When is it most important for the nurse to assess a pregnant client's deep tendon reflexes (DTRs)?
When the client has ankle edema.
If the client has an elevated blood pressure.
During admission to labor and delivery.
Within the first trimester of pregnancy.
The Correct Answer is B
Choice A reason: When the client has ankle edema, it is important for the nurse to assess for other signs of fluid retention, such as weight gain, jugular venous distension, and crackles in the lungs. However, ankle edema alone is not a specific indicator of preeclampsia or eclampsia, which are conditions that can cause hyperreflexia or increased DTRs.
Choice C reason: During admission to labor and delivery, it is important for the nurse to assess various aspects of the client's health status, such as vital signs, fetal heart rate, contractions, cervical dilation, and pain level. However, assessing DTRs is not a routine part of labor and delivery assessment unless there are signs of preeclampsia or eclampsia.
Choice D reason: Within the first trimester of pregnancy, it is important for the nurse to assess for signs of pregnancy-related nausea and vomiting, bleeding, infection, and ectopic pregnancy. However, assessing DTRs is not a routine part of first trimester assessment unless there are signs of neurological disorders or spinal cord injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A: Recommending the use of support stockings to enhance venous return is not a priority intervention for the nurse, as this does not address the underlying cause of the peripheral edema, which is fluid overload due to inadequate dialysis. This is a distractor choice.
Choice B: Ensuring the client receives frequent small meals containing complete proteins is a priority intervention for the nurse, as this can help improve the client's nutritional status and increase their serum albumin level, which can reduce fluid leakage into the interstitial spaces and decrease edema. Therefore, this is the correct choice.
Choice C: Evaluating patency of the AV graft for resumption of hemodialysis is not a priority intervention for the nurse, as this is not feasible at this point since the AV graft is no longer available to use. This is another distractor choice.
Choice D: Instructing the client to continue to follow the prescribed rigid fluid restriction amounts is not a priority intervention for the nurse, as this does not address the root problem of inadequate dialysis and low serum albumin level, which are contributing to fluid overload and edema. This is another distractor choice.
Correct Answer is ["B","C","E","F"]
Explanation
Choice B is correct because weight management is an important factor in preventing and controlling hypertension. Taking daily walks for thirty minutes can help reduce weight and lower blood pressure.
Choice C is correct because salt substitutes can help with maintaining a healthy diet by reducing sodium intake. Sodium intake is associated with increased blood pressure and should be limited to less than 2,300 mg per day.
Choice E is correct because sodium intake can be regulated by rinsing canned foods in water. Canned foods often contain high amounts of sodium as a preservative and rinsing them can remove some of the excess sodium.
Choice F is correct because uncontrolled hypertension can lead to renal damage. Hypertension can cause damage to the blood vessels and impair the function of the kidneys, leading to chronic kidney disease or failure.
Choice A is incorrect because alcohol consumption can produce vascular changes that increase blood pressure. Alcohol intake should be limited to no more than one drink per day for women and two drinks per day for men.
Choice D is incorrect because blood pressure readings should not be taken at noontime. Blood pressure readings should be taken at the same time each day, preferably in the morning before breakfast or in the evening before dinner.
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