A nurse is providing teaching to a client who is at 14 weeks of gestation about findings to report to the provider.
Which of the following findings should the nurse include in the teaching
Bleeding gums
Urinary frequency
preeclampsia
faintness upon rising
The Correct Answer is C
This is a sign of preeclampsia, a serious complication of pregnancy that can cause high blood pressure, proteinuria, and seizures.
Preeclampsia can affect the placenta, the kidneys, the liver, and the brain of the mother and the fetus. It requires immediate medical attention and may lead to early delivery.
Choice A, bleeding gums, is wrong because it is a common occurrence during pregnancy due to hormonal changes that increase blood flow to the gums. It is not a cause for concern unless it is excessive or accompanied by other symptoms.
Choice B, urinary frequency, is wrong because it is also a normal finding during pregnancy due to the growing uterus putting pressure on the bladder. It is not a sign of infection or kidney problems unless it is associated with pain, burning, or blood in the urine.
Choice D, faintness upon rising, is wrong because it is usually caused by orthostatic hypotension, a drop in blood pressure when changing positions.
This can happen during pregnancy due to the dilation of blood vessels and the increased blood volume. It can be prevented by rising slowly, drinking enough fluids, and avoiding prolonged standing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Evaluate the client’s ability to help with repositioning.
This is because the nurse should assess the client’s level of mobility, strength, and coordination before repositioning them to prevent injury and promote comfort.
The nurse should also use appropriate assistive devices, such as a drawsheet, a trapeze bar, or a mechanical lift, to facilitate safe repositioning and reduce the risk of skin breakdown and pressure ulcers.
Choice A is wrong because raising the side rails on both sides of the client’s bed during repositioning can increase the risk of falls and entrapment.
The nurse should only raise the side rail on the opposite side of the bed from where they are working and lower it when they are done.
Choice B is wrong because repositioning the client without assistive devices can cause strain and injury to both the nurse and the client.
The nurse should use assistive devices that are appropriate for the client’s condition and weight.
Choice C is wrong because discussing the client’s preferences for determining a repositioning schedule is not a priority action when preparing to reposition a client who had a stroke.
The nurse should follow the facility’s protocol for repositioning frequency, which is usually every 2 hours, and adjust it according to the client’s needs and comfort.
The nurse should also involve the client in the care plan and respect their preferences whenever possible.
Correct Answer is C
Explanation
, dizziness.
Dizziness is a manifestation of hypovolemia, which is a decrease in blood volume due to fluid loss.
Hypovolemia can cause orthostatic hypotension, which is a drop in blood pressure when changing positions. This can lead to dizziness, lightheadedness, or fainting.
Choice A, epistaxis, is wrong because it is not a sign of hypovolemia, but rather a possible cause of it. Epistaxis is a nosebleed that can result from trauma, infection, dryness, or coagulation disorders.
Choice B, headache, is wrong because it is not a specific sign of hypovolemia, but rather a nonspecific symptom that can have many causes. Headache can be associated with dehydration, but it can also be caused by stress, infection, inflammation, or other factors.
Choice D, shortness of breath, is wrong because it is not a sign of hypovolemia, but rather a sign of fluid volume excess.
Fluid volume excess is an increase in blood volume due to fluid retention or overload. Fluid volume excess can cause dyspnea, which is difficulty breathing or shortness of breath.
Normal ranges for blood pressure are 90/60 mm Hg to 120/80 mm Hg for adults.
Normal ranges for heart rate are 60 to 100 beats per minute for adults.
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