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The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.
- A. Hemoglobin
- B. Alanine aminotransferase (ALT)
- C. Blood pressure
- D. Platelet count
Correct Answer: C,D
Rationale: Sure, here is the step-by-step rationale for why options C and D (Platelet count) are correct:
1. Blood pressure: In preeclampsia, high blood pressure is a key characteristic. Elevated blood pressure is a common finding in patients with preeclampsia, making option C consistent with preeclampsia.
2. Platelet count: HELLP syndrome is a serious complication of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelet count. Therefore, a low platelet count is a hallmark feature of HELLP syndrome, aligning with option D.
Summary:
- Hemoglobin (Option A): Hemoglobin levels are not specific to either preeclampsia or HELLP syndrome. Therefore, this option is not selected.
- Alanine aminotransferase (ALT) (Option B): Elevated ALT levels are more specific to HELLP syndrome due to liver involvement. However, ALT
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Select the findings that indicate the client is experiencing adverse effects of the medication.
- A. Client states, 'I am feeling much better'
- B. Difficulty sleeping
- C. Client continues to deny any suicidal ideation
- D. BP 169/91 mm HG
- E. Respiratory rate 18/min
Correct Answer: B,D
Rationale: Hypertension and difficulty sleeping are potential side effects of certain medications.
Select the 2 findings that require immediate follow-up.
- A. Blood pressure
- B. Duration of contraction
- C. Fetal heart rate
- D. Fetal station
- E. Characteristics of amniotic fluid
Correct Answer: C,E
Rationale: An elevated fetal heart rate and meconium-stained amniotic fluid indicate potential distress, necessitating urgent intervention.
Which statement should the nurse include in the teaching?
- A. The test should be performed after your baby is 24 hours old.
- B. Genetic screening is only necessary if there is a family history of genetic disorders.
- C. Your baby cannot eat before the genetic screening test.
- D. If the first test is abnormal, no further testing is needed.
Correct Answer: A
Rationale: The correct answer is A because it accurately states the timing for performing the genetic screening test, which should be after the baby is 24 hours old to ensure accurate results. Choice B is incorrect because genetic screening may be recommended for all newborns, not just those with a family history. Choice C is incorrect because babies can eat before the test. Choice D is incorrect as further testing may be required if the initial results are abnormal.
Which risk factor should the nurse include as the best predictor of future violence?
- A. Previous violent behavior
- B. Low self-esteem
- C. Substance use disorder
- D. A history of depression
Correct Answer: A
Rationale: The correct answer is A: Previous violent behavior. This is the best predictor of future violence because past behavior is a strong indicator of future actions. Individuals who have a history of violent behavior are more likely to exhibit violent tendencies again. Low self-esteem (B), substance use disorder (C), and a history of depression (D) can contribute to increased risk of violence, but they are not as reliable predictors as previous violent behavior. A history of violence is a key factor in assessing the potential for future violent acts.
A charge nurse is teaching a newly licensed nurse about medication Administration. Which of the following information should the charge nurse include?
- A. Avoid preparing medications for more than two clients at one time.
- B. Inform clients about the action of the medication Prior to administration.
- C. Read medication labels at least two times prior to administration.
- D. Complete an incident report if a client vomits after taking a medication.
Correct Answer: C
Rationale: The correct answer is C: Read medication labels at least two times prior to administration. This is crucial to ensure accurate medication administration and prevent medication errors. Reading labels twice helps in verifying the right medication, dose, route, and time. It is a standard safety practice in medication administration. Option A is incorrect as there is no specific rule about preparing medications for multiple clients. Option B is important but not as critical as double-checking the medication labels. Option D is important in certain situations but not directly related to medication administration technique.