The nurse should first address the client’s
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}
Why Safety Comes First
- The client presents with multiple red flags for physical abuse and neglect, including bruises in various stages of healing, a fracture, and concerning behavior around the adult child.
- Ensuring the client is in a safe environment is the top priority to prevent further harm and initiate protective interventions.
Why Nutritional Status Is Next
- The client reports limited food availability and has a low BMI (18.3), suggesting possible malnutrition.
- Addressing nutritional needs is essential for recovery and overall well-being, especially in older adults who are vulnerable to rapid health decline.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Amnioinfusion is the infusion of saline into the amniotic cavity. It is used to treat umbilical cord compression or meconium staining, not to manage seizures. Initiating an amnioinfusion during a seizure would be an inappropriate and ineffective intervention that would not address the underlying physiological cause of eclampsia or the immediate post-seizure recovery.
Choice B rationale
An internal fetal heart monitor is an invasive procedure requiring the rupture of membranes and insertion of a fetal spiral electrode. This is not the priority action following a seizure. Post-seizure priority is maternal stabilization, ensuring a patent airway, and preventing further injury. External fetal monitoring is the standard first-line approach to assess fetal well-being.
Choice C rationale
Calcium gluconate is the antidote for magnesium sulfate toxicity, not a treatment for seizures. Administering calcium gluconate would be inappropriate unless magnesium toxicity (e.g., respiratory depression) is suspected. The primary treatment for eclamptic seizures is magnesium sulfate, which works by depressing the central nervous system and blocking neuromuscular conduction.
Choice D rationale
Placing the client on her side is the priority action following a seizure. This position prevents aspiration of secretions, promotes venous return to the heart, and improves placental perfusion. This is a critical safety measure to protect both the mother and the fetus from further harm and is part of standard post-ictal care. *.
Correct Answer is D
Explanation
Choice A rationale
Dark spots or floaters in vision are not a typical post-operative finding for cataract removal. They are more commonly associated with retinal detachment, which is a rare but serious complication. The client should be instructed to report this to the provider immediately.
Choice B rationale
Bruising of the eyelids is not a normal or expected outcome after cataract surgery. The procedure is typically performed with a small incision and does not cause significant trauma to the surrounding tissues, making bruising an uncommon occurrence.
Choice C rationale
Cataract surgery is almost always performed using a local anesthetic, not general anesthesia. A local anesthetic is administered to numb the eye and surrounding area, allowing the client to remain awake and aware during the procedure while feeling no pain.
Choice D rationale
The fundamental principle of cataract surgery is the removal of the clouded, opaque lens and its replacement with a clear, artificial intraocular lens (IOL). This is the definitive treatment for cataracts, restoring visual clarity and function to the eye. *.
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