The nurse is continuing to care for the client.

A nurse is evaluating the client's response to therapy. Which of the following recent findings indicate the client's condition has improved or not changed?

For each assessment finding, click to specify if the finding indicates that the client's condition has improved or has not changed.

Deep tendon patellar reflex

Heart rate

Blood pressure

Edema

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"}}

Rationale:

• Deep tendon patellar reflex: The client’s patellar reflex decreased from 4+ on day 1 to 2+ on day 2, indicating reduced hyperreflexia. This suggests a positive response to antihypertensive and preeclampsia management, lowering the risk for complications such as eclampsia or seizures.

• Heart rate: The client’s heart rate increased slightly from 84/min on day 1 to 90/min on day 2, which falls within a normal physiologic range and does not indicate significant improvement or deterioration. This shows that cardiovascular status has remained relatively stable.

• Blood pressure: Blood pressure decreased from severely elevated readings (162/112 mm Hg and 166/110 mm Hg) to 152/90 mm Hg, reflecting a partial response to antihypertensive therapy. Although still above normal, the downward trend indicates some improvement in maternal hemodynamic status.

• Edema: The client continues to have +3 pitting edema in bilateral lower extremities, which has not improved since the previous day. Persistent edema suggests that fluid balance and vascular permeability issues related to preeclampsia remain a concern and require ongoing monitoring.

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Correct Answer is D

Explanation

A. “I will overarticulate words when speaking.": Overarticulating words can distort speech and make it more difficult for a client with hearing loss to understand. Clear, normal articulation combined with visual cues is more effective for communication.

B. “I will repeat words not heard by the client": Repeating words is useful, but it is a secondary strategy. Effective communication begins with proper positioning and visual cues, which enhance understanding before repetition is needed.

C. “I will speak in a loud voice when addressing the client.": Speaking louder does not necessarily improve comprehension and can distort speech. Many clients with hearing loss benefit more from clear, normal-volume speech and lip-reading rather than increased volume.

D. “I will face the client when speaking": Facing the client allows them to use visual cues, such as lip reading and facial expressions, which significantly improves understanding. This technique is the primary and most effective communication strategy for clients with hearing loss.

A. Administer calcium gluconate for urine output less than 50 mL/hr. B. Check deep tendon reflexes every 8 hr C. Administer one dose of betamethasone now and repeat in 24 hr. D. Limit IV intake to no more than 200 mL/hr.

Correct Answer is C

Explanation

A. Administer calcium gluconate for urine output less than 50 mL/hr: Calcium gluconate is given to treat magnesium sulfate toxicity, which is indicated by absent deep tendon reflexes, respiratory depression, or high serum magnesium levels. Low urine output requires monitoring but does not automatically warrant calcium gluconate administration.

B. Check deep tendon reflexes every 8 hr: Deep tendon reflexes should be assessed frequently during magnesium sulfate therapy, usually every 1–2 hours, to detect early signs of toxicity. Checking only every 8 hours is insufficient for safe monitoring.

C. Administer one dose of betamethasone now and repeat in 24 hr: Betamethasone is given to accelerate fetal lung maturity in preterm gestation, which is critical at 31 weeks. Administering the two-dose course as prescribed helps reduce neonatal respiratory complications, making this a priority intervention alongside magnesium sulfate therapy.

D. Limit IV intake to no more than 200 mL/hr: Monitoring and limiting IV fluids helps prevent fluid overload and pulmonary edema in preeclamptic clients, but ensuring fetal lung maturity with betamethasone takes priority at this gestational age in case of an early delivery.

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Naxlex Comprehensive Predictor Exams

A charge nurse is discussing communication techniques to use with a client who has hearing loss with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates the teaching was effective?

Correct Answer is D

Explanation

A nurse is planning care for a client who is at 31 weeks of gestation and has preeclampsia with severe features. The client has a new prescription for magnesium sulfate via continuous IV infusion. Which of the following actions should the nurse plan to take?

Correct Answer is C

Explanation

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