Nokea
The nurse has admitted a client diagnosed with gestational hypertension who is in labor. The nurse monitors the client closely for which complication of gestational hypertension?
- A. Seizures
- B. Hallucinations
- C. Placenta previa
- D. Altered respiratory status
Correct Answer: A
Rationale: Gestational hypertension can lead to preeclampsia and eclampsia; therefore, a major complication of gestational hypertension is seizures. Hallucinations, placenta previa, and altered respiratory status are not directly associated with gestational hypertension.
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The nurse plans care for a client requiring intravenous (IV) fluids and electrolytes understanding that which are findings that correlate with the need for this type of therapy? Select all that apply.
- A. Hyponatremia
- B. Bounding pulse rate
- C. Chronic kidney disease
- D. Isolated syncope episodes
- E. Rapid, weak, and thready pulse
- F. Abnormal serum and urine osmolality levels
Correct Answer: A,E,F
Rationale: Abnormal assessment findings of major body systems offer clues to fluid and electrolyte imbalances. Rapid, weak, and thready pulse is an assessment abnormality found with fluid and electrolyte imbalances, such as hyponatremia. Abnormal serum and urine osmolality are laboratory tests that are helpful in identifying the presence of or risk of fluid imbalances. Isolated episodes of syncope are not indicators for intravenous therapy unless fluid and electrolyte imbalances are identified. A bounding pulse rate is a manifestation of fluid volume excess; therefore, IV fluids are not indicated. Clients with chronic kidney disease experience the inability of the kidneys to regulate the body's water balance; fluid restrictions may be used.
The nurse is caring for a client in active labor. Which intervention should the nurse implement to prevent fetal heart rate decelerations?
- A. Discourage the client from walking.
- B. Increase the rate of the oxytocin infusion.
- C. Monitor the fetal heart rate every 30 minutes.
- D. Encourage upright or side-lying maternal positions.
Correct Answer: D
Rationale: Side-lying and upright positions such as walking, standing, and squatting can improve venous return and encourage effective uterine activity. There are many nursing actions to prevent fetal heart rate decelerations without necessitating surgical intervention.
When a client with a chest injury is suspected of experiencing a pleural effusion, which typical manifestations of this respiratory problem should the nurse assess for? Select all that apply.
- A. Dry cough
- B. Moist cough
- C. Dyspnea at rest
- D. Productive cough
- E. Dyspnea on exertion
- F. Nonproductive cough
Correct Answer: A,E,F
Rationale: A pleural effusion is the collection of fluid in the pleural space. Typical assessment findings in the client with a pleural effusion include dyspnea, which usually occurs with exertion, and a dry, nonproductive cough. The cough is caused by bronchial irritation and possible mediastinal shift.
The nurse has developed a plan of care for a client with a diagnosis of anterior cord syndrome. Which intervention should the nurse include in the plan of care to minimize the client's long-term risk for injury?
- A. Change the client's positions slowly.
- B. Assess the client for decreased sensation to touch.
- C. Assess the client for decreased sensation to vibration.
- D. Teach the client about loss of motor function and decreased pain sensation.
Correct Answer: D
Rationale: Anterior cord syndrome is caused by damage to the anterior portion of the gray and white matter. Clinical findings related to anterior cord syndrome include loss of motor function, temperature sensation, and pain sensation below the level of injury. The syndrome does not affect sensations of fine touch, position, and vibration.
A client seeks medical attention for intermittent signs and symptoms that suggest a diagnosis of Raynaud's disease. The nurse should assess the trigger of these signs/symptoms by asking which question?
- A. Does being exposed to heat seem to cause the episodes?
- B. Do the signs and symptoms occur while you are asleep?
- C. Does drinking coffee or ingesting chocolate seem related to the episodes?
- D. Have you experienced any injuries that have limited your activity levels lately?
Correct Answer: C
Rationale: Raynaud's disease is vasospasm of the arterioles and arteries of the upper and lower extremities. It produces closure of the small arteries in the distal extremities in response to cold, vibration, or external stimuli. Episodes are characterized by pallor, cold, numbness, and possible cyanosis of the fingers, followed by erythema, tingling, and aching pain. Attacks are triggered by exposure to cold, nicotine, caffeine, trauma to the fingertips, and stress. Prolonged episodes of inactivity are unrelated to these episodes.