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The nurse is continuing to care for the client.

Exhibits

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

Perform a vaginal examination every 12 hr.

Obtain a 24-hr urine specimen.

Administer betamethasone.

Monitor intake and output hourly.

Give antihypertensive medication.

Provide a low-stimulation environment

Maintain bed rest.

Answer and Explanation

Correct Answer : B,C,E,F,G

A. Perform a vaginal examination every 12 hr. Routine vaginal examinations are not indicated at this stage of care, as there are no signs of labor or uterine contractions. Vaginal exams should only be performed if there are indications of preterm labor or changes in maternal symptoms.

B. Obtain a 24-hr urine specimen. Collecting a 24-hour urine specimen allows for accurate measurement of total protein excretion, which is critical for confirming the severity of preeclampsia. This diagnostic tool helps guide further management decisions.

C. Administer betamethasone. Betamethasone is given to promote fetal lung maturity in the event of a preterm delivery, which is a significant risk at 31 weeks of gestation in the presence of severe preeclampsia. It reduces neonatal morbidity and mortality.

D. Monitor intake and output hourly. While monitoring fluid status is essential, hourly monitoring is not typically required unless there are signs of worsening renal function, oliguria, or fluid imbalance. Regular but less frequent monitoring is sufficient for this client.

E. Give antihypertensive medication. The client's blood pressure readings of 162/112 mm Hg and 166/110 mm Hg require prompt antihypertensive treatment to reduce the risk of complications such as stroke, placental abruption, or eclampsia.

F. Provide a low-stimulation environment. A quiet, low-stimulation environment helps reduce the risk of seizures, which is a concern for clients with severe preeclampsia. This intervention supports neurological stability.

G. Maintain bed rest. Bed rest minimizes physical exertion, helping to lower blood pressure and improve placental perfusion, which is critical for fetal well-being in a client with severe preeclampsia.

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Correct Answer is B

Explanation

A. While noting changes in the medical record is important, it doesn’t specifically address communication between staff members.

B. Having interdisciplinary team meetings on a regular basis ensures that all healthcare providers involved in the client’s care are informed of the current treatment plan, goals, and changes. This promotes communication and collaboration across disciplines, which is especially important in the care of clients with conditions like expressive aphasia.

C. Recording progress in the nurses’ notes is important, but it alone does not foster active communication between different team members.

D. Posting swallowing precautions is important for the safety of the client but doesn’t address the need for better communication among the team.

A. "My sibling and I hired help at home for my parent. B. I found the title to the car today, signed over to me." C. Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. D. Client says, "Why don't you just leave me? I am of no use." E. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." F. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min G. Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 Ib in the past month. H. Heart rate 68/min

Correct Answer is ["B","C","D","G"]

Explanation

System	Findings
General	Adult child accompanying parent reports decline in client, expressing concern over memory and thought process, appetite, and self-care. Adult child states, "My sibling and I hired help at home for my parent. We thought that would help but it has not. I found the title to the car today, signed over to me."
Physical	Client makes poor eye contact, speaks in a monotone voice, and has a lack of facial expression. Client reports sleeping 7 hr a night and getting up "once or twice per night to go to the bathroom." Client reports not wanting to eat anymore. Client's child reports their parent has lost about 8 lb in the past month. Heart rate 68/min
Affect	Client says, "Why don't you just leave me? I am of no use."

Rationale

These findings suggest significant cognitive and physical decline, potential depression, and possible suicidal ideation, all of which require immediate attention and intervention.

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The nurse is continuing to care for the client. Exhibits The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is experiencing expressive aphasia and right The nurse should expect the adolescent to be in which of the nurse best promotes communication among staff caring for the client?

Correct Answer is B

Explanation

Correct Answer is ["B","C","D","G"]

Explanation

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The nurse is continuing to care for the client.

Exhibits

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