A nurse is caring for a client with a recent diagnosis of preeclampsia. The client's laboratory results show a hemoglobin of 9.8 g/dL and a platelet count of 120,000/mm³. What is the most appropriate nursing intervention for this client?

Encourage a high-protein diet to increase hemoglobin levels.

Initiate a blood transfusion to correct the low hemoglobin.

Implement seizure precautions due to the low platelet count.

Monitor for signs of bleeding or bruising.

Answer and Explanation

The Correct Answer is D

Choice A rationale

While a high-protein diet is generally healthy, it is not an effective intervention to rapidly correct the anemia associated with preeclampsia. Anemia in preeclampsia is often related to hemolysis, a component of HELLP syndrome, where red blood cells are destroyed. Increasing dietary protein will not reverse this pathophysiological process or correct the underlying cause of the anemia. The normal hemoglobin range is 12.0-15.5 g/dL for women.

Choice B rationale

A hemoglobin level of 9.8 g/dL is considered mild anemia and does not typically warrant a blood transfusion. Transfusions are reserved for severe anemia or acute blood loss. The client's condition is likely related to hemolysis, and transfusion may not address the underlying issue. Transfusion therapy carries risks and is not indicated for this degree of anemia.

Choice C rationale

Seizure precautions are indicated for preeclampsia, but they are not specifically a direct consequence of a low platelet count. A low platelet count, or thrombocytopenia, increases the risk of bleeding. Seizures in preeclampsia are related to cerebral vasospasm and endothelial dysfunction. Implementing seizure precautions is a part of general preeclampsia care, but not directly linked to the platelet count of 120,000/mm³. The normal platelet count is 150,000-450,000/mm³.

Choice D rationale

A platelet count of 120,000/mm³ is below the normal range, indicating thrombocytopenia. This condition impairs the blood's ability to clot, increasing the client's risk for hemorrhage and bruising. Monitoring for signs of bleeding, such as petechiae, purpura, or bleeding from injection sites, is a critical nursing intervention to detect and manage potential bleeding complications promptly.

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Correct Answer is C

Explanation

Choice A rationale

This rationale describes a Freudian psychoanalytic theory of development, which focuses on psychosexual stages and the unconscious mind. This theory is not the basis for explaining individual differences in the timing of physical milestones such as walking. Motor development is a biologically driven process, not a result of psychosexual energies.

Choice B rationale

This rationale describes Erikson's theory of psychosocial development, which posits that individuals progress through a series of stages based on social interactions. While this theory is important for understanding social and emotional development, it does not explain variations in the timing of physical milestones like walking.

Choice C rationale

Motor development follows a predictable sequence, but the exact timing of milestones is influenced by a combination of genetic factors and environmental influences. Each child has a unique biological timetable for maturation, and the range for achieving milestones like walking is broad. The nurse should reassure the parent that a 14-month-old not walking is within the normal developmental range.

Choice D rationale

This rationale describes Piaget's theory of cognitive development, which focuses on how children construct knowledge through adaptation and assimilation. This theory is centered on intellectual and cognitive processes and does not provide an explanation for variations in the timing of gross motor skills such as walking.

A. Provide opportunities for the grandparents to visit the children at home. B. Encourage the children to make small gifts and mementos for their brother. C. Tell the children stories using a scrapbook with pictures of their brother. D. Prepare the children for any changes in their brother before visiting in the hospital.

Correct Answer is D

Explanation

Choice A rationale

While grandparent support is valuable, it doesn't directly address the siblings' need to understand their brother's specific illness and hospitalization. The siblings require accurate, age-appropriate information about their brother's condition to reduce fear and anxiety, which external family visits do not provide. The focus should be on direct communication about the changes their brother is experiencing.

Choice B rationale

Making gifts can be a positive coping mechanism, but it does not address the underlying need for factual information. Without understanding what is happening to their brother, the siblings may still experience anxiety, confusion, or fear. The primary need is for clear, honest communication to help them process the situation effectively.

Choice C rationale

Using a scrapbook can be a helpful tool for reminiscence, but it might not adequately prepare children for the immediate and potentially frightening changes they will observe during a hospital visit. The primary goal is to manage expectations and provide accurate information about the brother's current state to prevent distress.

Choice D rationale

Preparing siblings for changes in their brother, such as different appearances or equipment, reduces fear and anxiety by providing a cognitive framework for what they will see. This anticipatory guidance allows them to mentally process the situation, normalizing the hospital environment and their brother's condition. This promotes emotional resilience and reduces potential trauma.

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A nurse is caring for a client with a recent diagnosis of preeclampsia. The client's laboratory results show a hemoglobin of 9.8 g/dL and a platelet count of 120,000/mm³. What is the most appropriate nursing intervention for this client?

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Correct Answer is C

Explanation

The mother of a 4-year-old boy who has been hospitalized multiple times asks the nurse how she can help her other children who are asking about their brother. To help the siblings cope with their brother's illness, which suggestion is best for the nurse to provide this mother?

Correct Answer is D

Explanation

Based on the assessment findings, the priority diagnosis suspected is the client is at risk of:

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