A nurse is collecting data from a client who is receiving magnesium sulfate via continuous IV infusion to treat preeclampsia. Which of the following findings indicates that the medication is having a therapeutic effect?
Positive clonus
Urinary output 20 mL/hr
Respiratory rate 10/min
Deep tendon reflexes 2+
The Correct Answer is D
A. Positive clonus is a sign of hyperreflexia and can indicate worsening preeclampsia or severe central nervous system irritability. It is not a therapeutic effect of magnesium sulfate.
B. Urinary output 20 mL/hr is below the minimum expected urine output (which is generally 30 mL/hr). This finding suggests oliguria and may be a sign of worsening renal function, which is not a therapeutic effect of magnesium sulfate.
C. Respiratory rate 10/min is too low. Magnesium sulfate can cause respiratory depression, and a respiratory rate of 10/min may indicate toxicity. This is not a therapeutic effect.
D. Deep tendon reflexes 2+ is the correct answer. Magnesium sulfate is used to prevent seizures in preeclampsia by acting as a CNS depressant. A normal response of 2+ for deep tendon reflexes indicates that magnesium sulfate is having a therapeutic effect and the client is not experiencing magnesium toxicity (which would typically cause a decreased reflex response..
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. “I will consider what is going to benefit the most people when making decisions.”: This is correct. Utilitarianism is an ethical theory that focuses on the greatest good for the greatest number of people. Decisions are made based on the outcomes that benefit the most individuals, even if they might not always align with individual preferences.
B. "I will respect the decision of a client who has a chronic illness to stop treatment.": This reflects the principle of autonomy, not utilitarianism. Autonomy focuses on respecting an individual's right to make their own decisions, rather than the greater good.
C. "I will place a higher emphasis on human dignity than on the needs of a group.": This statement leans more toward a deontological perspective, which prioritizes individual rights and dignity over collective benefits.
D. "I will withhold a terminal diagnosis from a client who has cancer.": This reflects a paternalistic approach, where decisions are made by healthcare providers for the patient, which is not a principle of utilitarianism. Utilitarianism would consider the benefits and harms of full disclosure to the patient, rather than withholding information.
Correct Answer is B
Explanation
A. Contacting the client's caregiver to discuss the client's comment might be helpful in some situations, but the priority in this scenario is to assess the possibility of abuse or mistreatment, not to confront the caregiver immediately.
B. Reviewing the medical record to see if the client has reported abuse in the past is correct. The nurse should first gather relevant information to understand the context of the client's statement. If the client has a history of reporting abuse or signs of mistreatment, it may provide critical insight.
C. Reporting suspected abuse to the nurse manager could be necessary if abuse is confirmed, but it is important to first assess the situation and gather information before making such a report.
D. Restricting family members from visiting with the client is an extreme response without any evidence of abuse. The nurse should assess the situation further before taking such action.
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