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. "I will support your decision and help you explain it to others.": This response respects the client's autonomy and decision-making rights. It also offers emotional support and assistance in communicating the client's wishes to other healthcare team members or family, promoting dignity and advocacy.
B. "Let me explain the pros and cons of your decision.": This response may sound judgmental and suggest that the nurse is trying to influence the client's decision. Once a competent client has made a choice, the nurse’s role is to support it rather than attempt to persuade or second-guess it.
C. "I suggest you discuss this decision with your family first.": While family discussions can be valuable, the client has the primary right to make healthcare decisions. Suggesting they must discuss it with family could delay honoring the client’s wishes or create unnecessary emotional pressure.
D. "I will send the social worker in to discuss this decision with you.": While a social worker can provide additional support, immediately deferring to someone else instead of acknowledging the client’s decision can make the client feel dismissed. The nurse should first validate and support the client’s expressed wishes.
Correct Answer is B
Explanation
A. Black out the line with a felt-tip pen: Blacking out a space or entry is inappropriate because it obscures the original documentation, making the record appear altered or falsified. Medical documentation must remain clear, transparent, and legally defensible at all times.
B. Draw a horizontal line through the space and sign at the end of the line: Drawing a single horizontal line through the blank space ensures that no unauthorized additions can be made later. Signing at the end of the line maintains the integrity and completeness of the medical record, following accepted documentation standards.
C. Place the date at the beginning of the space, followed by double lines: Simply dating the space without properly securing it with a line could leave it open to later insertions. Double lines are also not a recognized standard method for handling blank spaces in documentation.
D. Leave the space as it is within the entry: Leaving a blank space unmarked can create opportunities for someone to add unauthorized information later. This poses legal and ethical risks and compromises the reliability and security of the medical record.
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