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
Explanation
Choice A rationale:
The nurse should encourage the client to be assertive. Dependent Personality Disorder is characterized by a pervasive and excessive need to be taken care of, leading to submissive and clinging behavior. One of the treatment goals is to help the client develop assertiveness skills to reduce their dependence on others. Encouraging assertiveness allows the client to express their needs and make decisions for themselves, which is an essential aspect of their therapeutic journey toward independence.
Choice B rationale:
Assuming responsibility for making the client's decisions would not be appropriate. It would further reinforce the client's dependent behavior and hinder their progress towards independence. The goal of therapy is to promote autonomy and self-reliance, not to perpetuate dependency.
Choice C rationale:
Maintaining a verbal no-harm contract with the client may be necessary in some cases, especially if the client exhibits self-harming behaviors. However, it is not a primary teaching point when educating the caregiver about managing a client with Dependent Personality Disorder. The focus should primarily be on helping the client develop assertiveness and self-reliance.
Choice D rationale:
Limiting the client's social interactions is not an appropriate intervention. Social support can be beneficial for individuals with Dependent Personality Disorder, as it can help them build self-confidence and reduce their excessive reliance on one individual. Isolating the client would not be in their best interest.
Correct Answer is B
Explanation
Choice A rationale:
Soft bowel sounds at a rate of 1 per minute describe hypoactive bowel sounds, which indicate decreased motility. This choice does not describe hyperactive bowel sounds.
Choice B rationale:
High-pitched bowel sounds are characteristic of hyperactive bowel sounds. These sounds are associated with increased motility and can indicate conditions such as diarrhea or early bowel obstruction. This choice correctly describes hyperactive bowel sounds.
Choice C rationale:
The absence of bowel sounds after listening for 3 to 5 minutes is indicative of absent or hypoactive bowel sounds, not hyperactive bowel sounds.
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