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The client is at 34 weeks of gestation.
A nurse is caring for a client who is at 34 weeks of gestation. Which of the following statements by the client is the nurse's priority to report to the provider?
- A. My heart feels like it skips a beat.
- B. I have nosebleeds once per week.
- C. The palms of my hands are red and blotchy.
- D. I'm experiencing persistent headaches.
Correct Answer: D
Rationale: Persistent headaches at 34 weeks may indicate preeclampsia, a priority concern.
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A nurse is assisting with teaching a class about the importance of fire safety. Which of the following hazards should the nurse include as an example of the leading cause of residential fires?
- A. Placing a space heater 5 ft from bed
- B. Smoking in bed
- C. Leaving the stove on
- D. Lack of smoke detectors
Correct Answer: B
Rationale: Smoking in bed is a leading cause of residential fires.
A nurse is reinforcing dietary teaching with a client who has constipation about appropriate food choices. Which of the following food selections by the client demonstrates an understanding of the teaching?
- A. Puffed rice cereal
- B. Tomato juice
- C. Bran muffin
- D. Cottage cheese
- E. None
- F. None
Correct Answer: C
Rationale: Bran muffins are high in fiber, which promotes bowel regularity and indicates understanding.
A nurse is collecting data from a client who has placenta previa. Which of the following findings should the nurse expect?
- A. Persistent uterine contractions
- B. Increased fetal movement
- C. Rigid abdomen
- D. Bright red vaginal bleeding
Correct Answer: D
Rationale: Bright red vaginal bleeding is characteristic of placenta previa.
The client has a history of hypertension.
A nurse is caring for a client who has a history of hypertension. Which of the following findings should the nurse recognize is indicative of transient ischemic attacks?
- A. Epigastric pain
- B. Seizure activity
- C. Sudden loss of vision in one eye
- D. Pain radiating down the left arm
Correct Answer: C
Rationale: Sudden monocular vision loss is a classic TIA symptom.
The client becomes combative and threatens other clients and staff.
A nurse is working with a client who becomes combative and threatens other clients and staff. Which of the following actions should the nurse take?
- A. Stand in front of the client to block them from others in the room.
- B. Apply restraints according to the facility's standing order.
- C. Ensure there are enough staff members available for assistance.
- D. Obtain a PRN prescription for restraints from the provider.
Correct Answer: C
Rationale: Ensuring staff availability ensures safety without immediate restraint use.