protecting exposed organs, preventing further injury, and preparing for surgical intervention. Positioning is critical to reduce tension on the incision and minimize additional protrusion of abdominal contents.
Rationale:
A. Placing the client in a supine position with knees flexed helps reduce strain on the abdominal incision and decreases tension on the exposed organs. Flexing the knees relaxes abdominal muscles, minimizing further evisceration. This position is the immediate priority to stabilize the situation while awaiting surgical intervention.
B. Semi-Fowler’s position increases pressure on the abdominal cavity due to gravitational force and may worsen organ protrusion. This position places additional strain on the surgical incision and is therefore contraindicated in cases of evisceration. Immediate reduction of abdominal tension is the priority.
C. Covering the wound with a transparent dressing is not appropriate because it does not adequately protect exposed abdominal organs. Evisceration requires sterile, moist, and bulky dressings to prevent tissue drying and contamination. Transparent dressings do not provide sufficient coverage or moisture maintenance.
D. Covering the wound with a dry sterile dressing is also incorrect because exposed abdominal organs must be kept moist to prevent tissue desiccation and necrosis. Dry dressings can cause damage to protruding tissues. Instead, sterile gauze soaked in sterile saline is typically used to cover the site.
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