A nurse is caring for a client who is at 32 weeks gestation and has a history of hypertension. Which of the following statements by the client should the nurse report to the provider?
"My ankles get swollen after standing at work."
"My gums bleed when I brush my teeth."
"I have constant pain in the middle of my upper abdomen."
"I feel dizzy when I lay flat on my back.
The Correct Answer is C
Choice A rationale:
Ankle swelling can be a common symptom of pregnancy and is not necessarily indicative of a complication.
Choice B rationale:
Gums can become more sensitive during pregnancy, leading to bleeding while brushing teeth. This finding is common and not necessarily indicative of a complication.
Choice C rationale:
Constant pain in the middle of the upper abdomen can be a sign of preeclampsia, a serious pregnancy complication that requires prompt medical attention.
Choice D rationale:
Feeling dizzy when lying flat on the back (supine hypotension) can be a common discomfort during pregnancy due to pressure on the vena cava. However, it does not necessarily indicate a complication in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Postoperative pain management is crucial for the client's comfort and recovery.
Choice B rationale:
Excoriated folds of the client's panniculus might be related to skin irritation and can be addressed without immediate provider notification.
Choice C rationale:
Hypoactive bowel sounds can be expected after surgery and might not require immediate reporting.
Choice D rationale:
Urine output of 80 mL in the past hour might be influenced by various factors and is not as high a priority as severe pain.
Correct Answer is ["B","C","D"]
Explanation
Choice A rationale:
Asking the client to explain what she is hearing may not be helpful, as the client's perception of the hallucinations may not match reality.
Choice B rationale:
Conveying empathy is important to establish a therapeutic relationship and provide emotional support.
Choice C rationale:
Encouraging the client to listen to music through headphones can help distract from auditory hallucinations.
Choice D rationale:
Speaking simply and clearly when communicating helps the client understand and process information more effectively.
Choice E rationale:
Using therapeutic touch might not be appropriate for all clients and should be based on the client's preferences and comfort level.
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