The nurse is continuing to care for the client.
Drag words from the choices below to fill in each blank in the following sentence.
The client is at greatest risk for developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"C"}
Rationale for correct choices
• Seizures: The client presents with severe hypertension (BP 162/112 mm Hg and 166/110 mm Hg), +3 pitting edema, and proteinuria (3+), which are classic indicators of severe preeclampsia. These factors place the client at high risk for eclampsia, which manifests as seizures during pregnancy. Close monitoring and early intervention are critical to prevent maternal and fetal complications.
• Placental abruption: Severe hypertension and preeclampsia increase the risk of placental abruption, a condition in which the placenta separates prematurely from the uterine wall. This can compromise fetal oxygenation and lead to significant maternal bleeding. The client’s elevated blood pressure, edema, and decreased fetal movement indicate a higher likelihood of this obstetric emergency.
Rationale for incorrect choices
• Heart failure: Although hypertension and fluid shifts in preeclampsia can strain the heart, there is no current evidence of pulmonary edema, dyspnea, or heart failure symptoms in this client. Heart failure is a less immediate risk compared with seizures and placental abruption in the context of severe preeclampsia.
• Hypoglycemia: There is no indication of low blood glucose in the client; laboratory results show glucose within normal limits (85 mg/dL). Hypoglycemia is not a typical complication of preeclampsia and is therefore not an immediate concern in this scenario.
• Cervical insufficiency: Cervical insufficiency typically presents earlier in gestation with painless dilation and risk of preterm birth, rather than in a 31-week client with hypertensive complications. The client’s symptoms of headache, edema, and proteinuria do not indicate cervical insufficiency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Denial: Denial is an expected initial stage of grief in response to terminal illness. Clients may have difficulty accepting the diagnosis and may refuse to believe the reality of their condition as a coping mechanism.
B. Reorganization: Reorganization is a later stage of grief associated with adapting to loss after bereavement. It is not typically part of the immediate response to a terminal diagnosis in the dying process.
C. Numbing: Numbing is more commonly associated with acute grief reactions following sudden loss, rather than the anticipatory grief experienced after a terminal diagnosis.
D. Reinvesting: Reinvesting refers to redirecting emotional energy into new relationships or activities after loss. This stage occurs after bereavement and is not part of the expected stages of grief during the dying process.
Correct Answer is A
Explanation
A. Take this medication at the same time each day: Consistent timing helps maintain stable anticoagulation levels and reduces the risk of under- or over-anticoagulation. Warfarin’s effectiveness and safety depend on steady dosing and adherence to a regular schedule.
B. Take ginger for constipation while on this medication: Ginger can increase the risk of bleeding when taken with warfarin due to its antiplatelet properties. Clients should avoid supplements or herbal remedies that may interact with anticoagulants unless approved by the healthcare provider.
C. Eat foods high in vitamin K: Foods high in vitamin K, such as leafy greens, can decrease the effectiveness of warfarin by promoting clotting. Clients should maintain a consistent intake rather than increasing consumption to avoid fluctuations in anticoagulation levels.
D. Shave with disposable razors: Clients on warfarin are advised to use electric razors instead of disposable or manual razors to reduce the risk of cuts and bleeding. Using disposable razors increases the likelihood of minor injuries that can lead to excessive bleeding.
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