The nurse is continuing to assist with the care of the client.
Select words from the choices below to fill in each blank in the following sentence.
The complications that the client is at greatest risk for developing are
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
- Seizures: The client’s symptoms of severe hypertension, persistent headache, hyperreflexia, proteinuria, and low platelet count strongly indicate severe preeclampsia, a condition that can rapidly progress to eclampsia, where seizures occur. This is a critical obstetric emergency requiring immediate intervention to prevent maternal and fetal morbidity.
- Hypoglycemia: The client’s blood glucose level is 85 mg/dL, which is within the normal range. There are no signs such as diaphoresis, confusion, or weakness that would suggest hypoglycemia, and this condition is unrelated to the client's primary diagnosis of severe preeclampsia.
- Cervical insufficiency: Cervical insufficiency typically causes painless cervical dilation and is associated with second-trimester pregnancy losses. The client is at 31 weeks with no reported cervical changes, contractions, or painless dilation, making this complication unlikely in the current clinical scenario.
- Placental abruption: Severe hypertension increases the risk of placental abruption due to damage to the placental blood vessels. Signs of decreased fetal movement and the high-risk profile of preeclampsia support the concern that abruption could occur, leading to serious maternal and fetal compromise.
- Heart failure: Although the client has some edema, there are no other clinical signs such as dyspnea, crackles, or orthopnea that would suggest heart failure. The edema seen here is consistent with preeclampsia rather than decompensated cardiac function.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Tachycardia: Tachycardia, or an increased heart rate, is a common manifestation of opioid withdrawal. Withdrawal stimulates the sympathetic nervous system, leading to symptoms like tachycardia, sweating, anxiety, and restlessness.
B. Miosis: Miosis, or pinpoint pupils, is associated with opioid intoxication, not withdrawal. During withdrawal, pupils are often dilated (mydriasis) rather than constricted.
C. Hypotension: Hypertension, not hypotension, is more commonly seen during opioid withdrawal due to increased sympathetic nervous system activity. Blood pressure tends to rise rather than fall during withdrawal episodes.
D. Sedation: Sedation is a sign of opioid intoxication rather than withdrawal. Clients experiencing withdrawal are more likely to display agitation, irritability, and insomnia rather than drowsiness or sedation.
Correct Answer is ["B","C","E"]
Explanation
A. Withhold the medication until the provider signs the prescription: Telephone prescriptions are considered valid once received and properly documented. Delaying administration until a signature is obtained could compromise timely care. The provider must later sign the prescription, but administration should not be delayed if properly authorized.
B. Ask the provider to spell out the name of the medication: Asking for the spelling of the medication name helps prevent errors, especially with drugs that sound alike or have complex names. Clarification ensures correct medication administration and enhances client safety.
C. Request that the provider confirm the read-back of the prescription: Reading back the prescription and obtaining confirmation is a critical safety step. It verifies that the prescription was accurately understood and recorded, significantly reducing the risk of medication errors.
D. Instruct another user to record the prescription in the medical record: The nurse receiving the prescription must personally document it. Assigning this task to someone else increases the chance of miscommunication or transcription errors and violates professional documentation standards.
E. Record the date and time of the telephone prescription: Proper documentation of the date and time ensures an accurate, complete medical record. It establishes when the prescription was received, which is important for both clinical tracking and legal accountability.
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