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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.

Provide a low-stimulation environment.

Maintain bed rest

Give antihypertensive medication

Obtain a 24-hr urine specimen

Perform a vaginal examination every 12 hr.

Monitor intake and output hourly

Administer betamethasone

Answer and Explanation

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

Rationale:

A. Provide a low-stimulation environment: The client has a severe headache, 3+ proteinuria, and elevated BP, indicating severe preeclampsia. A quiet, low-light environment reduces the risk of seizure by limiting neurologic stimulation.

B. Maintain bed rest: Bed rest in a side-lying position improves uteroplacental blood flow and helps lower blood pressure. It also decreases metabolic demand, which is critical in hypertensive pregnancies.

C. Give antihypertensive medication: The BP readings (162/112 and 166/110 mm Hg) require immediate antihypertensive therapy to prevent cerebral hemorrhage, eclampsia, or placental abruption.

D. Obtain a 24-hr urine specimen: A 24-hour urine collection for protein is the gold standard for quantifying proteinuria and confirming the diagnosis of preeclampsia. While a dipstick of 3+ is a strong indicator, the 24-hour collection provides a definitive measurement.

E. Perform a vaginal examination every 12 hr: There are no contractions or signs of labor, so regular vaginal exams are not indicated and increase the risk of infection in a preterm pregnancy.

F. Monitor intake and output hourly: Decreased renal perfusion is a complication of preeclampsia. Hourly monitoring detects oliguria early and helps assess for fluid overload or worsening renal function.

G. Administer betamethasone: At 31 weeks, betamethasone is indicated to enhance fetal lung maturity due to risk of preterm delivery from severe maternal complications.

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Correct Answer is C

Explanation

Rationale:

A. Prolonged QT interval: This is not a typical sign of morphine toxicity. QT prolongation is more commonly associated with certain antipsychotics, antiarrhythmics, or methadone, not opioids like morphine.

B. Fluid retention: Morphine does not typically cause fluid retention. While it may contribute to urinary retention, generalized fluid accumulation is not characteristic of opioid toxicity and may point to other causes like heart or renal failure.

C. Bradypnea: Respiratory depression, including bradypnea, is the hallmark sign of opioid toxicity. Morphine suppresses the brainstem’s respiratory centers, reducing respiratory rate and depth, which can become life-threatening without intervention.

D. Hyperactive deep tendon reflexes: Opioids tend to cause central nervous system depression, which would more likely lead to diminished reflexes. Hyperactive reflexes are not associated with morphine toxicity and may suggest a different neurological issue.

A. Use a mechanical voice amplifier. B. Provide educational materials with large print. C. Have the client's glasses brought from home. D. Establish alternatives to verbal conversation.

Correct Answer is D

Explanation

Rationale:

A. Use a mechanical voice amplifier: A voice amplifier benefits clients with impaired vocal strength but does not help clients with expressive aphasia, who struggle to form or express language, not to project it audibly.

B. Provide educational materials with large print: Large print materials are helpful for clients with visual impairments but do not address language expression difficulties. Expressive aphasia requires alternative communication strategies, not visual aids.

C. Have the client's glasses brought from home: Glasses improve vision, not speech or language production. While helpful overall, they do not assist with the core issue of expressive aphasia, which is rooted in brain-language pathways.

D. Establish alternatives to verbal conversation: Using picture boards, writing tools, gestures, or communication apps helps clients express needs and ideas despite speech limitations. These strategies support more effective communication in expressive aphasia.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is D

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.