The nurse is reviewing the findings.

For each finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

Blood pressure

Platelet count

Alanine aminotransferase (ALT)

Hemoglobin

Answer and Explanation

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

Blood pressure: The client's significantly elevated blood pressure (162/112 mm Hg and 166/110 mm Hg) is characteristic of preeclampsia, which is defined by new-onset hypertension after 20 weeks of gestation. Hypertension is a major diagnostic criterion for preeclampsia but is not required for diagnosing HELLP syndrome.
Platelet count: The platelet count of 98,000/mm³ is lower than normal, supporting both preeclampsia and HELLP syndrome. In preeclampsia, thrombocytopenia can occur as the disease progresses, and in HELLP syndrome, low platelets are one of the triad components (Hemolysis, Elevated Liver enzymes, Low Platelet count).
Alanine aminotransferase (ALT): An ALT level of 40 Units/L is above the normal limit, indicating liver involvement. Elevated liver enzymes occur in both severe preeclampsia and HELLP syndrome, reflecting hepatic dysfunction or injury caused by systemic endothelial damage.
Hemoglobin: A hemoglobin of 18.0 g/dL is unusually high and suggests hemoconcentration, which is typical of preeclampsia due to fluid shifts out of the vascular space. In contrast, HELLP syndrome typically causes hemolysis leading to anemia, where hemoglobin would be expected to be low rather than elevated.

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

Explanation

Report of menstrual cycle (absent for 3 months): The nurse’s notes state that the client has not had a menstrual period for three months. In hyperthyroidism, menstrual irregularities such as amenorrhea are common due to hormonal imbalance. This supports hyperthyroidism based on the client's current symptoms..
Weight change (unplanned weight loss): The client reports experiencing unplanned weight loss over three months despite having a good appetite. This suggests an increased metabolic rate, which is consistent with hyperthyroidism. Unintentional weight loss despite normal eating is a key indicator.
Skin condition (warm and moist): The client's skin is described as warm and moist during physical assessment. Hyperthyroidism causes increased blood flow and sweat gland activity, leading to this type of skin condition. It reflects the body's accelerated metabolic processes.
Neck exam (goiter visualized): The nurse notes the presence of a visible goiter on neck examination. A goiter indicates thyroid gland enlargement, which occurs in hyperthyroidism due to overstimulation and overproduction of thyroid hormones. This is a major physical finding.
Laboratory results (T3, T4, TSI ordered): The provider orders tests for T3, Free T4, and TSI to evaluate thyroid function. These specific labs are ordered when hyperthyroidism is suspected, particularly TSI which is associated with Graves’ disease. The decision to order them aligns with the findings.
Eye appearance (exophthalmos noted): Exophthalmos, or outward bulging of the eyes, is noted by the nurse. This finding is strongly associated with hyperthyroidism, especially Graves' disease. It occurs due to inflammation and fluid buildup behind the eyes, worsening as thyroid dysfunction progresses.

A. Lung assessment B. Vertigo C. Facial nerve assessment D. Pain rating E. Diminished hearing F. Pupils

Correct Answer is ["B","C","D","E"]

Explanation

Lung assessment: The client's lungs are clear bilaterally with no signs of respiratory distress or abnormal breath sounds. There is no indication of pulmonary complications, so no further immediate action is needed regarding the lung assessment.
Vertigo: Vertigo is a common complication following a stapedectomy due to disturbance of the inner ear structures. However, it still requires monitoring because severe or worsening vertigo can increase the risk of falls and indicate inner ear trauma or dysfunction.
Facial nerve assessment: The presence of left facial droop and asymmetrical smile indicates possible injury to the facial nerve during surgery. This finding is abnormal and requires immediate provider notification for further neurological evaluation and management.
Pain rating: A pain rating of 5 out of 10 is moderate and, following ear surgery, it should be addressed. Proper pain control is important not only for comfort but also to reduce the risk of increased intracranial pressure from straining or agitation.
Diminished hearing: Some decrease in hearing can occur temporarily after a stapedectomy due to packing or swelling, but it still needs further monitoring. Persistent or worsening hearing loss could suggest a surgical complication, such as prosthesis dislocation.
Pupils: The pupils are equal, smaller postoperatively but still reactive to light, which is expected following anesthesia and is not concerning. No immediate intervention is necessary based on pupil assessment findings.

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The nurse is reviewing the findings. For each finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client in a provider's clinic. For each finding of the client, click to specify if the finding is consistent with Hyperthyroidism or Hypothyroidism. Each finding may support more than one disease process.

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

Explanation

Which of the following findings requires further action by the nurse? Select all that apply.

Correct Answer is ["B","C","D","E"]

Explanation

A nurse is reviewing the home medications of a client who recently had transient ischemic attacks and is to begin taking clopidogrel. The nurse should instruct the client that which of the following over-the-counter medications interacts adversely with clopidogrel?

A nurse is reinforcing teaching with a guardian about receiving a PCA pump following a hysterectomy. Which of the following findings should the nurse include as a potential effect of the medication?

A nurse is collecting data from a group of clients. Which of the following images indicates a client the nurse should identify as exhibiting clubbing of the fingers?

A nurse is caring for a client who has lung cancer. The client tells the nurse they do not want to be resuscitated in the event of a cardiac arrest. Which of the following statements should the nurse make?

A nurse is assisting with the care of a group of clients. Which of the following actions should the nurse take to manage her time effectively? (Select all that apply)

A nurse is caring for a client who has a fractured arm in a cast. Which of the following findings about the affected arm should the nurse report to the provider?

A nurse is reinforcing teaching for a client who has been receiving a PCA pump following a hysterectomy. Which of the following medications should the nurse anticipate the provider to prescribe?

The nurse is reviewing the findings.

For each finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.