The nurse is continuing to assist with the care of the client.

Nurses' Notes.

0900: 0930: Client is at 31 weeks of gestation and presents with a severe headache unrelieved by acetaminophen.

Client also reports urinary frequency and decreased fetal movement.

Client is a. gravida 3, para 2 with one preterm birth.

Client reports a constant and throbbing headache and rates their pain as a 6 on a scale of 0 to 10.

Denies visual disturbances.

+3 pitting edema in bilateral lower extremities.

Patellar reflex 4+ without the presence of clonus.

Client reports occasional nighttime leg cramps.

Reports 3 fetal movements within the last 30 min.

External fetal monitor applied with a. baseline FHR 140/min with occasional accelerations and moderate variability.

No uterine contractions noted.

The nurse is reviewing the findings.

For each finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome.

Each finding may support more than one disease process.

Blood pressure

Hemoglobin

Platelet count

Alanine aminotransferase

Answer and Explanation

The Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}

Blood pressure: This finding is consistent with preeclampsia, but not HELLP syndrome. Preeclampsia is defined as new-onset hypertension (systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg) after 20 weeks of gestation, with or without proteinuria. HELLP syndrome is a severe form of preeclampsia that involves hemolysis, elevated liver enzymes, and low platelets, but does not necessarily cause hypertension. Hemoglobin: This finding is consistent with HELLP syndrome, but not preeclampsia.

Hemolysis is one of the main features of HELLP syndrome, which causes a decrease in hemoglobin levels. Preeclampsia does not typically affect hemoglobin levels, unless there is significant blood loss or hemodilution.

Platelet count: This finding is consistent with both preeclampsia and HELLP syndrome. Low platelets (thrombocytopenia) are a common complication of preeclampsia, especially in severe cases. They are also a diagnostic criterion for HELLP syndrome, which requires a platelet count of less than 100,000/mm3.

Alanine aminotransferase: This finding is consistent with HELLP syndrome, but not preeclampsia. Elevated liver enzymes are another hallmark of HELLP syndrome, which indicates liver damage and inflammation. Preeclampsia may cause mild elevations of liver enzymes, but not to the same extent as HELLP syndrome.

Nursing Test Bank

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Correct Answer is C

Explanation

Choice A rationale:

A pulled-pork sandwich is not appropriate for a client following a kosher diet, as pork is not considered kosher due to dietary restrictions in Jewish dietary law (kashrut)

Choice B rationale:

Shrimp salad is not suitable for a client following a kosher diet, as shellfish is not considered kosher according to Jewish dietary laws.

Choice C rationale:

Roasted salmon is an appropriate choice for a client following a kosher diet, as salmon is typically considered kosher, provided it has been prepared and cooked according to kosher guidelines.

Choice D rationale:

Clam chowder is not appropriate for a client following a kosher diet, as it contains shellfish (clams), which is not considered kosher in Jewish dietary law.

A. "What would your family do without you?” B. "When you get better you will not feel this way.” C. "Why would you think a thing like that?” D. "Are you thinking of hurting yourself?”

Correct Answer is D

Explanation

Choice A rationale:

Asking, "What would your family do without you?" can be seen as judgmental and may not encourage open communication. It doesn't directly address the client's statement about feeling like a burden or wanting to be gone.

Choice B rationale:

Saying, "When you get better you will not feel this way," minimizes the client's feelings and can be invalidating. It does not show empathy or concern for the client's current emotional state.

Choice C rationale:

Asking, "Why would you think a thing like that?" can come across as judgmental and may make the client defensive. It does not directly address the client's emotional distress or suicidal ideation.

Choice D rationale:

This is the correct answer. "Are you thinking of hurting yourself?" is a direct and appropriate question to assess the client's risk of self-harm or suicide. It demonstrates concern for the client's well-being and opens the door for a more in-depth conversation about their feelings and thoughts. Assessing for suicidal ideation is a crucial step in providing appropriate care for a client with depressive disorder.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who follows a kosher diet.Which of the following menu items should the nurse include on the tray?

Correct Answer is C

Explanation

A nurse is caring for a client who has depressive disorder.The client states, "Everyone would be better off if I were not around." Which of the following responses should the nurse make?

Correct Answer is D

Explanation

A nurse is caring for a client who has AIDS.Which of the following solutions should the nurse use to disinfect the client's overbed table following a blood spill?

A nurse is assisting with the planning of an in-service about updates in wound care for nursing staff.Which of the following sources should the nurse identify as providing the best evidence-based information?

A nurse is reviewing the plan of care for a group of clients.The nurse should identify that informed consent is required for which of the following procedures?

A nurse is contributing to the plan of care for an older adult client.Which of the following physiological changes should the nurse recommend considering when administering medication?

A nurse in a provider's office is collecting data from a client who has candidiasis.Which of the following findings should the nurse expect?

A nurse is preparing to administer carbamazepine suspension 150 mg via NG tube every 6 hr. The amount available is 100 mg/5 mL. How many mL should the nurse administer with each dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)