A nurse is caring for a client who is at 34 weeks of gestation, has a blood pressure of 188/112 mm Hg, and has a severe headache. Which of the following actions should the nurse take first?
Document the fetal heart rate.
Check urine for protein.
Administer IV beta blocker medication.
Implement seizure precautions.
The Correct Answer is D
A. Document the fetal heart rate: While monitoring fetal well-being is important, the immediate priority is the safety of the mother. In the presence of severe hypertension (188/112 mm Hg) and neurological symptoms, maternal stabilization takes precedence because maternal compromise can directly impact fetal oxygenation and survival.
B. Check urine for protein: Proteinuria is a diagnostic criterion for preeclampsia, but testing urine is not the first priority. The nurse must first address immediate risks to prevent life-threatening complications such as eclampsia.
C. Administer IV beta blocker medication: Administering antihypertensive medication is necessary to lower dangerously high blood pressure, but interventions to prevent seizures (e.g., magnesium sulfate and seizure precautions) take precedence because seizures can occur rapidly and pose an immediate threat to maternal and fetal life.
D. Implement seizure precautions: The first action is to implement seizure precautions because the client’s blood pressure and severe headache indicate severe preeclampsia with high risk for eclampsia. Ensuring safety (e.g., padding side rails, maintaining airway readiness, having suction and emergency equipment available) is critical to prevent injury if a seizure occurs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Amino acid: Amino acids are the protein component of total parenteral nutrition (TPN). They provide essential and nonessential amino acids necessary for tissue repair, nitrogen balance, and protein synthesis. Amino acids are water-soluble and do not form emulsions, so they do not function as the fat component in TPN.
B. Egg phospholipid: Egg phospholipids serve as an emulsifying agent in intravenous fat emulsions. In TPN, the fat emulsion contains triglycerides suspended in water, and the phospholipid stabilizes the mixture, preventing separation. This allows safe delivery of essential fatty acids and caloric energy intravenously, making egg phospholipid a key component of the fat emulsion.
C. Folic acid: Folic acid is a water-soluble B vitamin included in TPN to prevent megaloblastic anemia and support DNA synthesis. It is not part of the lipid or fat component and does not function as an emulsifier.
D. Calcium gluconate: Calcium gluconate is an electrolyte added to TPN to maintain calcium balance. While important for metabolic and cardiac function, it is not a fat emulsion and does not provide caloric energy or act as an emulsifying agent.
Correct Answer is D
Explanation
A. Perseveration: Perseveration is the repetition of a particular response, such as a word, phrase, or gesture, despite the absence or cessation of a stimulus. The client’s statement does not demonstrate repeateOId speech or behavior, so perseveration is not the appropriate finding.
B. Anhedonia: Anhedonia refers to the inability to experience pleasure from activities that were once enjoyable. While this is a common negative symptom in schizoaffective disorder, the client specifically describes fatigue and difficulty concentrating rather than a loss of pleasure or interest.
C. Loose associations: Loose associations involve disorganized thinking where ideas are poorly connected or illogical. The client’s statement is coherent and contextually relevant, showing no evidence of thought derailment or tangential thinking.
D. Anergia: Anergia is characterized by a lack of energy, fatigue, and difficulty initiating or sustaining activity. The client reports feeling constantly tired and unable to concentrate, which aligns with anergia, a negative symptom commonly observed in schizoaffective disorder and depressive episodes.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.