A nurse is assessing a client who is at 37 weeks of gestation and reports sudden, severe abdominal pain with moderate vaginal bleeding and persistent uterine contractions. The client's blood pressure is 88/50 mm Hg and her abdomen is rigid. The nurse should identify these findings as Indicating which of the following complications?

Placental abruption

Amniotic fluid embolus

Placenta previa

Uterine rupture

Answer and Explanation

The Correct Answer is A

A. Placental abruption – This is the correct answer because placental abruption occurs when the placenta detaches prematurely from the uterine wall, leading to severe abdominal pain, vaginal bleeding, uterine rigidity, and signs of hypovolemic shock (low blood pressure). The hallmark sign is a painful, rigid abdomen with contractions.

B. Amniotic fluid embolus – This condition presents with sudden respiratory distress, hypotension, and disseminated intravascular coagulation (DIC), but it does not typically cause uterine rigidity or persistent contractions.

C. Placenta previa – Placenta previa typically presents with painless vaginal bleeding rather than severe abdominal pain and a rigid uterus.

D. Uterine rupture – Uterine rupture is usually associated with a history of uterine surgery (e.g., previous cesarean section). It presents with sudden, severe pain followed by cessation of contractions, not persistent contractions.

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Correct Answer is B

Explanation

A. Almonds – While nut allergies exist, they are not strongly associated with latex allergies.

B. Bananas – Correct. Latex-fruit syndrome is a known cross-reactivity between latex and certain fruits, including bananas, avocados, kiwis, and chestnuts. These foods contain proteins similar to latex, which can trigger allergic reactions.

C. Strawberries – Strawberries are not commonly linked to latex allergies.

D. Hazelnuts – While hazelnuts can cause allergic reactions, they are not a known cross-reactive food with latex.

A. Weigh the client every 48 hr. B. Allow the client to eat meals in his room. C. Observe the client for 1 hr after meals D. Obtain the client's vital signs every other day.

Correct Answer is C

Explanation

A. Weigh the client every 48 hr. – Clients with anorexia nervosa should be weighed daily at the same time to monitor for fluctuations in weight and refeeding complications.

B. Allow the client to eat meals in his room. – Clients should eat meals in a monitored dining area to prevent food hoarding, purging, or avoidance of meals.

C. Observe the client for 1 hr after meals. – This is the correct answer because clients with anorexia nervosa are at risk of purging or excessive exercise after meals. Close observation helps prevent these behaviors.

D. Obtain the client’s vital signs every other day. – Vital signs should be monitored daily or more frequently if the client is medically unstable.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is performing an admission assessment of a school-age child who has spina bifida. The parent states that the child is allergic to latex. The nurse should assess further for cross-sensitivity to which of the following foods?

Correct Answer is B

Explanation

A nurse in an acute care facility is caring for a client who has anorexia nervosa. During the first week of care, which of the following actions should the nurse take?

Correct Answer is C

Explanation

A nurse is teaching a client who has GERD about appropriate dietary choices. Which of the following food choices by the client indicates an understanding of the teaching?

A community health nurse is developing a plan of care for an older adult client who has type 2 diabetes mellitus and lives independently in a rural area. Which of the following interventions should the nurse include?

A nurse is teaching a newly licensed nurse about caring for a client who has neutropenia. Which of the following instructions should the nurse include?

A home health nurse is planning care for an older adult client who has vision loss and takes medications throughout the day. Which of the following actions should the nurse include in the plan?

A nurse is caring for a client who is taking lithium. The nurse should monitor for which of the following findings as an adverse effect of the medication?

A nurse is teaching a newly licensed nurse about informed consent. Which of the following information should the nurse include in the teaching?

A nurse is reviewing the results of laboratory tests a client had as part of a comprehensive nutritional assessment. Which of the following results should the nurse report to the provider?

A nurse is assessing a client who is postoperative following orthopedic surgery. Which of the following findings should the nurse identify as an indication of paralytic ileus?