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.

Choice A rationale:

Identification is a defense mechanism where an individual associates themselves with another person or group. It does not apply to the situation described in the question.

Choice B rationale:

Reaction formation involves expressing the opposite of one's true feelings or desires. It is not the most suitable defense mechanism for the situation where the adolescent blames the teacher for their failure.

Choice C rationale:

Regression refers to reverting to an earlier stage of development in response to stress or conflict. It does not align with the adolescent's statement about their teacher disliking athletes.

Choice D rationale:

Rationalization is the defense mechanism in which a person provides logical or socially acceptable reasons for their behavior, even if these reasons are not accurate. In this case, the adolescent is rationalizing their poor performance by blaming the teacher's bias against athletes. This choice best fits the situation described.

Choice A rationale:

Encourage the client to have continual bed rest. Rationale: Continual bed rest is not the appropriate intervention for a client experiencing chronic fatigue due to leukemia. Prolonged bed rest can lead to further weakness and deconditioning. Encouraging some level of physical activity, such as gentle exercise, can help improve strength and reduce fatigue.

Choice B rationale:

Encourage strength-training exercise. Rationale: This is the correct intervention for a client with leukemia experiencing chronic fatigue. Strength-training exercises, when appropriate and under the guidance of healthcare professionals, can help improve muscle strength and overall endurance. It can combat the fatigue commonly associated with leukemia and its treatment.

Choice C rationale:

Increase the client's fluids to 4 L per day. Rationale: While adequate hydration is essential, increasing fluids to 4 liters per day may not be appropriate for every client. The optimal fluid intake for a client should be determined based on their individual needs and medical condition. Excessive fluid intake without medical indication can lead to complications like fluid overload.

Choice D rationale:

Increase protein in the diet. Rationale: Increasing protein intake can be beneficial for clients with leukemia as it helps in tissue repair and supports the immune system. However, it should be done in consultation with a registered dietitian to ensure that the client's specific dietary needs are met.