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
_
and
_

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Tachycardia: Amphetamines are central nervous system stimulants that increase sympathetic nervous system activity. Tachycardia is a common manifestation of acute toxicity, along with hypertension, hyperthermia, and agitation. Monitoring cardiovascular status is essential to prevent complications.

B. Headache: While headaches can occur with amphetamine use, they are not a primary or consistent finding in acute toxicity. More prominent signs are cardiovascular and neurological stimulation rather than mild symptoms like headache.

C. Increased appetite: Amphetamines typically suppress appetite rather than increase it. Clients experiencing acute toxicity are more likely to have decreased hunger due to stimulant effects on the hypothalamus.

D. Pupil constriction: Amphetamines usually cause mydriasis (pupil dilation) due to sympathetic stimulation. Pupil constriction is more characteristic of opioid toxicity rather than amphetamine toxicity.

A. "Attempt to gag” B. "Take an antiemetic when feeling nauseated." C. "Apply firm pressure to the eyes." D. "Eat a high-fiber diet to keep stools soft." E. "Bear down to slow the pulse rate."

Correct Answer is ["B","D"]

Explanation

A. "Attempt to gag": Gagging stimulates the vagus nerve and can worsen bradycardia. Clients should be instructed to avoid actions that trigger the gag reflex, so this instruction is not recommended.

B. "Take an antiemetic when feeling nauseated.": Nausea and vomiting can increase vagal stimulation. Taking an antiemetic as prescribed helps prevent excessive vagal nerve activation, which can reduce the risk of further slowing the heart rate.

C. "Apply firm pressure to the eyes": Applying pressure to the eyes can stimulate the vagus nerve, potentially exacerbating bradycardia. Clients should avoid eye rubbing or pressure.

D. "Eat a high-fiber diet to keep stools soft": Straining during defecation stimulates the vagus nerve and can worsen bradycardia. A high-fiber diet promotes regular, soft stools and helps prevent straining, thereby reducing vagal stimulation.

E. "Bear down to slow the pulse rate": Bearing down (Valsalva maneuver) directly increases vagal stimulation, which can dangerously slow the heart rate in clients with bradycardia. This action should be avoided.

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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 _____ and _____

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is experiencing acute amphetamine toxicity. Which of the following findings should the nurse expect?

Correct Answer is A

Explanation

A nurse is teaching a client who has bradycardia about how to prevent vagal stimulation. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["B","D"]

Explanation

A nurse is leading a grief support group. Which of the following statements by a participant should the nurse identify as an indication of an appropriate grief response?

The nurse is continuing to care for the client. The nurse is assessing the client. Which of the following findings indicate an improvement in the client's condition? Select all that apply.

A nurse is teaching a client about routine prenatal testing, which of the following statements should the nurse include in the teaching?

A nurse manager is teaching a group of nurses about bacterial meningitis. Which of the following information should the nurse include in the teaching?

A nurse is caring for a client who wants to leave the facility against medical advice. In an attempt to prevent the client from leaving, an assistive personnel (AP) has hidden the client's car keys. Which of the following torts is the AP committing by hiding the client's car keys?

A nurse is providing fire safety training to a newly licensed nurse. Which of the following statements indicates an understanding of the teaching?

A nurse is caring for a client who has recently undergone a bilateral mastectomy. The client states they do not want to live anymore. Which of the following actions should the nurse take?

A nurse is teaching a quality improvement course about decreasing the number of urinary tract infections for clients who have indwelling urinary catheters. Which of the following information should the nurse include in the teaching?

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
_
and
_