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Zorluk: Çok zorData Collection Techniques

A practical nurse (PN) is conducting a focused health evaluation on a 30-year-old client at 34 weeks of gestation who presents to the prenatal clinic reporting a persistent throbbing headache and "seeing spots" in their vision. Which of the following data collection techniques should the PN implement? (Select all that apply.)

  1. Obtain a blood pressure reading and compare it with the client's first-trimester baseline measurements.Cevap
  2. Collect a urine specimen to perform a bedside dipstick test for proteinuria.Cevap
  3. Interview the client regarding the presence of any right upper quadrant or epigastric abdominal pain.Cevap
  4. D
    Reassure the client that visual disturbances are an expected physiological adaptation of the third trimester.
  5. E
    Review the client's chart and delay reporting a critically low platelet level since there is no active bleeding.
  6. F
    Perform an independent, comprehensive obstetrical assessment to diagnose the cause of the headache.

Cevap

The correct data collection techniques include obtaining a blood pressure reading to compare with baseline, collecting a urine specimen for a proteinuria dipstick test, and interviewing the client about right upper quadrant or epigastric pain.
The client's presentation of a persistent headache and visual spots at 34 weeks of gestation strongly suggests preeclampsia. To safely collect relevant data, the PN must assess blood pressure to identify hypertension, perform a urine dipstick to check for proteinuria, and interview the client regarding right upper quadrant or epigastric pain, which indicates dangerous liver involvement. These actions are highly focused, pertinent to the symptoms, and safely within the PN's scope of practice.

Adım Adım Çözüm

1
Analyze the client's presenting symptoms of a persistent throbbing headache and visual changes at 34 weeks of gestation.
Identify these findings as classic warning signs of severe preeclampsia, which requires immediate and focused clinical data collection.
Recognizing high-risk obstetrical complications dictates which focused data the practical nurse must prioritize to ensure maternal-fetal safety.
2
Determine the appropriate focused data collection techniques within the PN scope of practice for suspected preeclampsia.
Select measuring blood pressure, testing urine for protein, and inquiring about right upper quadrant pain.
Preeclampsia is characterized by new-onset hypertension and proteinuria after 20 weeks of gestation. Right upper quadrant pain indicates potential liver involvement (HELLP syndrome).
3
Identify and exclude actions that fall outside the PN scope, represent communication barriers, or violate safety protocols.
Exclude offering false reassurance, failing to report critical lab values, and performing comprehensive independent assessments.
Providing false reassurance is non-therapeutic, withholding critical data compromises patient safety, and comprehensive assessments require RN-level clinical judgment.

Anahtar Kavram

Focused Data Collection for Preeclampsia
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Konular

Data Collection Techniques

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