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 B
Explanation
Choice A rationale:
Removing wrist restraints one at a time from a calm client, while not following the recommended two-person verification process, is a potential safety concern but may not require an incident report. However, it should be addressed according to the facility's policies and procedures.
Choice B rationale:
An electronic IV pump delivering twice the prescribed amount of fluid is a critical incident that should be reported immediately via an incident report. Such errors can have serious consequences for the patient and may require immediate intervention.
Choice C rationale:
Discovering that a client's family member administered a PCA dose is also a significant event that should be reported via an incident report. PCA (Patient-Controlled Analgesia) dosing should only be administered by healthcare professionals to ensure safe and accurate medication delivery.
Choice D rationale:
Observing a client vomiting after receiving an oral pain medication should be addressed and documented in the patient's medical record as a change in the patient's condition, but it may not necessarily require an incident report unless there are extenuating circumstances or complications.
Correct Answer is C
Explanation
Choice A rationale:
Replacing the ear molds once per year is not a standard recommendation for hearing aid maintenance. The frequency of ear mold replacement may vary depending on individual needs and wear and tear. It is not necessary to replace them annually unless there is a specific issue with the ear molds.
Choice B rationale:
Disinfecting the hearing aid with isopropyl alcohol is not recommended for routine cleaning. Isopropyl alcohol can damage the components of the hearing aid, including the microphone and receiver. Cleaning solutions specifically designed for hearing aids or a soft cloth are safer options for routine cleaning.
Choice C rationale:
Cleaning the hearing aid with a soft cloth is the correct action to take when caring for hearing aids. Routine cleaning with a soft cloth helps remove dust, debris, and earwax from the hearing aid's surface without causing damage to the components. It is a safe and effective method of maintaining hearing aid hygiene.
Choice D rationale:
Changing the battery once per month is not a fixed rule for all hearing aids. The frequency of battery replacement depends on the type of hearing aid, battery size, and individual usage patterns. Some batteries may last longer than a month, while others may need replacement sooner. Clients should be instructed to replace the battery when it no longer functions effectively.
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