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
The correct answer is choice b. Charge nurse.
Choice b rationale: The charge nurse is the appropriate personnel to report the incorrect blood glucose monitoring by the assistive personnel. As the nurse in charge of the unit, the charge nurse has the authority and responsibility to address issues related to patient care and ensure that nursing staff, including assistive personnel, are providing care according to facility policies and procedures
Choice a rationale: While the nurse manager is responsible for overseeing the nursing staff and ensuring quality patient care, it is more appropriate to report the incident to the charge nurse first, as they are directly responsible for the unit and can immediately address the issue
Choice c rationale: The risk manager is responsible for identifying, assessing, and mitigating risks within the healthcare facility. While the incorrect blood glucose monitoring could be considered a risk, it is not the primary role of the risk manager to address issues related to patient care. The charge nurse is better positioned to address the immediate concern and ensure proper training or corrective action for the assistive personnel.
Choice d rationale: The nurse supervisor is responsible for overseeing and managing nursing staff, similar to the nurse manager. However, the charge nurse is the more appropriate personnel to report the incident to, as they are directly responsible for the unit and can immediately address the issue
Correct Answer is D
Explanation
The correct answer is d. To cremate the client’s body.
Choice A reason: This choice is incorrect because Hinduism does not generally prohibit medical personnel from touching the deceased’s body. In fact, it is customary for family members to prepare the body for cremation, which may include washing and dressing.
Choice B reason: This statement is incorrect as there is no specific tradition in Hinduism that requires the family to stay with the body for 8 hours following death.
Choice C reason: This option is incorrect because Hinduism typically does not prescribe burial within 24 hours of death. While some religions have specific time frames for burial, Hinduism generally prefers cremation over burial.
Choice D reason: This is the correct choice. Cremation is preferred in Hinduism and is usually performed as soon as possible, traditionally by the next day. It is believed to release the soul and help in its onward journey.
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