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

and

Answer and Explanation

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.

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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.

A. Place the client in a room near the nurses' station. B. Check on the client every 4 hr. C. Place the call light within the client's reach D. Place the client's glasses on the bedside table

Correct Answer is A

Explanation

A. Place the client in a room near the nurses' station: Clients with quadriplegia are at high risk for complications such as respiratory difficulties, pressure injuries, and autonomic dysreflexia. Placing them near the nurses’ station allows for closer monitoring and quicker response to any urgent needs.

B. Check on the client every 4 hr: Clients with quadriplegia require more frequent monitoring than every 4 hours. Regular repositioning, skin assessments, and prompt attention to needs must occur at much shorter intervals to prevent complications.

C. Place the call light within the client's reach: A client with quadriplegia typically has limited or no use of their upper extremities. Therefore, they would be unable to effectively use a standard call light and would need alternative methods, such as a specialized call device.

D. Place the client's glasses on the bedside table: If the client is unable to move their arms due to quadriplegia, placing glasses on the bedside table would not be useful. Necessary personal items should be made accessible through assistance or adaptive equipment.

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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 ______ and ______

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is documenting client care in the nurses' notes and notices that a space was left blank. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is assisting in the care of a client who has quadriplegia. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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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

and