The nurse is continuing to care for the client.
Drag words from the choices below to fill in each blank in the following sentence.
The client is at greatest risk for developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Rationale for Correct Choices:
- Seizures: The client presents with severe preeclampsia, indicated by BP >160/110 mm Hg, 3+ proteinuria, hyperreflexia (patellar reflex 4+), and persistent headache. These are strong predictors of progression to eclampsia, which is marked by seizures.
- Placental Abruption: Severe hypertension increases the risk of placental abruption due to vascular compromise in the uteroplacental circulation. Decreased fetal movement may be an early warning sign of impaired placental perfusion or separation.
Rationale for Incorrect Choices:
- Cervical Insufficiency: This is a painless cervical dilation often leading to second-trimester loss, unrelated to hypertension or proteinuria. The client is in the third trimester with no signs of cervical changes.
- Hypoglycemia: The client has no history of diabetes, glucose intolerance, or related symptoms. Her urine glucose was only trace, and no medications suggest insulin use.
- Heart Failure: No signs of pulmonary congestion, dyspnea, or elevated heart rate are present. Oxygen saturation is normal, and breath sounds are not mentioned as abnormal, making CHF unlikely at this stage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B"},"D":{"answers":"A,B,C"}}
Explanation
Rationale:
- Sensation: Tingling indicates possible nerve irritation or mild neurovascular compromise. This is often seen in fractures when swelling or bone displacement compresses nerves near the injury site, especially in long bones like the radius.
- Ecchymosis: Bruising results from soft tissue bleeding and is common in all three conditions due to trauma to blood vessels. Ligament tears (sprain), bone injury (fracture), and capsule damage (dislocation) can all lead to ecchymosis.
- Pain level: Moderate pain, such as a 4/10 rating, is consistent with both sprains and fractures. Sprains stretch or tear ligaments, while fractures disrupt bone structure. Dislocations usually present with severe, sharp pain that impairs joint movement entirely.
- Edema: Swelling is a nonspecific but common response to tissue injury. It occurs with ligament strain (sprain), bone disruption (fracture), and joint trauma (dislocation), all of which lead to localized inflammation and fluid accumulation.
Correct Answer is B
Explanation
Rationale:
A. Increased hemoglobin: Elevated hemoglobin levels are generally associated with dehydration, high altitude, or chronic hypoxia, but they are not specific indicators of infection. Hemoglobin does not provide direct evidence of a bacterial process.
B. Increased absolute neutrophils: Neutrophils are the primary white blood cells involved in fighting bacterial infections. An elevated absolute neutrophil count suggests an acute bacterial infection or an inflammatory response caused by bacterial pathogens.
C. Decreased C-reactive protein: CRP is a marker of inflammation, often elevated during bacterial infections. A decreased CRP level makes bacterial infection less likely and is not consistent with the inflammatory response usually seen in such cases.
D. Decreased platelets: Low platelet counts (thrombocytopenia) can result from viral infections, autoimmune diseases, or bone marrow disorders. While they may be altered in sepsis, they are not a reliable or primary marker of a typical bacterial infection.
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