Nokea
The nurse is caring for a client with a diagnosis of gestational hypertension. Which complication is most likely to occur?
- A. Preeclampsia
- B. Preterm labor
- C. Fetal macrosomia
- D. All of the above
Correct Answer: A
Rationale: Gestational hypertension can progress to preeclampsia characterized by proteinuria and other systemic symptoms and is the most likely complication. Preterm labor and macrosomia are less directly related.
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The nurse is caring for a client with a history of a pleural effusion who is scheduled for a thoracentesis. The nurse should:
- A. Position the client flat in bed
- B. Administer a sedative before the procedure
- C. Place the client in a sitting position
- D. Restrict fluids after the procedure
Correct Answer: C
Rationale: Sitting upright with arms supported facilitates access to the pleural space during thoracentesis and reduces complications. Sedatives and fluid restrictions are not routine.
A 3-year-old child is admitted with a diagnosis of possible noncommunicating hydrocephalus. What is the first symptom that indicates increased intracranial pressure?
- A. Bulging fontanelles
- B. Seizure
- C. Headache
- D. Ataxia
Correct Answer: C
Rationale: Headache is the earliest symptom of increased intracranial pressure in children, preceding other signs like seizures or ataxia.
A client is pleased about being pregnant, yet states, 'It is really not the best time, but I guess it will be OK.' The nurse's assessment of this response is:
- A. Initial maternal-infant bonding may be poor.
- B. Client may have a poor relationship with her husband.
- C. This response is normal in the first trimester.
- D. This response is abnormal, to be re-evaluated at the next visit.
Correct Answer: C
Rationale: Ambivalence is normal during the first trimester. Reva Rubin addresses the issue of 'not now' in the first trimester. The statement still leaves room for exploration. There are no data to support this. This statement by the mother still leaves room for exploration. Ambivalence is normal during the first trimester. Reva Rubin addresses the issue of 'not now.' This fact should be shared with the mother during further exploration of the comment. It is not abnormal. If it were, another month would also be too long to wait.
A client with a history of atrial flutter is admitted with complaints of dizziness. The nurse should give priority to:
- A. Monitoring heart rate
- B. Administering pain medication
- C. Monitoring respiratory rate
- D. Administering diuretics
Correct Answer: A
Rationale: Atrial flutter causes rapid heart rates, which can lead to dizziness due to reduced cardiac output, so monitoring heart rate is the priority.
Which clients can be assigned to share a room in the emergency department during a disaster?
- A. A client having auditory hallucinations and a client with ulcerative colitis
- B. A client who is pregnant and a client with a fractured arm
- C. A child who is cyanotic with severe dyspnea and a client with a frontal head injury
- D. A client who arrives with a large puncture wound to the abdomen and a client with chest pain
Correct Answer: B
Rationale: A pregnant client and a client with a fractured arm have stable non-infectious conditions suitable for sharing a room. The other pairs include clients with unstable (cyanosis abdominal wound chest pain) or infectious (MRSA) conditions or psychiatric issues requiring isolation.