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

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A,B"}}

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Correct Answer is D

Explanation

The correct answer is choice d. Privately interview the client about the injuries.

Choice A rationale:

Contacting the family regarding the client’s condition might not be appropriate if the family is suspected of being involved in the abuse. It could potentially put the client at further risk.

Choice B rationale:

Notifying risk management is important for documentation and internal review, but it does not directly address the immediate need to assess and ensure the client’s safety.

Choice C rationale:

Informing the transferring agency of the client’s condition is necessary for continuity of care, but it does not address the immediate need to investigate the cause of the injuries and ensure the client’s safety.

Choice D rationale:

Privately interviewing the client about the injuries allows the nurse to gather more information about the cause of the injuries in a safe and confidential manner. This step is crucial in assessing the situation and determining if further action, such as reporting to authorities, is needed. It ensures the client’s safety and helps in identifying any potential abuse.

A. Assess for urinary retention. B. Encourage the client to turn from side to side. C. Monitor for elevated temperature. D. Inform the client to expect drowsiness. E. Assist the client with ambulation.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

No explanation

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the client's coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse?

Correct Answer is D

Explanation

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"B"}}

A nurse is assessing a client following an esophagogastroduodenoscopy.Which of the following findings should the nurse report to the provider?

A nurse is developing a plan of care for a newborn whose mother tested positive for heroin during pregnancy.The newborn is experiencing neonatal abstinence syndrome.Which of the following actions should the nurse include in the plan?

A nurse is teaching about preventative measures to a female client who has chronic urinary tract infections.Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who is on bed rest.The nurse should recognize that which of the following findings is a complication of immobility?

A nurse enters a client's room and finds her sitting on the floor next to the shower. The client states that she slipped on some water outside of the shower. Which of the following actions should the nurse take first?

A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago.The client has a respiratory rate of 10/min.The nurse should prepare to administer which of the following medications? .

A nurse is teaching a client about family planning using the basal body temperature method.Which of the following instructions should the nurse include in the teaching?