The nurse is continuing to care for the client.
Nurses' Notes.
Day 1, 0900:. Day 1, 0930:. Client is at 31 weeks of gestation and presents with a severe.
headache unrelieved by acetaminophen.
Client also reports.
urinary frequency and decreased fetal movement.
Client is a G3. P2 with one preterm birth.
Client reports a constant and throbbing headache and rates it. as a 6 on a scale of 0 to 10. Denies visual disturbances.
+3. pitting edema in bilateral lower extremities.
Patellar reflex 4+. without the presence of clonus.
Client reports occasional.
nighttime leg cramps.
Reports three fetal movements within the.
last 30 min.
External fetal monitor applied with a baseline FHR.
140/min with occasional accelerations and moderate variability.
No uterine contractions noted.
Vital Signs.
Day 1, 0900:. Temperature (oral) 36.9° C (98.4° ). Heart rate 72/min.
Respiratory rate 16/min.
BP 162/112 mm Hg. Oxygen saturation 979% on room air.
Day 1, 0930:. Temperature (oral) 37.1° C (98.8° ). Heart rate 84/min.
Respiratory rate 18/min.
BP 166/110 mm Hg. Oxygen saturation 999% on room air.
Color yelow yelow). pH 5.9 (4.6 to 8). Protein 3+ (negative). Specific gravity 1.013 (1.005 to 1.03). Leukocyte esterase negative (negative). Nitrites negative (negative). Ketones negative (negative). Crystals negative (negative). Casts negative (negative). Glucose trace (negative). WBC 5 (0 to 4). WBC casts none (none). RBC 1 (less than or equal to 2). RBC casts none (none). Day 1, 1030:. CBC:. Hemoglobin 18.0 g/dL (12 to 16 g/dL). Hematocrit 35% (37 to 479%). Platelets 98,000/mm³ (150,000 to 400,000/mm³). BUN 19 mg/dL (10 to 20 mg/dL). Creatinine 0.8 mg/dL (0.5 to 1 mg/d). WBC 8,000/mm³ (5,000 to 10,000/mm³). Glucose 85 mg/dL (74 to 106 mg/dL). Liver Enzymes:. Alanine aminotransferase (ALT) 40 units/L (4 to 36 units/L). Aspartate aminotransferase (AST) 42 units/L (0 to 35 units/L). Total bilirubin 1.2 mg/dL (0.3 to 1 mg/dL). The nurse is reviewing the assessment findings.
For each assessment finding, click to specify if the finding is consistent with.
preeclampsia or HELLP syndrome.
Each finding may support more than one.
disease process.
Platelet count
Hemoglobin
Alanine aminotransferase (ALT)
Blood pressure
The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B"}}
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Asking about past coping mechanisms can provide valuable information, but in this situation, where the client is expressing thoughts of hopelessness, it's crucial to assess the immediate risk of suicide. Therefore, this choice is not the best option in this context.
Choice B rationale:
Involving significant others in the client's care is important, but it doesn't address the client's current emotional state and suicidal ideation. This choice does not take priority in this scenario.
Choice C rationale:
While exploring family history, including suicide, is relevant, it's not the first question to ask. Assessing the client's current thoughts and feelings should be the priority before delving into family history. Therefore, this choice is not the best option at this moment.
Choice D rationale:
(Correct Choice) This is the most appropriate question to ask first. Assessing the client's suicidal ideation is crucial for ensuring their safety. If the client expresses suicidal thoughts, the nurse can take immediate steps to keep the client safe, such as involving a mental health professional or initiating a suicide risk assessment.
Correct Answer is B
Explanation
The correct answer is Choice B
Choice A rationale: Advance directives are voluntary and revocable; clients can change their decisions at any time as long as they are mentally competent.
Choice B rationale: Discussing advance directives with family ensures clarity, reduces future conflict, and supports informed decision-making aligned with the client’s wishes.
Choice C rationale: Witnesses are typically required, but a partner’s presence is not legally mandated unless designated as a healthcare proxy.
Choice D rationale: Notarization is not universally required; validity depends on state laws, and many jurisdictions accept signed and witnessed documents without attorney involvement.
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