The nurse is continuing to care for the client.

Exhibits
Which of the following conditions is the client is at greatest risk for developing? Select all that apply

seizures

hypoglycemia

cervical insufficiency

heart failure

placental abruption

Answer and Explanation

Correct Answer : A,E

Rationale for Correct Choices

• Seizures: The client’s BP of 166/110 mm Hg, +3 pitting edema, hyperreflexia (4+), and 3+ proteinuria are hallmark findings of severe preeclampsia, which places the client at high risk for progression to eclampsia (seizures). Cerebral edema and vasospasm associated with preeclampsia can precipitate convulsions if untreated.

• Placental abruption: Severe hypertension causes vasoconstriction and endothelial damage in uteroplacental vessels, predisposing the placenta to premature separation. This can lead to fetal distress, decreased movement, and potential maternal hemorrhage, both consistent with placental abruption risk in preeclampsia.

Rationale for Incorrect Choices

• Hypoglycemia: This condition is not related to preeclampsia; it more commonly occurs in clients with diabetes or from medication effects such as insulin overuse.

• Cervical insufficiency: This condition involves painless cervical dilation leading to preterm birth, unrelated to hypertension or proteinuria.

• Heart failure: Although hypertension increases cardiac workload, the current findings (normal heart rate, no dyspnea, clear lungs) do not indicate heart failure in this client.

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Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale:
A. Instruct the client’s partner to assume care of the colostomy for the client: Having the partner take over care may reinforce the client’s avoidance and hinder acceptance of the stoma. The goal is to promote gradual involvement and self-care.

B. Encourage the client and partner to avoid expressing negative feelings about the colostomy: Suppressing emotions can delay psychological adjustment. The nurse should instead encourage open discussion of feelings.

C. Transfer the client to a rehabilitation facility for instruction about self-management of the colostomy: Transferring the client is unnecessary at this stage and may add emotional stress. Education and emotional support can be effectively provided in the current care setting.

D. Suggest the client join a support group for people who have colostomies: Support groups provide opportunities to share experiences with others who have undergone similar surgeries. Peer support can reduce isolation, promote acceptance, and help the client adapt to lifestyle changes more confidently.

A. Reassure the client that their injuries are not life threatening. B. Limit the number of staff members providing care for the client. C. Ask the client for details about the assault. D. Instruct the client to shower and change their clothes.

Correct Answer is B

Explanation

Rationale:
A. Reassure the client that their injuries are not life threatening: While reassurance may seem supportive, minimizing the client’s experience or focusing on injury severity too early may invalidate their emotional trauma and hinder trust-building.

B. Limit the number of staff members providing care for the client: Limiting staff exposure promotes a sense of safety and control for the client, who may feel vulnerable and traumatized. Consistency in caregivers helps reduce anxiety and supports trauma-informed care principles by minimizing re-traumatization and promoting trust.

C. Ask the client for details about the assault: The nurse should not probe for specific details because repeated questioning can intensify trauma and emotional distress. Instead, the nurse should allow the client to share voluntarily when ready and defer detailed questioning to a trained sexual assault nurse examiner (SANE).

D. Instruct the client to shower and change their clothes: The client should not bathe, change, or wash clothing before evidence collection. The nurse should explain the importance of preserving evidence and provide clean clothing after the forensic examination is complete.

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The nurse is continuing to care for the client. Exhibits Which of the following conditions is the client is at greatest risk for developing? Select all that apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a newly created colostomy. The client's partner tells the nurse that the client refuses to look at the stoma. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse on a mental health unit is planning care for a client who is being admitted immediately following a sexual assault. Which of the following interventions should the nurse include in the plan of care?

Correct Answer is B

Explanation

A nurse is caring for a client who has expressive aphasia. Which of the following actions should the nurse take to assist the client in overcoming communication barriers?

A nurse is caring for a client who has bacterial vaginosis. Which of the following medications should the nurse expect the provider to prescribe?

A nurse in an outpatient clinic is assessing a client who is pregnant for unsafe behaviors during pregnancy. Which of the following findings indicates a need for further evaluation?

A nurse is counseling a group of clients from a town that was affected by a hurricane 6 months ago. For which of the following clients should the nurse initiate a referral to assess for the presence of posttraumatic stress disorder? (Select all that apply.)

A nurse is conducting a workshop on the importance of interprofessional collaboration. Which of the following is included in the tertiary prevention phase in interprofessional care?

A nursery nurse is attending the birth of a post-term infant. Exhibits Upon review of the medical record, the infant newborn is at risk for developing which of the following symptoms? Select all that apply

A nurse is assessing self-management skills for a client who has preeclampsia without severe features. Which of the following client statements should the nurse recognize as an indication the client is coping effectively?

The nurse is continuing to care for the client.

Exhibits
Which of the following conditions is the client is at greatest risk for developing? Select all that apply