Nokea
The client is admitted with a diagnosis of preterm premature rupture of membranes (PPROM). The nurse should prepare to administer which medication?
- A. Magnesium sulfate
- B. Terbutaline
- C. Betamethasone
- D. All of the above
Correct Answer: C
Rationale: Betamethasone is administered in PPROM (24-34 weeks) to enhance fetal lung maturity in anticipation of preterm delivery. Magnesium sulfate may be used for neuroprotection or preeclampsia and terbutaline is a tocolytic but betamethasone is the priority.
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Which complaint is frequently expressed by a client with macular degeneration?
- A. Problems with activities requiring focused vision such as sewing
- B. Severe eye and face pain accompanied by nausea and vomiting
- C. Seeing halos around lights
- D. Veil-like loss of vision
Correct Answer: A
Rationale: Macular degeneration affects central vision, impairing activities like sewing or reading that require focused vision. Severe pain with nausea is typical of acute glaucoma, halos suggest cataracts or glaucoma, and veil-like vision loss is more associated with retinal detachment.
Which client clinical manifestation during a bone marrow transplantation procedure alerts the nurse to the possibility of an adverse reaction?
- A. Fever
- B. Red colored urine
- C. Hypertension
- D. Shortness of breath
Correct Answer: D
Rationale: Shortness of breath may indicate an acute transfusion reaction (e.g., TRALI) during bone marrow transplantation, requiring immediate action. Fever (A), red urine (B), and hypertension (C) are less specific or expected.
The nurse is caring for a client with a diagnosis of hyperemesis gravidarum. Which laboratory finding is most likely to be present?
- A. Metabolic alkalosis
- B. Hyponatremia
- C. Hypokalemia
- D. All of the above
Correct Answer: D
Rationale: Hyperemesis gravidarum causes prolonged vomiting leading to metabolic alkalosis (loss of stomach acid) hyponatremia (electrolyte loss) and hypokalemia (potassium loss). All are likely findings in severe cases.
A nurse is taking a maternal history for a client at her first prenatal visit. Her pregnancy test was positive, she has two living children, she had one spontaneous abortion, and one infant died at the age of 3 months. Which of the following best describes the client at the present?
- A. Gravida 4, para 2, ab 1
- B. Gravida 5, para 3, ab 1
- C. Gravida 5, para 4, ab 0
- D. Gravida 4, para 3, ab 0
Correct Answer: B
Rationale: The client has been pregnant five times (current pregnancy, two living children, one spontaneous abortion, one infant death), delivered three children (two living, one died), and had one abortion.
The nurse is trying to help a mother understand what is happening with her son who has recently been diagnosed with paranoid schizophrenia. At present, he is experiencing hallucinations and delusions of persecution and suffers from poor hygiene. The nurse can best help her understand her son's condition by which of the following statements?
- A. Sometimes these symptoms are caused by an overstimulation of a chemical called dopamine in the brain.'
- B. Has anyone in your family ever had schizophrenia?'
- C. If your son has a twin, he probably will eventually develop schizophrenia, too.'
- D. Some of his symptoms may be a result of his lack of a strong mother-child bonding relationship.'
Correct Answer: A
Rationale: The most plausible theory to date is that dopamine causes an overstimulation in the brain, which results in the psychotic symptoms.