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

The nurse is assisting with initiating the client's plan of care. Which of the following interventions should the nurse include? Select all that apply.

Administer betamethasone.

Monitor intake and output every hour.

Assist RN with performing a vaginal examination every 12 hr.

Obtain a 24-hr urine specimen.

Provide a low-stimulation environment.

Give antihypertensive medication.

Maintain bedrest.

Answer and Explanation

Correct Answer : A,B,D,E,F,G

Administer betamethasone: Betamethasone is administered to pregnant clients at risk of preterm delivery to promote fetal lung maturity. Given the client's gestational age of 31 weeks and signs of severe preeclampsia, administering corticosteroids is critical to prepare for potential early delivery.
Monitor intake and output every hour: Severe preeclampsia can impair renal function, leading to decreased urine output and worsening fluid retention. Hourly monitoring of intake and output helps detect early signs of renal compromise and fluid overload, both of which require immediate intervention.
Assist RN with performing a vaginal examination every 12 hr: Vaginal examinations are avoided in cases of severe preeclampsia unless absolutely necessary because they can stimulate uterine contractions or introduce infection. Therefore, routinely assisting every 12 hours with vaginal exams is not appropriate in this client's plan of care.
Obtain a 24-hr urine specimen: A 24-hour urine collection assesses the degree of proteinuria and provides a clearer diagnostic picture of the severity of preeclampsia. Quantifying protein excretion helps guide clinical management and decisions about timing of delivery.
Provide a low-stimulation environment: A calm, quiet environment minimizes the risk of seizure activity in clients with severe preeclampsia. Reducing auditory, visual, and environmental stimulation is a standard preventative measure to decrease neurological irritability.
Give antihypertensive medication: Severe hypertension must be promptly treated to prevent complications like stroke, placental abruption, and progression to eclampsia. Administering antihypertensive therapy helps stabilize maternal blood pressure and protects both maternal and fetal health.
Maintain bedrest: Bedrest helps reduce blood pressure and physical stress, promoting better perfusion to the placenta. Although strict bedrest is controversial long-term, short-term bedrest is often used in severe preeclampsia management while stabilization measures are implemented.

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Correct Answer is A

Explanation

A. Drink high-protein nutritional supplements between meals: Clients with COPD often experience anorexia due to fatigue, difficulty breathing while eating, and early satiety. High-protein, high-calorie supplements between meals help meet nutritional needs without overwhelming them during main meals, supporting energy levels and respiratory muscle strength.

B. Eat more hot foods than cold foods at mealtime: Hot foods can produce stronger odors that may worsen appetite loss. Cold foods tend to have milder smells and may be better tolerated by clients with anorexia, making cold foods preferable rather than focusing on hot foods.

C. Eat low-calorie foods first at mealtime: Clients with anorexia and COPD should prioritize high-calorie, nutrient-dense foods first to maximize intake before feeling full. Eating low-calorie foods first could reduce overall calorie intake, worsening weight loss and malnutrition risks.

D. Increase liquids during meals: Consuming large amounts of liquid during meals can cause early satiety, making it harder for clients to consume enough food. It is better to encourage drinking fluids between meals to optimize food intake during eating times.

A. BMI 32 B. Alcohol use C. Age 35 years D. Medical history of asthma

Correct Answer is A

Explanation

A. BMI 32: A BMI of 30 or higher indicates obesity, which is a major risk factor for developing type 2 diabetes mellitus. Excess body fat, especially abdominal fat, contributes to insulin resistance, increasing the likelihood of diabetes.

B. Alcohol use: While excessive alcohol intake can affect overall health, moderate alcohol consumption is not a primary direct risk factor for type 2 diabetes. Other factors like obesity and sedentary lifestyle have a stronger association.

C. Age 35 years: Advancing age increases diabetes risk, but significant age-related risk typically rises after age 45. At 35 years old, age alone is not considered a major risk factor without additional contributing conditions.

D. Medical history of asthma: Asthma is a chronic respiratory condition but is not recognized as a risk factor for type 2 diabetes mellitus. The primary risk factors involve metabolic, genetic, and lifestyle components rather than respiratory history.

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Body System	Findings
Cardiovascular	S1, S2, no murmur, bradycardia
Respiratory	decreased respiratory effort, equal chest expansion, bilateral crackles
Neurologic	somnolent
Head, Ears, Eyes, Nose, and Throat (HEENT)	oropharynx clear, mucous membranes moist, pinpoint pupils
Vital Signs	Temperature 37.4° C (99.4° F) Heart rate 58/min Respiratory rate 10/min Blood pressure 98/58 mm Hg

The nurse is continuing to assist with the care of the client. The nurse is assisting with initiating the client's plan of care. Which of the following interventions should the nurse include? Select all that apply.

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

The nurse is assisting with initiating the client's plan of care. Which of the following interventions should the nurse include? Select all that apply.