the nurse is caring for a client 28 weeks pregnant that complains of swollen hands and feet which symptom below would cause the greatest concern
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NCLEX-PN

NCLEX Question of The Day

1. The nurse is caring for a client who is 28 weeks pregnant and complains of swollen hands and feet. Which symptom below would cause the greatest concern?

Correct answer: Muscle spasms

Rationale: The correct answer is muscle spasms because they can be indicative of a severe condition like preeclampsia, which is a serious complication during pregnancy characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys. Nasal congestion and hiccups are common discomforts during pregnancy and do not pose a severe risk to the client or fetus. A blood glucose level of 150, while slightly elevated, may not be alarming in a pregnant individual and can be managed through dietary modifications or medication adjustments. Muscle spasms, especially in the context of pregnancy, should be taken seriously and thoroughly assessed to rule out any underlying serious conditions.

2. The client is undergoing an induction for fetal demise at 34 weeks. Immediately after delivery, the mother asks to see the infant. What is the nurse’s best response?

Correct answer: Bring the swaddled fetus to the mother

Rationale: The nurse should bring the swaddled fetus to the mother as the best response. Allowing the mother to see the infant immediately after delivery is crucial for her grieving process. It provides her with the opportunity to bond, say goodbye, and start the grieving process. Choice B is incorrect because delaying the mother's request to see the baby can hinder her grieving process and prolong her suffering. Choice C is inappropriate as it questions the mother's decision at a sensitive time, potentially causing distress. Choice D is also not the best response as it suggests waiting, which may not be in the mother's best interest at that moment, as she needs immediate support and closure.

3. While assessing a patient in the ICU, a nurse observes signs of a weak pulse, quick respiration, acetone breath, and nausea. Which of the following conditions is most likely occurring?

Correct answer: Hyperglycemic patient

Rationale: The correct answer is a hyperglycemic patient. The signs described - weak pulse, quick respiration, acetone breath, and nausea - are indicative of hyperglycemia. A hypoglycemic patient would typically present with different signs such as pale skin, sweating, and confusion. Cardiac arrest would manifest with sudden loss of heart function and consciousness, not the signs described. End-stage renal failure would present with symptoms related to kidney dysfunction like edema, fatigue, and changes in urine output, which are not mentioned in the scenario.

4. The client in the Emergency Department, who has suffered an ankle sprain, should be taught to:

Correct answer: use cold applications to the sprain during the first 24–48 hours.

Rationale: When a client suffers an ankle sprain, the nurse should teach them to use cold applications to the sprain during the first 24–48 hours. Cold applications are believed to produce vasoconstriction and reduce the development of edema. Expecting disability to decrease within the first 24 hours of injury (choice B) is incorrect as disability and pain are anticipated to increase during the first 2–3 hours after injury. Expecting pain to decrease within 3 hours after injury (choice C) is also incorrect as pain and swelling usually increase initially. Beginning progressive passive and active range of motion exercises immediately (choice D) is not recommended; these exercises are usually started 2–5 days after the injury, according to the physician's recommendation. Treatment for a sprain involves support, rest, and alternating cold and heat applications. X-ray pictures are often necessary to rule out any fractures.

5. What is pica?

Correct answer: eating ice

Rationale: Pica is a disorder characterized by the ingestion of nonfood substances, which can lead to a clinical iron deficiency. It may be the first sign of an underlying issue. Individuals with pica consume a variety of nonfood items such as ice, clay, dirt, or paste. Choice A, dependency on alcohol, is incorrect as it is not related to pica. Choice B, increased iron in the diet, is incorrect because pica involves ingesting nonfood items rather than having an increased intake of iron. Choice C, the sickle cell trait, is unrelated to pica and is therefore incorrect.

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