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Exhibits

Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.

Initiate contact precautions.

Check urinary output.

Decrease lighting in the client's room.

Monitor blood pressure.

Prepare for amniocentesis.

Apply Internal fetal monitor.

Assess DTR.

Get bed rest.

Answer and Explanation

Correct Answer : B,C,D,G,H

A. Contact precautions are not indicated based on the assessment findings provided.

Preeclampsia is primarily a hypertensive disorder of pregnancy characterized by systemic manifestations such as elevated blood pressure, proteinuria, and multiorgan involvement. It is not transmitted through direct contact, so contact precautions are unnecessary.
B.   The client is exhibiting signs and symptoms consistent with preeclampsia, including right upper abdominal pain, headache, nausea, vomiting, facial edema, weight gain, and elevated blood pressure. Monitoring urinary output is essential for assessing renal function and detecting oliguria, which is a potential complication of preeclampsia.

C.   a deep tendon reflex (DTR) grade of 3+ indicates a brisker than average response, which could be normal or potentially indicative of neurological hyperactivity. In such cases, creating a calming environment, which may include dimmed lighting, could potentially help in reducing stimuli that might exacerbate neurological excitability.
D.   The client's blood pressure readings are elevated, indicating hypertension, which is a hallmark sign of preeclampsia. Monitoring blood pressure regularly is crucial for assessing the severity of hypertension and guiding management.
E.   Amniocentesis is not indicated based on the assessment findings provided. Amniocentesis is a diagnostic procedure typically performed to obtain amniotic fluid for various purposes, such as fetal lung maturity assessment or genetic testing. In the context of preeclampsia, it is not a standard intervention.
F.   Preeclampsia can have adverse effects on fetal well-being, including intrauterine growth restriction and placental insufficiency. However, an external fetal monitoring provides a more accurate assessment of fetal heart rate patterns and allows for closer monitoring of fetal status in cases of maternal hypertension.
G.   Deep tendon reflexes (DTRs) are assessed to monitor for signs of neurological involvement in preeclampsia. Hyperreflexia, as indicated by a 3+ DTR bilaterally, is a characteristic finding in severe preeclampsia and may indicate central nervous system irritability.
H.   Bed rest is often recommended for clients with preeclampsia to reduce physical activity and minimize the risk of complications such as eclampsia or stroke. It can help lower blood pressure and reduce the risk of placental abruption.

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Correct Answer is B

Explanation

A. Using rubbing alcohol to remove ink markings is not recommended as it can irritate the skin, especially in areas undergoing radiation therapy.
B. Altered taste sensations are a common side effect of radiation therapy, especially when the therapy is targeted near the head or neck. The nurse should inform the client about potential changes in taste perception and provide strategies to cope with them.
C. Wearing a binder over the radiation site is unnecessary and may cause discomfort or interfere with treatment.
D. Washing the skin thoroughly with a washcloth after each treatment is not necessary; gentle cleansing with mild soap and water is sufficient.

Correct Answer is []

Explanation

Condition Most Likely Experiencing:

The client's admission to the behavioral health unit for prolonged weight loss and refusal to eat suggests a significant disordered eating pattern. The client's weight of 37.2 kg (82 lb) and BMI of 15 fall significantly below the healthy range for their height, indicating severe underweight status characteristic of anorexia nervosa. The client's behaviors during meal times, such as pushing food around the plate, eating only a small percentage of meals and snacks, and expressing anxiety about eating in front of others, are consistent with the restrictive eating patterns and fear of weight gain seen in anorexia nervosa.

Physical signs such as dry and flaky skin, dry and chapped lips, thin and dull hair, dry buccal mucosa, diminished bowel sounds, swollen and bloated abdomen, and lanugo (fine, downy hair) are commonly associated with anorexia nervosa due to malnutrition and starvation. The client's reported feelings of depression, initiation of dieting due to feeling fat compared to others, and cessation of menstrual cycles for the past 3 months are all indicative of the psychological and emotional distress often seen in individuals with anorexia nervosa.

Actions to take:

Clients with anorexia nervosa often benefit from a structured meal plan to promote regular eating habits and prevent skipping meals.

Focusing on the client’s underlying feelings of dysphoria and lack of control can help the client develop a more positive self-image and cope with emotional stressors that may trigger their eating disorder.

Parameters to monitor:

Monitoring weight is essential in assessing nutritional status and tracking changes in body composition, especially in clients with anorexia nervosa who may experience rapid weight loss.

Cardiac function with ECG can help the nurse detect any signs of cardiac arrhythmias, bradycardia, hypotension, or electrolyte imbalances that may result from severe malnutrition and dehydration.

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Exhibits Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.

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Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who is to begin external radiation therapy for cancer. Which of the following information should the nurse include?

Correct Answer is B

Explanation

Correct Answer is []

Explanation

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Exhibits

Click to specify which of the following actions the nurse should anticipate including in the client's plan of care. Select all that apply.