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

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

The correct answer is: d. Location of the identification tag on the client’s body.

Choice A reason: The cause of the client’s death is determined by a physician or a medical examiner and is not typically documented by nurses in postmortem documentation. The cause of death is a medical determination that involves a complex process, including examination and possibly an autopsy.

Choice B reason: The last set of the client’s vital signs is relevant prior to death and is part of the end-of-life documentation. However, once the client has passed away, recording vital signs is no longer applicable and is not included in postmortem documentation.

Choice C reason: A copy of the client’s advance directives is an important document that outlines the client’s wishes regarding medical treatment and interventions. While it is crucial before the client’s death, it does not need to be included in postmortem documentation, as it serves no purpose after death.

Choice D reason: The location of the identification tag on the client’s body is a critical piece of information that must be included in postmortem documentation. This ensures that the body is correctly identified throughout the postmortem process, including during transfer to a mortuary or funeral home.

A. New onset of hearing loss. B. Slurred speech. C. Hyperthermia. D. Hypotension.

Correct Answer is A

Explanation

Choice A rationale:

Gentamicin is known to have ototoxic effects and can lead to hearing loss, especially when administered via IV infusion. Monitoring for hearing changes is crucial to prevent permanent damage.

Choice B rationale:

Slurred speech is not a common adverse effect of gentamicin. It is more associated with neurological issues or medications affecting the central nervous system.

Choice C rationale:

Hyperthermia is not a typical adverse effect of gentamicin. It may be a sign of infection or another underlying condition but is not directly related to the medication.

Choice D rationale:

Hypotension is not a common adverse effect of gentamicin. It is more commonly associated with medications that affect blood pressure or underlying medical conditions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is completing postmortem documentation for a client. Which of the following information should the nurse include in the documentation?

Correct Answer is D

Explanation

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion.Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

Correct Answer is A

Explanation

A nurse is caring for an older adult client who wears hearing aids with detachable ear molds.Which of the following actions should the nurse take when caring for the hearing aids?

A nurse is assisting a client who has irritable bowel syndrome with meal selections.Which of the following foods should the nurse remind the client to include in her diet?

A nurse is reinforcing teaching with a client who is postpartum about the measles, mumps, and rubella (MMR) vaccine.Which of the following instructions should the nurse include in the teaching?

A nurse is reinforcing teaching with a client who has an open leg wound and is experiencing difficulty healing.The nurse should encourage the client to increase which of the following nutrients in his diet?

A nurse is reinforcing teaching about foot care with a client who has type 2 diabetes mellitus.Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for an adolescent who states, "I failed my math exam because the teacher doesn't like athletes." The nurse should identify that the adolescent is using which of the following defense mechanisms?

A nurse is assisting with the admission of a client who has varicella zoster. Which of the following interventions should the nurse plan to implement?

A nurse is contributing to an in-service for newly licensed nurses about situations requiring an incident report. Which of the following examples should the nurse include?