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 C
Explanation
Choice A rationale:
Expressing concern about another shift's holiday hours does not necessarily involve interpersonal conflict. It may reflect dissatisfaction but doesn't involve direct conflict between individuals.
Choice B rationale:
A personal difficulty with caring for clients who have HIV could be a challenge for the nurse, but it's not an example of interpersonal conflict. It represents a personal struggle rather than a conflict with another individual.
Choice C rationale:
Insulting comments directed at a nurse by another nurse represent interpersonal conflict. Such behavior involves a direct clash of personalities and can create a hostile work environment, affecting the nurse's well-being and job performance. Addressing this type of conflict is crucial for maintaining a positive work atmosphere.
Choice D rationale:
Submitting a complaint about another department's handoff reporting might indicate dissatisfaction or concerns about workflow, but it's not necessarily an interpersonal conflict. It could be a communication issue or a difference in professional opinion rather than a direct clash between individuals.
Correct Answer is A
Explanation
Choice A rationale:
This action requires intervention by the nurse. Antiembolic stockings should be smooth and free of creases to ensure even pressure distribution along the legs. Creases, especially if on the front of the legs, can lead to areas of increased pressure, which might compromise circulation and increase the risk of skin breakdown or clot formation.
Choice B rationale:
Applying the stockings before the client gets out of bed is appropriate, as it ensures proper application and minimizes the risk of injury due to the client's leg swelling
Choice C rationale:
Asking the client to point their toes before applying the stockings is appropriate, as it helps with correct placement and reduces the risk of skin damage or discomfort
Choice D rationale:
Turning the stockings inside out (at least down to the heel) before applying them is a common technique to make it easier to position the stocking on the foot and leg properly. This method helps avoid excessive stretching of the stocking and ensures a better fit.
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