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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 C

Explanation

A. Inability to read: Difficulty reading is not a hallmark symptom of delirium. It may be associated with visual impairment, literacy issues, or chronic cognitive decline such as dementia, but delirium is primarily characterized by acute mental status changes, not isolated reading difficulties.

B. Echopraxia: Echopraxia, the involuntary imitation of another person’s movements, is typically associated with schizophrenia or other severe psychiatric disorders. It is not a defining feature of delirium, which primarily affects attention, awareness, and cognition rather than imitation behaviors.

C. Acute onset of confusion: Delirium is distinguished by a sudden, acute onset of confusion and fluctuating levels of consciousness. Clients may exhibit disorganized thinking, poor attention, and impaired awareness, which are hallmark features that help differentiate delirium from chronic conditions like dementia.

D. Aphasia: Aphasia, or loss of the ability to understand or express speech, is more commonly related to neurological injuries such as stroke. While speech may be disorganized during delirium, the specific loss of language function like aphasia is not a primary or expected feature of this acute condition.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Explanation

Reviewing fetal heart rate tracing: Reviewing the fetal heart rate tracing is the first action because the client has signs of severe preeclampsia, which can quickly lead to fetal distress. The fetal monitor will provide immediate information about the baby’s oxygenation status. Detecting any late decelerations or bradycardia would require urgent intervention to protect fetal life.
Administering IM betamethasone: Administering IM betamethasone is important to accelerate fetal lung maturity in case early delivery is necessary. Since the client is only at 31 weeks, promoting lung development is crucial to improve neonatal outcomes. However, confirming fetal well-being comes first before giving medications.
Scheduling an emergency cesarean section: An emergency cesarean section is not the first step without evidence of fetal compromise or maternal instability. At this point, the fetal heart rate shows moderate variability and accelerations, which are reassuring. A cesarean is only scheduled if fetal distress or worsening maternal condition occurs after further monitoring.
Insert a Foley catheter to monitor urine output: Inserting a Foley catheter is important to monitor kidney function and fluid status in preeclampsia. Reduced urine output can signal worsening disease. However, it is not the priority over assessing the fetal condition first, because fetal distress can occur rapidly and needs immediate identification.
Administering antibiotics: There is no current indication for administering antibiotics based on the client's data. The client does not have signs of infection, such as fever, elevated WBCs, or positive urinalysis for infection. Administering antibiotics would not address the current primary risks related to severe preeclampsia.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who is experiencing delirium. Which of the following findings should the nurse expect?

Correct Answer is C

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}

Explanation

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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.