Question

A nurse is reviewing the medical record of a client who has HELLP syndrome. Which of the following findings should the nurse expect?

Answer 1

Correct Answers:

Platelet count 98,000/mm3

Rationale :

🔷 Low platelets are a defining sign of HELLP syndrome (Hemolysis, Elevated Liver enzymes, Low Platelets).

🔷 Thrombocytopenia increases the risk of postpartum hemorrhage and DIC.

🔷 Platelet count monitoring guides immediate medical intervention or delivery.

🔷 Early identification prevents severe complications like liver rupture or kidney failure.

🔷 Other listed findings (polyhydramnios, normal BUN, placenta previa) are not consistent with HELLP.

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Answer 2

Correct Answers:

“This medication might cause flu-like symptoms.”

Rationale :

🟡 Interferon-beta-1a for multiple sclerosis commonly causes fever, chills, and myalgia, similar to flu symptoms.

🟡 Teaching patients to take it at night or with NSAIDs minimizes discomfort.

🟡 It works by modulating the immune response, slowing MS progression.

🟡 Educating on expected side effects improves medication adherence.

🟡 Monitoring liver enzymes and CBC is necessary due to potential hepatotoxicity.

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Answer 3

Correct Answers:

Instruct the parent to remove his shirt

Rationale :

🔶 Skin-to-skin contact enhances bonding by transferring heat and maternal pheromones to the newborn.

🔶 Removing the shirt maximizes chest-to-chest contact.

🔶 This stabilizes newborn temperature, glucose, and heart rate.

🔶 Early bonding improves breastfeeding success and emotional attachment.

🔶 The environment should be calm, not brightly lit, to promote relaxation.

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Answer 4

Correct Answers:

Nicotine

Rationale :

🟢 Nicotine withdrawal causes irritability, anger, difficulty concentrating, and decreased appetite.

🟢 Symptoms appear within hours of cessation due to nicotine’s short half-life.

🟢 Education on withdrawal expectations improves compliance with cessation programs.

🟢 Nicotine replacement or varenicline can reduce withdrawal discomfort.

🟢 Supportive therapy helps prevent relapse.

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Answer 5

Correct Answers:

Obtain an IV with a 18-gauge catheter

Rationale :

⭐ In placental abruption, rapid IV access is critical to manage maternal hemorrhage.

⭐ Large-bore (18-gauge) allows infusion of blood products and crystalloids.

⭐ Fluid replacement stabilizes hemodynamics and uteroplacental perfusion.

⭐ Other interventions (FHR monitoring, VS) follow after establishing vascular access.

⭐ Early preparation reduces maternal-fetal mortality risk.

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Answer 6

Correct Answers:

Sertraline

Rationale :

♦ SSRIs such as sertraline can cause sexual dysfunction and erectile dysfunction due to serotonin effects.

♦ Educating patients prevents medication discontinuation without medical advice.

♦ Alternative therapies may be considered if dysfunction affects quality of life.

♦ Open discussion encourages adherence and trust in therapy.

♦ Other options listed (vancomycin, topiramate) are not typical causes of ED

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Answer 7

Correct Answers:

“I will identify distorted thoughts about my body image.”

Rationale :

💠 Cognitive-behavioral therapy (CBT) targets cognitive distortions in anorexia nervosa.

💠 Identifying negative body image thoughts promotes healthier self-perception.

💠 CBT helps replace distorted thinking with realistic and positive beliefs.

💠 Correcting cognitive patterns improves long-term recovery and weight restoration.

💠 Insight building is a primary goal in treating eating disorders.

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Answer 8

Correct Answers:

Proteinuria

Rationale :

🟣 Proteinuria is a diagnostic sign of preeclampsia in gestational hypertension.

🟣 It indicates renal involvement and endothelial dysfunction.

🟣 Early detection allows prompt antihypertensive and magnesium sulfate therapy.

🟣 Protein loss increases risk of edema and maternal-fetal complications.

🟣 Regular urine dipstick tests are key in antenatal care.

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Answer 9

Correct Answers:

Flush with 0.9% sodium chloride after administration.

Rationale :

🔵 Phenytoin is only compatible with normal saline (NS) due to precipitation risks in dextrose.

🔵 NS flush prevents crystallization in IV lines.

🔵 Infuse slowly to prevent cardiac arrhythmias and hypotension.

🔵 Continuous cardiac monitoring is essential during IV administration.

🔵 Following compatibility guidelines prevents catheter occlusion and drug inactivation.

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Answer 10

Correct Answers:

“Initiate continuous monitoring of the FHR and uterine contractions.”

Rationale :

🔷 Placenta previa places the fetus at risk for hypoxia due to potential bleeding and placental separation; therefore, continuous FHR monitoring is essential.

🔷 Monitoring uterine contractions detects early signs of preterm labor or uterine irritability.

🔷 Vaginal exams are contraindicated in placenta previa as they can cause placental rupture and increased bleeding.

🔷 Corticosteroids are recommended before 34 weeks gestation to promote fetal lung maturity, not after 34 weeks.

🔷 Terbutaline is used to relax the uterus in preterm labor, not for uterine atony in placenta previa.

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RN Concept-Based Assessment Level 3 with NGN

No.

1 :
A nurse is reviewing the medical record of a client who has HELLP syndrome. Which of the following findings should the nurse expect?

2 :
A nurse is teaching a client who has multiple sclerosis and a new prescription for interferon-beta-1a. Which of the following statements should the nurse make?

3 :
A nurse is assisting the parent of a newborn to perform skin-to-skin care to enhance parental bonding. Which of the following actions should the nurse take?

4 :
A nurse is assessing a client who has a history of multiple substance use disorders. The client is currently experiencing anger, difficulty concentrating, and decreased appetite. The nurse should suspect the client is withdrawing from which of the following substances?

5 :
A nurse is planning care for a client who is experiencing moderate vaginal bleeding due to a placental abruption. Which of the following interventions should the nurse include in the plan?

6 :
A nurse is instructing a client about medications that can cause erectile dysfunction. Which of the following medications should the nurse include in the teaching?

7 :
A nurse is teaching a group of clients who have anorexia nervosa about cognitive-behavioral therapy. Which of the following client statements indicates an understanding of the teaching?

8 :
A nurse is a provider’s office is assessing a client who is at 28weeks of gestation and has gestational hypertension. Which of the following findings indicates the client might be developing preeclampsia?

9 :
A nurse is preparing to administer 800 mg of phenytoin via IV infusion to a client who is experiencing status epilepticus. Which of the following actions should the nurse take when administering the medication?

10 :
A nurse manager on a labor and delivery unit is discussing care of clients who have vaginal bleeding due to placenta previa with a newly licensed nurse. Which of the following statements should the nurse manager make?

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RN Concept-Based Assessment Level 3 with NGN

No.

1 : A nurse is reviewing the medical record of a client who has HELLP syndrome. Which of the following findings should the nurse expect?

2 : A nurse is teaching a client who has multiple sclerosis and a new prescription for interferon-beta-1a. Which of the following statements should the nurse make?

3 : A nurse is assisting the parent of a newborn to perform skin-to-skin care to enhance parental bonding. Which of the following actions should the nurse take?

4 : A nurse is assessing a client who has a history of multiple substance use disorders. The client is currently experiencing anger, difficulty concentrating, and decreased appetite. The nurse should suspect the client is withdrawing from which of the following substances?

5 : A nurse is planning care for a client who is experiencing moderate vaginal bleeding due to a placental abruption. Which of the following interventions should the nurse include in the plan?

6 : A nurse is instructing a client about medications that can cause erectile dysfunction. Which of the following medications should the nurse include in the teaching?

7 : A nurse is teaching a group of clients who have anorexia nervosa about cognitive-behavioral therapy. Which of the following client statements indicates an understanding of the teaching?

8 : A nurse is a provider’s office is assessing a client who is at 28weeks of gestation and has gestational hypertension. Which of the following findings indicates the client might be developing preeclampsia?

9 : A nurse is preparing to administer 800 mg of phenytoin via IV infusion to a client who is experiencing status epilepticus. Which of the following actions should the nurse take when administering the medication?

10 : A nurse manager on a labor and delivery unit is discussing care of clients who have vaginal bleeding due to placenta previa with a newly licensed nurse. Which of the following statements should the nurse manager make?

1 :
A nurse is reviewing the medical record of a client who has HELLP syndrome. Which of the following findings should the nurse expect?

2 :
A nurse is teaching a client who has multiple sclerosis and a new prescription for interferon-beta-1a. Which of the following statements should the nurse make?

3 :
A nurse is assisting the parent of a newborn to perform skin-to-skin care to enhance parental bonding. Which of the following actions should the nurse take?

4 :
A nurse is assessing a client who has a history of multiple substance use disorders. The client is currently experiencing anger, difficulty concentrating, and decreased appetite. The nurse should suspect the client is withdrawing from which of the following substances?

5 :
A nurse is planning care for a client who is experiencing moderate vaginal bleeding due to a placental abruption. Which of the following interventions should the nurse include in the plan?

6 :
A nurse is instructing a client about medications that can cause erectile dysfunction. Which of the following medications should the nurse include in the teaching?

7 :
A nurse is teaching a group of clients who have anorexia nervosa about cognitive-behavioral therapy. Which of the following client statements indicates an understanding of the teaching?

8 :
A nurse is a provider’s office is assessing a client who is at 28weeks of gestation and has gestational hypertension. Which of the following findings indicates the client might be developing preeclampsia?

9 :
A nurse is preparing to administer 800 mg of phenytoin via IV infusion to a client who is experiencing status epilepticus. Which of the following actions should the nurse take when administering the medication?

10 :
A nurse manager on a labor and delivery unit is discussing care of clients who have vaginal bleeding due to placenta previa with a newly licensed nurse. Which of the following statements should the nurse manager make?