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":"D"}
Rationale for Correct Choices:
- Seizures: The client presents with severe preeclampsia, indicated by BP >160/110 mm Hg, 3+ proteinuria, hyperreflexia (patellar reflex 4+), and persistent headache. These are strong predictors of progression to eclampsia, which is marked by seizures.
- Placental Abruption: Severe hypertension increases the risk of placental abruption due to vascular compromise in the uteroplacental circulation. Decreased fetal movement may be an early warning sign of impaired placental perfusion or separation.
Rationale for Incorrect Choices:
- Cervical Insufficiency: This is a painless cervical dilation often leading to second-trimester loss, unrelated to hypertension or proteinuria. The client is in the third trimester with no signs of cervical changes.
- Hypoglycemia: The client has no history of diabetes, glucose intolerance, or related symptoms. Her urine glucose was only trace, and no medications suggest insulin use.
- Heart Failure: No signs of pulmonary congestion, dyspnea, or elevated heart rate are present. Oxygen saturation is normal, and breath sounds are not mentioned as abnormal, making CHF unlikely at this stage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Penicillin: Saw palmetto does not interfere with antibiotic action or metabolism. No significant pharmacodynamic or pharmacokinetic interaction exists between penicillin and saw palmetto.
B. Zolpidem: While both may cause some central nervous system effects, there is no established adverse interaction between zolpidem and saw palmetto. Co-administration is generally not contraindicated.
C. Clopidogrel: Saw palmetto has antiplatelet properties and can potentiate the effects of clopidogrel, increasing the risk of bleeding. Clients taking both may face elevated risk of gastrointestinal or intracranial hemorrhage.
D. Ipratropium: Ipratropium is an anticholinergic agent used primarily for respiratory conditions. It does not have a known interaction with saw palmetto, and their pharmacologic mechanisms do not overlap.
Correct Answer is B
Explanation
Rationale:
A. A client who has heart failure and received a diuretic 30 min ago: While this client should be monitored for urine output and signs of dehydration or electrolyte imbalance, there is no indication of acute distress requiring immediate attention.
B. A client who has hypertension and reports a severe headache: This could indicate a hypertensive crisis or impending stroke, both of which are life-threatening and require urgent assessment and intervention to prevent neurological damage or organ failure.
C. A client who reports frequent and painful urination: These are signs of a urinary tract infection, which, while uncomfortable, is not typically emergent unless accompanied by fever, flank pain, or systemic symptoms.
D. A client who reports left arm pain following a fall: The arm pain may indicate a fracture, but it is less urgent than potential end-organ damage from a hypertensive emergency, assuming no deformity or vascular compromise is described.
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