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The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process
- A. Hemoglobin
- B. Alanine aminotransferase (ALT)
- C. Blood pressure
- D. Platelet count
Correct Answer: C: Preeclampsia; A, B, D: HELLP
Rationale: The correct answer is: C: Preeclampsia; A, B, D: HELLP.
1. Blood pressure is consistent with preeclampsia as elevated blood pressure is a key characteristic.
2. Hemoglobin, Alanine aminotransferase (ALT), and Platelet count are consistent with HELLP syndrome, as these markers are commonly affected in this condition.
3. Preeclampsia is characterized by hypertension and proteinuria, while HELLP syndrome involves hemolysis, elevated liver enzymes, and low platelet count.
4. Therefore, based on the assessment findings provided, elevated blood pressure aligns with preeclampsia, while abnormalities in hemoglobin, ALT, and platelet count suggest HELLP syndrome.
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A nurse in a clinic is planning care for a child who has ADHD and is taking atomoxetine. Which of the following laboratory values should the nurse monitor?
- A. Liver function tests
- B. Kidney function tests
- C. Hemoglobin and hematocrit
- D. Serum sodium and potassium
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Atomoxetine is known to potentially cause liver injury. Monitoring liver function tests is crucial to detect any signs of liver damage early on. Kidney function tests (B), hemoglobin and hematocrit (C), and serum sodium and potassium (D) are not directly associated with atomoxetine use in ADHD. Monitoring liver function is the priority in this case.
A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
- A. Initiate seclusion protocol.
- B. Use a face shield with a mask when providing care to the client
- C. Tell the client, 'You seem to be very upset.'
- D. Engage the panic alarm
Correct Answer: C
Rationale: The correct answer is C. When a client is aggravated, pacing, and speaking loudly, it is important to acknowledge their feelings. By telling the client, "You seem to be very upset," the nurse shows empathy and validates the client's emotions. This can help de-escalate the situation by demonstrating understanding and openness to communication. It also allows the nurse to assess the client's needs and concerns effectively.
Choice A is incorrect as initiating seclusion protocol should only be considered for extreme cases where the client poses a danger to themselves or others. Choice B is unnecessary in this situation as it does not address the client's emotional state. Choice D, engaging the panic alarm, is premature and could escalate the situation further.
For each potential action, click to specify if the action is indicated or contraindicated for the client.
- A. Allow the client to watch TV at a high volume.
- B. Ask the client about the content of their hallucinations
- C. Instruct the client on expected hygiene practices.
- D. Assess the client for suicidal ideation.
- E. Place the client in a room near the activity room
Correct Answer: B, C, D indicated; A, E contraindicated
Rationale: Correct Answer: B, C, D indicated; A, E contraindicated
Rationale:
1. B is indicated because asking about hallucinations can help assess the client's mental state.
2. C is indicated as maintaining hygiene is important for the client's well-being.
3. D is indicated to assess and address any suicidal ideation for client safety.
4. A is contraindicated as high TV volume can worsen auditory hallucinations.
5. E is contraindicated as placing near activity room may cause overstimulation and distress.
A nurse is collecting a sputum specimen from a client who has tuberculosis. Which of the following actions should the nurse take?
- A. Wait 1 day to collect the specimen if the client cannot provide sputum.
- B. Wear sterile gloves to collect the specimen from the client.
- C. Ask the client to provide 15 to 20 mL of sputum into the container
- D. Obtain the specimen immediately upon the client waking up.
Correct Answer: D
Rationale: The correct answer is D: Obtain the specimen immediately upon the client waking up. This is the correct action because sputum is most concentrated in the morning, making it easier to collect a good sample for testing. Waiting 1 day (A) can delay treatment. Wearing sterile gloves (B) is important but not specific to sputum collection. Asking for 15-20mL of sputum (C) is appropriate, but the timing of collection is crucial.
A nurse is teaching a client who is trying to conceive. Which of the following should the nurse instruct the client to increase in her diet to prevent a neural tube defect?
- A. Calcium
- B. Folate
- C. Iron
- D. Zinc
Correct Answer: B
Rationale: The correct answer is B: Folate. Folate is essential for preventing neural tube defects in newborns. It helps in the formation of the neural tube during early pregnancy. Calcium (A) is important for bone health but not specifically for preventing neural tube defects. Iron (C) is crucial for preventing anemia but not directly related to neural tube defects. Zinc (D) is important for immune function and wound healing but not specifically for neural tube defects.