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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Free Nursing Study Resources

Correct Answer is ["A","B"]

Explanation

A. Elevates the legs before applying the stockings: This is a correct action. Elevating the client's legs before applying elastic antiembolic stockings can help reduce swelling and improve blood flow. It's an appropriate step to prepare the client for the stockings.

B. Measures the client's calf circumference before selecting the stocking size: This is a correct action. Proper sizing of elastic antiembolic stockings is crucial to ensure they are effective and do not cause discomfort or complications. Measuring the client's calf circumference helps in selecting the right size.

C. Applies lotion to the client's legs before putting on the stockings: This is an incorrect action. Applying lotion to the legs before putting on stockings can make the stockings less effective and may cause them to slide down. Lotions or creams can create a barrier that interferes with the compression provided by the stockings.

D. Rolls down the stockings from the thigh to the ankle: This is an incorrect action. Elastic antiembolic stockings should be applied carefully, starting at the ankle and rolling them up to the thigh. Rolling them down from the thigh to the ankle is not the correct technique, as it can impede blood flow and be uncomfortable for the client.

So, the correct answers are A and B. These actions indicate that the AP is performing the skill correctly by preparing the client appropriately and ensuring proper sizing of the stockings.

A. Nausea. B. Hand tremors. C. Swelling of the lips. D. Hyperglycemia.

Correct Answer is C

Explanation

Choice A rationale:

Epinephrine is not typically used to treat nausea. Nausea is usually managed with antiemetic medications.

Choice B rationale:

Epinephrine is not used to treat hand tremors. Hand tremors may be related to various conditions, and their management would depend on the underlying cause.

Choice C rationale:

The correct manifestation that epinephrine can help treat is "Swelling of the lips." Epinephrine is commonly used to treat severe allergic reactions (anaphylaxis), which can cause swelling of the lips, tongue, and throat. Epinephrine helps to reverse these symptoms by constricting blood vessels and opening the airways.

Choice D rationale:

Epinephrine is not used to treat hyperglycemia. Hyperglycemia is managed with insulin or other antidiabetic medications, not epinephrine.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is monitoring an assistive personnel (AP) who is applying elastic antiembolic stockings for a client who has phlebitis. Which of the following actions by the AP indicates that they are performing the skill correctly?

Correct Answer is ["A","B"]

Explanation

A nurse is reinforcing teaching with a client who has a new prescription for epinephrine auto-injector PRN.The nurse should reinforce with the client that the medication can help treat which of the following manifestations?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has pernicious anemia.The nurse should identify that which of the following findings increases the client's risk for injury?

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 care of a client. Exhibits Data Collection Findings. For each data collection finding, click to specify if the finding is consistent with: ulcerative colitis, diverticulitis, or Crohn's disease. Each finding may support more than 1 disease process.

A nurse is caring for a client who recently gave birth to her first child.The newborn is crying, and the client states, "I can't seem to do anything right.What should I do?" Which of the following responses should the nurse make?

A nurse is caring for a client who has bulimia nervosa.Which of the following actions should the nurse take first?

A nurse is reinforcing teaching with a client who is about to undergo electroconvulsive therapy.The nurse should explain to the client that which of the following adverse reactions can occur following the procedure?

A nurse is reinforcing teaching with a client who has a urinary tract infection. Which of the following instructions should the nurse include in the teaching?

A nurse is reviewing information about ethical client care with a newly licensed nurse.Which of the following statements by the newly licensed nurse indicates an understanding of fidelity?