The nurse is continuing to care for the client.
Vital Signs.
Day 1, 0900:. Temperature (oral) 36.9° C (98.4° F). Heart rate 72/min.
Respiratory rate 16/min.
BP 162/112 mm Hg. Day 1, 0930:. Oxygen saturation 97% on room air.
Temperature (oral) 37.1° C (98.8° F). Heart rate 84/min.
Respiratory rate 18/min.
BP 166/110 mm Hg. Oxygen saturation 99% on room air.
Drag words from the choices below to fill in each blank in the following.
sentence.
The client is at greatest risk for developing Target 1 and Target 2. Conditions.
Placental abruption.
Cervical insufficiency.
Seizures.
Hypoglycemia.
Heart failure.
Correct Answer : A,C
The correct answers are Choices A and C.
Choice A rationale: Severe hypertension in pregnancy disrupts placental perfusion and vascular integrity, increasing risk of placental abruption due to premature separation and hemorrhage, threatening both maternal and fetal outcomes.
Choice B rationale: Cervical insufficiency is linked to structural weakness or trauma, not hypertension; it typically presents with painless dilation and is unrelated to elevated blood pressure or vascular compromise.
Choice C rationale: Hypertensive encephalopathy and preeclampsia can progress to eclampsia, marked by seizures. Elevated BP increases cerebral edema and excitability, triggering convulsions if unmanaged.
Choice D rationale: Hypoglycemia is not a direct consequence of hypertension; it’s more associated with insulin dysregulation, poor intake, or medication effects, not elevated blood pressure.
Choice E rationale: Heart failure may occur in chronic hypertension but is less acute than seizure or abruption risk in this context. No signs of fluid overload or cardiac decompensation are present in the vitals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Dysphagia (difficulty swallowing) is a common complication of esophageal cancer and can lead to malnutrition and aspiration pneumonia. It is the priority finding because addressing the client's ability to swallow is essential for maintaining adequate nutrition and preventing complications.
Choice B rationale:
Xerostomia (dry mouth) is another common side effect of radiation therapy, but while uncomfortable, it does not pose an immediate risk to the client's health compared to dysphagia.
Choice C rationale:
Excoriation of the skin on the neck and chest is likely due to the radiation therapy and can be managed with appropriate skin care measures. Although important, it is not the priority compared to dysphagia.
Choice D rationale:
The client's self-reported pain level of 6 on a scale from 0 to 10 is concerning and requires attention, but addressing dysphagia takes precedence due to its potential impact on the client's nutritional status and overall well-being.
Correct Answer is B
Explanation
An advance directive is a legal document that allows a client to express their wishes regarding medical care in case they become incapacitated. The client should discuss this document with their family before signing it, so that they are aware of the client's preferences and can respect them. The other options are incorrect because the client can change their mind at any time, their partner does not need to be present, and an attorney does not need to notarize the document.
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