The nurse is continuing to assist with the care of the client.
Nurses' Notes.
0900: 0930: Client is at 31 weeks of gestation and presents with a severe headache unrelieved by acetaminophen.
Client also reports urinary frequency and decreased fetal movement.
Client is a. gravida 3, para 2 with one preterm birth.
Client reports a constant and throbbing headache and rates their pain as a 6 on a scale of 0 to 10.
Denies visual disturbances.
+3 pitting edema in bilateral lower extremities.
Patellar reflex 4+ without the presence of clonus.
Client reports occasional nighttime leg cramps.
Reports 3 fetal movements within the last 30 min.
External fetal monitor applied with a. baseline FHR 140/min with occasional accelerations and moderate variability.
No uterine contractions noted.
The nurse is reviewing the findings.
For each finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome.
Each finding may support more than one disease process.
Blood pressure
Hemoglobin
Platelet count
Alanine aminotransferase
The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}
Blood pressure: This finding is consistent with preeclampsia, but not HELLP syndrome. Preeclampsia is defined as new-onset hypertension (systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg) after 20 weeks of gestation, with or without proteinuria. HELLP syndrome is a severe form of preeclampsia that involves hemolysis, elevated liver enzymes, and low platelets, but does not necessarily cause hypertension. Hemoglobin: This finding is consistent with HELLP syndrome, but not preeclampsia.
Hemolysis is one of the main features of HELLP syndrome, which causes a decrease in hemoglobin levels. Preeclampsia does not typically affect hemoglobin levels, unless there is significant blood loss or hemodilution.
Platelet count: This finding is consistent with both preeclampsia and HELLP syndrome. Low platelets (thrombocytopenia) are a common complication of preeclampsia, especially in severe cases. They are also a diagnostic criterion for HELLP syndrome, which requires a platelet count of less than 100,000/mm3.
Alanine aminotransferase: This finding is consistent with HELLP syndrome, but not preeclampsia. Elevated liver enzymes are another hallmark of HELLP syndrome, which indicates liver damage and inflammation. Preeclampsia may cause mild elevations of liver enzymes, but not to the same extent as HELLP syndrome.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B,C"},"C":{"answers":"B,C"},"D":{"answers":"B,C"},"E":{"answers":"B,C"},"F":{"answers":"A"}}
Explanation
|
Condition |
Definition |
Causes |
Symptoms |
Treatment |
|
Agranulocytosis |
A severe and potentially life-threatening reduction in the number of white blood cells (neutrophils) that fight infection. |
Can be caused by some antipsychotic medications, such as clozapine, olanzapine, and quetiapine. |
Sore throat, fever, chills, mouth ulcers, infections, bleeding, and fatigue. |
Discontinuation of the offending medication, antibiotics, antifungals, and granulocyte colony-stimulating factor (G-CSF) injections to stimulate the bone marrow to produce more white blood cells. |
|
Neuroleptic Malignant Syndrome (NMS) |
A rare but serious reaction to antipsychotic medications, especially the older ones, such as haloperidol, fluphenazine, and chlorpromazine. |
Can be triggered by high doses, rapid dose changes, or switching of antipsychotic medications. |
High fever, muscle rigidity, altered mental status, autonomic instability (blood pressure changes, tachycardia, sweating, etc.), and elevated creatine kinase levels. |
Discontinuation of the offending medication, supportive care, cooling measures, hydration, and medications such as dantrolene, bromocriptine, or amantadine to counteract the effects of dopamine blockade. |
|
Serotonin Syndrome |
A potentially life-threatening condition caused by excessive levels of serotonin in the brain. |
Can be caused by taking too much of a serotonin-enhancing medication, such as selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), or other drugs that affect serotonin levels, such as tramadol, linezolid, or St. John’s wort. Can also be caused by combining two or more serotonin-enhancing medications. |
Agitation, confusion, disorientation, anxiety, hallucinations, muscle spasms, tremors, shivering, hyperreflexia, incoordination, diarrhea, nausea, vomiting, blood pressure changes, tachycardia, and hyperthermia. |
Discontinuation of the offending medication(s), supportive care, hydration, and medications such as benzodiazepines, cyproheptadine, or serotonin antagonists to reduce serotonin levels. |
Correct Answer is D
Explanation
The correct answer is Choice D: Obtain the client's weight.
Choice D rationale: Obtaining the client's weight is crucial in planning hemodialysis treatment, as it helps determine the amount of fluid that needs to be removed during the procedure. This information contributes to accurate calculation of the ultrafiltration rate, ensuring adequate fluid balance and preventing potential complications associated with fluid overload or excessive fluid removal.
Choice A rationale: Encouraging the client to increase fluid intake is not recommended in the context of hemodialysis, as excessive fluid intake may result in fluid overload, a common complication in patients undergoing this treatment. Instead, the nurse should advise the client on appropriate fluid restrictions, taking into account their individualized plan of care.
Choice B rationale: Reinforcing the practice of sleeping on the side of the access site is not advisable because it could lead to increased pressure on the arteriovenous fistula, potentially causing complications such as thrombosis or stenosis. It is generally recommended that clients avoid putting pressure on the access site, particularly during sleep or when engaging in activities that could cause direct contact with the area.
Choice C rationale: Obtaining the client's blood pressure in either arm is not the appropriate approach, as the arm with the arteriovenous fistula should not be used for blood pressure measurements or any other procedures that could damage the fistula. Blood pressure should be measured in the non-access arm to ensure the integrity of the vascular access and minimize the risk of complications.
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