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 ["C","E","F","H"]

Explanation

Rationale for Correct Choices:

• Right forearm and fingers are edematous: Swelling after trauma can indicate a fracture, severe soft tissue injury, or early compartment syndrome. Prompt assessment and imaging are necessary to prevent complications such as impaired circulation or permanent tissue damage.

• Fingers slightly cool to touch: Cool fingers suggest compromised blood flow, possibly due to vascular injury or compartment syndrome. Immediate evaluation is critical to restore perfusion and prevent ischemic injury.

• Child can move fingers and reports a mild "tingling" sensation: Paresthesia signals potential nerve compression or early compartment syndrome. Timely intervention can prevent permanent nerve damage or loss of function.

• Multiple areas of bruising are noted on lower extremities in various stages of healing: Bruises in different stages of healing may indicate non-accidental trauma. This finding requires urgent reporting and investigation according to child protection policies.

Rationale for Findings Not Requiring Immediate Follow-Up

• Respirations easy and unlabored: Normal respiratory effort indicates that airway and oxygenation are adequate, so no immediate intervention is required.

• Abdomen non-distended: A soft, non-distended abdomen suggests no acute abdominal injury or internal bleeding, reducing the urgency of intervention.

• Ecchymotic area noted on outer aspect of the forearm: Localized bruising is consistent with the reported fall and mild trauma; it does not indicate immediate threat to circulation or nerve function.

• Child verbalizes a pain level of 4 on a scale of 0 to 10: Moderate pain is expected after minor trauma and can be managed with standard analgesics; it does not indicate an emergent complication.

A. Red meat B. Canned black beans C. Fish D. Cheese

Correct Answer is C

Explanation

Rationale:
A. Red meat: Red meat is often high in saturated fat and cholesterol, which can contribute to hypertension and cardiovascular disease. Regular consumption may increase blood pressure and arterial stiffness, so clients with hypertension should limit or avoid it.

B. Canned black beans: Although beans are generally healthy, canned varieties are often high in sodium, which can worsen hypertension. Unless the beans are labeled low-sodium or rinsed thoroughly before eating, they can contribute to elevated blood pressure.

C. Fish: Fish, especially fatty varieties like salmon or mackerel, are rich in omega-3 fatty acids, which support cardiovascular health by reducing inflammation and improving lipid profiles. Including fish in the diet promotes heart health and helps manage blood pressure effectively.

D. Cheese: Cheese contains significant amounts of sodium and saturated fat, both of which can increase blood pressure and cardiovascular risk. Clients with hypertension should consume cheese in moderation or select low-sodium, low-fat varieties when possible.

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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

Correct Answer is ["C","E","F","H"]

Explanation

A nurse is providing nutrition teaching for a client who has hypertension. Which of the following foods should the nurse suggest the client include in their diet?

Correct Answer is C

Explanation

A nurse is assessing a client who was placed in restraints for aggressive behavior. The client is now calm and cooperative. Which of the following actions should the nurse take?

A nurse is instructing a client about food safety during pregnancy. Which of the following information should the nurse include?

A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use?

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 planning care for a client who is Chinese American and reports adhering to Chinese cultural postpartum practices. Which of the following should the nurse anticipate?

A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?

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