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Questions 158

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Question 1 of 5

A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her 7th to 8th month; her face and hands indicate edema. She is diagnosed as having PIH and referred to the high-risk prenatal clinic. The client's weight increase is most likely due to:

Correct Answer: D

Rationale: Overeating can lead to obesity, but not to edema. There is no indication of obesity prior to pregnancy. PIH is more prevalent in the underweight than in the obese in this age group. Hypertension can be due to kidney lesions, but it would have been apparent earlier in the pregnancy. The weight gain in PIH is due to the retention of sodium ions and fluid and is one of the three cardinal symptoms of PIH.

Question 2 of 5

The client is admitted with a diagnosis of gestational hypertension. Which assessment finding requires immediate notification of the physician?

Correct Answer: C

Rationale: Headache and visual disturbances in gestational hypertension suggest severe preeclampsia or impending eclampsia requiring immediate physician notification. BP of 140/90 proteinuria and edema are concerning but less urgent unless severe.

Question 3 of 5

The serial sevens test is often used to determine delirium and dementia. This test aids in assessing which of the following?

Correct Answer: B

Rationale: This answer is incorrect. The test measures the abilities to concentrate and calculate. The use of proverbs is the most common way to test abstraction. This answer is correct. The serial sevens test is a common test of calculation ability. It is difficult for the demented or delirious client to perform. This answer is incorrect. The test for judgment should predict whether the individual will behave in a socially accepted manner. This answer is incorrect. In testing memory, the nurse would attempt to get the client either to recall recent events or to think about past events.

Question 4 of 5

The nurse is caring for a child in a plaster-of-Paris hip spica cast. To facilitate drying, the nurse should:

Correct Answer: C

Rationale: Turning the child every two hours ensures even drying of the cast and prevents pressure sores, promoting proper cast setting.

Question 5 of 5

A client has renal failure. Today's lab values indicate he has an elevated serum potassium. What additional priority information does the nurse need to obtain?

Correct Answer: B

Rationale: The level of consciousness is not affected by elevated potassium levels. An electrocardiogram (EKG) can tell the nurse whether this client is experiencing any cardiac dysfunction or arrhythmias related to the elevated potassium level. Measurement of the urine output is not a priority nursing action at this time. The client's serum potassium values for the past several days may provide information about his renal function, but they are not a priority at this time.

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