What is the most likely cause of the client's symptoms, and what is the nurse's priority intervention?

The client is experiencing an allergic reaction; the nurse should administer epinephrine immediately.

The client has developed a urinary tract infection; the nurse should collect a urine sample for culture and sensitivity.

The client is presenting with signs of preeclampsia; the nurse should monitor for seizure activity and administer prescribed medications.

The client is experiencing a hypertensive crisis; the nurse should prepare for immediate surgery.

Answer and Explanation

The Correct Answer is C

Choice A rationale

The client's symptoms, including severe headache, nausea, right-sided upper abdominal pain, and hyperreflexia (4+ DTRs), are classic indicators of severe preeclampsia, not an allergic reaction. An allergic reaction typically involves hives, itching, and respiratory distress. Administering epinephrine is an inappropriate intervention and would likely worsen the client's condition.

Choice B rationale

A urinary tract infection (UTI) typically presents with symptoms such as dysuria, frequency, and suprapubic pain. While a headache and nausea can be systemic symptoms of an infection, they do not explain the hyperreflexia or the right-sided upper abdominal pain. A UTI is a less likely diagnosis given the constellation of symptoms.

Choice C rationale

The symptoms presented, including a severe headache, nausea, right-sided upper abdominal pain (suggesting liver involvement), and hyperreflexia, are the hallmarks of severe preeclampsia. The priority intervention is to monitor for seizure activity and administer prescribed medications, such as magnesium sulfate, to prevent the progression to eclampsia, which is a life-threatening complication.

Choice D rationale

While the client is experiencing hypertension, the constellation of symptoms points to preeclampsia, a specific condition, rather than a general hypertensive crisis. Immediate surgery is not the first intervention. The priority is to stabilize the client and prevent a seizure while preparing for delivery, which is the definitive treatment.

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Correct Answer is D

Explanation

Choice A rationale

Ophthalmic ointments like erythromycin or tetracycline do not have properties that dilate the pupils. Their chemical composition is designed to inhibit bacterial growth. Pupillary dilation is typically achieved with mydriatic agents, which are not included in these prophylactic treatments. The red reflex is a normal finding and not the purpose of the medication.

Choice B rationale

While the ointment is effective against certain sexually transmitted infections, a herpes simplex virus infection is a viral infection. The prophylactic ophthalmic ointments are bacteriostatic or bactericidal, specifically targeting bacterial pathogens like Neisseria gonorrhoeae and Chlamydia trachomatis. They are not effective in preventing viral infections.

Choice C rationale

The ointment is a thick, viscous substance that can temporarily cause blurred vision immediately after administration. It does not clear the infant's vision; rather, it is a prophylactic measure to prevent a severe infection that could lead to corneal scarring and blindness. The visual effect is temporary and not therapeutic.

Choice D rationale

Prophylactic ophthalmic ointment, typically erythromycin or tetracycline, is administered to all newborns to prevent ophthalmia neonatorum, which is an eye infection caused by bacteria such as Neisseria gonorrhoeae and Chlamydia trachomatis. These bacteria can be transmitted from the mother's birth canal and can cause serious eye damage, including blindness.

A. Your child is manipulating you. Encourage independence by requiring that your child feed themself. B. Your child is probably lonely for friends. Perhaps you can get one of them to visit for a short while. C. When children are sick, they often regress to an earlier age. This should pass soon. D. Sounds like your child is pretty angry with you for having the tonsils taken out.

Correct Answer is C

Explanation

Choice A rationale

Suggesting that the child is "manipulating" the parent is a non-therapeutic and judgmental response. It fails to recognize the psychological and emotional stress a child experiences after surgery. Post-surgical regression is a well-documented phenomenon. Labeling a child's behavior as manipulative can lead to a breakdown in the parent-child relationship and prevent the parent from providing the necessary emotional support and comfort the child needs during recovery. The nurse’s role is to educate, not judge.

Choice B rationale

While loneliness can be a factor, suggesting a friend visit immediately after a tonsillectomy is not the most appropriate advice. The child is in a recovery period and needs rest, comfort, and close observation. The presence of a visitor, while well-intentioned, could overstimulate the child and interfere with the necessary rest needed for healing. Post-tonsillectomy care prioritizes quiet recovery and minimizing activity. This advice is not aligned with the child’s physiological needs.

Choice C rationale

This response accurately explains the concept of regression, which is a common psychological defense mechanism in children who are ill or stressed. Regression involves reverting to behaviors characteristic of an earlier developmental stage to cope with overwhelming feelings or circumstances. Acknowledging this as a normal and temporary response validates the parent's concern and provides a scientific explanation, allowing them to respond with empathy and support. It reassures the parent that this behavior is expected and will likely resolve as the child recovers.

Choice D rationale

This response inappropriately suggests that the child's behavior stems from anger towards the parent. While children can be angry, framing this behavior solely as anger over the surgery is speculative and does not account for the more common and well-documented phenomenon of regression. This response can create guilt in the parent and distract from the actual cause of the behavior, which is a stress response to illness and surgery. It is not the most scientific or helpful explanation for the observed behavior.

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What is the most likely cause of the client's symptoms, and what is the nurse's priority intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A father watching the admission of his newborn to the nursery notices that eye ointment is placed in the infant's eyes. He asks the nurse what the purpose of the ointment is. Which response by the nurse will best explain the purpose for administering the ointment?

Correct Answer is D

Explanation

A 4-year-old child returns home after day surgery for a tonsillectomy. When the nurse calls the parent that evening to check on the child, the parent tells the nurse that the child said, “I'm too sick to feed myself. Will you feed me?” Which response should the nurse provide to this parent?

Correct Answer is C

Explanation

A nurse is reviewing a client's vital signs and notes the following measurements: temperature 98.4° F, heart rate 88 beats/minute, respirations 16 breaths/minute, and blood pressure 167/107 mm Hg. What is the most appropriate nursing action based on these vital signs?

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The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

During a well child visit, the parents of a client who has an autosomal dominant disorder, inform the nurse that they do not plan on having any more children since the next child is likely to inherit the disorder. How should the nurse respond?

The nurse is obtaining a history of a 9-year-old boy who is brought to the clinic for a well-child visit. The parent begins to provide all the information when the child is interviewed. How should the nurse include the child in the conversation?

Which nutritional information should the nurse plan to provide the mother of a 6-month-old regarding introduction of solid foods?

A laboring client's membranes rupture spontaneously. The nurse notices that the amniotic fluid is greenish-brown. Which intervention should the nurse implement first?