The nurse is continuing to care for the client.
seizures
hypoglycemia
cervical insufficiency
heart failure
placental abruption
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. "I realize it can be hard to know what to expect at the moment my partner passes away.": This statement shows acknowledgment of the approaching death and emotional preparedness. It reflects acceptance and anticipatory grieving rather than denial.
B. "I have been taking pictures of others who visit with my partner so I can remember these days.": This indicates emotional awareness and an effort to preserve memories, suggesting the partner is coping and processing the impending loss.
C. "I'm shocked everyone has lost hope that my partner will overcome this illness.": This reflects denial, a common early grief reaction where the person struggles to accept the reality of impending death. The partner’s belief that recovery is still possible, despite the terminal prognosis, indicates difficulty facing the truth of the illness.
D. "I have been making arrangements so I can be at my partner's side when they pass away.": This demonstrates planning and emotional acceptance. The partner is preparingwhich reflects adaptive coping rather than denial.
Correct Answer is B
Explanation
Rationale:
A. "I will remain with my child throughout each timeout session.": The purpose of a timeout is to remove the child from stimulation and provide an opportunity to calm down and reflect. Staying with the child during a timeout defeats this purpose, as it may reinforce attention-seeking behaviors instead of encouraging self-regulation.
B. "My child is most likely to correct behaviors when they experience natural consequences.": Allowing children to experience natural consequences helps them learn cause-and-effect relationships and develop responsibility for their actions.
C. "My child will learn rules when we offer rewards for positive behavior instead of verbal praise.": While tangible rewards can be helpful initially, consistent verbal praise is a more effective long-term strategy for reinforcing desired behaviors. It builds intrinsic motivation and encourages the child to repeat good behavior without expecting material rewards.
D. "I will be careful not to ignore it when my child misbehaves.": Ignoring minor attention-seeking behaviors can be an effective discipline strategy, as it prevents reinforcement through attention. Overreacting to small misbehaviors may inadvertently increase their frequency rather than reduce them.
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