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The nurse is assessing a client who is in the third trimester of pregnancy. Which finding would require immediate intervention by the nurse?
- A. Blood pressure of 142/92 mmHg
- B. Pulse of 92 beats per minute
- C. Respiratory rate of 24 per minute
- D. Weight gain of 16 oz per week
Correct Answer: A
Rationale: A blood pressure of 142/92 mmHg in a client in the third trimester of pregnancy is elevated and could indicate the development of preeclampsia, a serious hypertensive disorder that can have adverse effects on both the mother and the fetus. Preeclampsia is characterized by high blood pressure accompanied by signs of organ damage, such as proteinuria and changes in other laboratory values. Immediate intervention is required in this situation, as preeclampsia can lead to complications such as seizures (eclampsia), stroke, and placental abruption. It is essential for the nurse to further assess the client and notify the healthcare provider promptly for appropriate management.
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A client is prescribed enalapril (Vasotec) for treatment of heart failure. Which adverse effect should the nurse assess for following the initial administration of this drug?
- A. Jaundice
- B. Ototoxicity
- C. Low blood pressure
- D. Blurred vision
Correct Answer: C
Rationale: Enalapril is an angiotensin-converting enzyme (ACE) inhibitor commonly used in the treatment of heart failure. One of the potential adverse effects of ACE inhibitors, including enalapril, is hypotension or low blood pressure. This is especially a concern following the initial administration of the drug, as it can cause a significant drop in blood pressure. Nurses should assess the patient for signs and symptoms of hypotension, such as dizziness, light-headedness, weakness, or fainting, after starting enalapril therapy. Monitoring blood pressure regularly and educating the patient about the possibility of low blood pressure is important to ensure patient safety and optimal outcomes.
The nurse has a 7-year-old client recovering from partial-thickness burns to the arms and hands. This client has shown sensitivity to loud noises and bright lights, and at times if she is overstimulated she won't speak to or look at anyone but her parents until she calms down. The nurse considers the best teaching environment for this client to be the
- A. client's room.
- B. pediatric ward waiting area.
- C. hospital cafeteria.
- D. pediatric ward play area.
Correct Answer: A
Rationale: For a 7-year-old client recovering from partial-thickness burns with sensitivity to loud noises and bright lights, along with a tendency to become overstimulated, the best teaching environment would be the client's room. This setting provides a familiar and comforting space where the client feels secure and less exposed to external stimuli that may trigger discomfort or anxiety. Being in her own room allows the client to focus better, feel more at ease, and have better communication with the nurse without distractions from bright lights, loud noises, or other people around. This controlled and peaceful environment contributes to a more effective teaching and learning experience for the client, promoting better understanding and retention of information.
A nurse is caring for a client who was involved in a motor vehicle accident and has lost approximately 1,550 mL of blood. The nurse should recognize that the client's shock will be classified as:
- A. Class I
- B. Class II
- C. Class III
- D. Class IV
Correct Answer: C
Rationale: Class III hemorrhagic shock typically involves the loss of 1,500-2,000 mL of blood, which aligns closely with the approximately 1,550 mL of blood lost by the client in this scenario. Class III shock is considered severe and can lead to significant physiological consequences, including decreased blood pressure, increased heart rate, altered mental status, and potential organ dysfunction. Therefore, based on the amount of blood loss and severity of symptoms, the client's shock would be classified as Class III.
After being diagnosed with polycystic kidney disease, an adult patient asks if current children are at risk for developing the disorder. How should the nurse respond?
- A. The adult form of this disorder is rare and should not affect grown children
- B. The children should undergo genetic testing and screening for evidence of the disease
- C. Because the condition was just diagnosed, there is no risk of passing the condition on to any children
- D. The children would have developed symptoms of the disorder in utero or shortly after birth if they had inherited the defective gene
Correct Answer: B
Rationale: Polycystic kidney disease (PKD) is a genetic disorder that can be inherited by children if one or both parents have the gene mutation responsible for the condition. In cases where a parent has been diagnosed with PKD, their children are at risk of inheriting the faulty gene. As such, it is recommended for the children to undergo genetic testing and screening to identify any evidence of the disease early on. By identifying the gene mutation in the children, appropriate monitoring and management can be initiated, potentially leading to better outcomes and quality of life for the affected individuals. Therefore, genetic testing and screening are crucial in cases where there is a known genetic component to a disorder like PKD.
What is the most accurate tool for assessing and diagnosing venous thrombosis?
- A. Ascending contrast venography
- B. Duplex venous ultrasonography
- C. Magnetic resonance imaging
- D. Plethysmography
Correct Answer: B
Rationale: Duplex venous ultrasonography is the most accurate tool for assessing and diagnosing venous thrombosis. It is a non-invasive imaging technique that combines Doppler flow studies with conventional ultrasonography. This allows for the visualization of blood flow in the veins and identification of any blood clots or obstructions. Duplex venous ultrasonography is highly sensitive and specific for detecting deep vein thrombosis (DVT) in the lower extremities, making it the preferred imaging modality for diagnosing venous thrombosis. Other imaging modalities like ascending contrast venography, magnetic resonance imaging, and plethysmography are less commonly used due to their disadvantages compared to duplex venous ultrasonography such as invasiveness, cost, and lower accuracy.