A nurse is caring for a client who is at 36 weeks of gestation and reports a headache.
Which of the following actions should the nurse take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Graphic Results Temperature 37° C (98.6° F) Heart rate 88/min Respiratory rate 18/min
Blood pressure 144/94 mm Hg
Upper abdominal pain rating 4/10 on a scale from 0 to 10
Perform a contraction stress test.
Prepare for delivery of the fetus.
Increase the client's dietary salt intake to 2 g/day.
Administer ferrous sulfate to the client.
Upper abdominal pain rating 4/10 on a scale from 0 to 10
The Correct Answer is B
Choice A rationale:
A contraction stress test is not appropriate in this context and would not address the potential risks associated with the client's symptoms.
Choice B rationale:
The elevated blood pressure and upper abdominal pain suggest potential preeclampsia, a serious complication of pregnancy that can lead to significant maternal and fetal risks. Delivery may be indicated to prevent further complications.
Choice C rationale:
Increasing dietary salt intake is not recommended for managing elevated blood pressure in pregnancy.
Choice D rationale:
Administering ferrous sulfate is unrelated to the client's symptoms and concerns.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
This is not a priority intervention for a client who is in the manic phase of bipolar disorder. The nurse should monitor the client's vital signs as indicated, but blood pressure is not likely to be affected by mania unless the client has a preexisting condition or is taking medications that affect blood pressure.
Choice B rationale:
This is not an appropriate intervention for a client who is in the manic phase of bipolar disorder. The nurse should not restrict the client's physical activity, as this can increase their frustration and agitation. The nurse should provide a safe environment for the client to expend their energy and channel it into productive activities.
Choice C rationale:
This is not a suitable intervention for a client who is in the manic phase of bipolar disorder. The nurse should avoid stimulating the client's already elevated mood and arousal, as this can worsen their symptoms and increase their risk of injury or aggression. The nurse should limit the client's exposure to noise, crowds, and bright lights, and provide them with opportunities for rest and quiet time.
Choice D rationale:
A client who is in the manic phase of bipolar disorder has increased energy, activity, and metabolism, which can lead to weight loss and nutritional deficiencies. The nurse should provide the client with high-calorie finger foods that are easy to eat and do not require utensils or sitting down. This way, the nurse can help the client meet their nutritional needs while respecting their need for movement and autonomy.
Correct Answer is C
Explanation
Choice A rationale:
Scheduling appointments earlier in the day accommodates the client's potential "on" periods when Parkinson's symptoms are better controlled.
Choice B rationale:
Looking down at the feet while walking is a technique that can help improve gait and stability, as Parkinson's disease often affects balance.
Choice C rationale:
Thicker liquids are less likely to cause aspiration in individuals with Parkinson's disease, as they can have difficulty coordinating the muscles needed for swallowing.
Choice D rationale:
Constipation is a common issue in Parkinson's disease due to decreased gastrointestinal motility. However, focusing on dietary fiber and fluid intake is preferred before considering laxatives.
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.
