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The nurse is continuing to care for the client.

Exhibits
The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.

Provide a low-stimulation environment.

Maintain bed rest

Give antihypertensive medication

Obtain a 24-hr urine specimen

Perform a vaginal examination every 12 hr.

Monitor intake and output hourly

Administer betamethasone

Answer and Explanation

Correct Answer : A,B,C,D,F,G

Rationale:

A. Provide a low-stimulation environment: The client has a severe headache, 3+ proteinuria, and elevated BP, indicating severe preeclampsia. A quiet, low-light environment reduces the risk of seizure by limiting neurologic stimulation.

B. Maintain bed rest: Bed rest in a side-lying position improves uteroplacental blood flow and helps lower blood pressure. It also decreases metabolic demand, which is critical in hypertensive pregnancies.

C. Give antihypertensive medication: The BP readings (162/112 and 166/110 mm Hg) require immediate antihypertensive therapy to prevent cerebral hemorrhage, eclampsia, or placental abruption.

D. Obtain a 24-hr urine specimen: A 24-hour urine collection for protein is the gold standard for quantifying proteinuria and confirming the diagnosis of preeclampsia. While a dipstick of 3+ is a strong indicator, the 24-hour collection provides a definitive measurement.

E. Perform a vaginal examination every 12 hr: There are no contractions or signs of labor, so regular vaginal exams are not indicated and increase the risk of infection in a preterm pregnancy.

F. Monitor intake and output hourly: Decreased renal perfusion is a complication of preeclampsia. Hourly monitoring detects oliguria early and helps assess for fluid overload or worsening renal function.

G. Administer betamethasone: At 31 weeks, betamethasone is indicated to enhance fetal lung maturity due to risk of preterm delivery from severe maternal complications.

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Correct Answer is A

Explanation

Rationale:

A. Smoked salmon: Smoked and aged foods are high in tyramine, which can interact dangerously with phenelzine, a monoamine oxidase inhibitor (MAOI). This interaction can trigger a hypertensive crisis, making smoked salmon a food to avoid during therapy.

B. Cottage cheese: Cottage cheese contains low levels of tyramine compared to aged cheeses and is generally considered safe for clients taking MAOIs like phenelzine. It does not pose a significant risk for hypertensive crisis.

C. Grapefruit: Grapefruit can interact with many medications by affecting liver enzymes, but it does not have a known interaction with phenelzine. The concern with phenelzine is primarily with tyramine-rich foods, not citrus fruits.

D. Spinach: Spinach is not high in tyramine and does not interact with MAOIs. It is a leafy green that is safe and healthy for clients to consume while on phenelzine.

A. Call in additional medical-surgical unit nursing care staff. B. Act as a liaison between the facility and the media. C. Determine the medical needs of incoming clients through the emergency department. D. Recommend to the provider specific acute care clients for discharge.

Correct Answer is D

Explanation

Rationale:

A. Call in additional medical-surgical unit nursing care staff: The initial priority during a mass casualty event is to maximize available resources and free up beds by discharging stable clients. Staffing adjustments come after determining how to expand capacity.

B. Act as a liaison between the facility and the media: This role falls under the responsibilities of public relations or designated administrative personnel. Nurses should focus on patient care and operational tasks relevant to their scope during a crisis.

C. Determine the medical needs of incoming clients through the emergency department: Triage of incoming casualties is performed by designated emergency department staff. Nurses from other units typically assist by creating space or relocating stable clients.

D. Recommend to the provider specific acute care clients for discharge: Identifying stable clients who can be safely discharged allows beds and resources to be allocated to incoming critical cases. This is an appropriate and immediate nursing response during mass casualty.

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The nurse is continuing to care for the client. Exhibits The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.

Nursing Test Bank

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The nurse is continuing to care for the client.

Exhibits
The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.