Section: Questions Set D
Explanation:
(A) Dyspnea is a common complaint during the third trimester owing to the increasing size of the uterus and the resulting pressure against the diaphragm. (B) Edema of the face, hands, or pitting edema after 12 hours of bed rest may be indicative of preeclampsia and would be of great concern to the healthcare provider. (C) An increase in heart rate of 10-15 bpm is a normal physiological change in pregnancy due to the multiple hemodynamic changes. (D) A hematocrit value of 39% is within the normal range. A value <35% would indicate anemia.

Explanation/Reference:
Explanation:
(A) Stinging or burning when nitroglycerin is placed under the tongue is to be expected. This effect indicates that the medication is potent and effective for use. Failure to have this response means that the client needs to get a new bottle of nitroglycerin. (B, C, D) The other responses are not expected in this situation and are not even side effects.

Explanation/Reference:
Explanation:
(A) This answer is incorrect. Bargaining is a manipulative act, which the nurse could expect from the client.
(B) This answer is incorrect. Confrontation is an effective nursing strategy with manipulative behavior.
Redirection is appropriate for the client who is out of touch with reality. (C) This answer is correct.
Manipulative clients must abide by consistent rules. (D) This answer is incorrect. Manipulation is kept at a minimum if the same staff person is assigned to the client. Often the client will attempt to play staff persons against each other.

Explanation/Reference:
Explanation:
(A) Reaction formation is the development and demonstration of attitudes and/or behaviors opposite to what an individual actually feels. The client's comment does reveal her anger and hostility. (B) Rationalization, another ego defense mechanism, is offering a socially acceptable or seemingly logical explanation to justify one's feelings, behaviors, or motives. The client's comment does not reflect rationalization. (C) Splitting, the viewing of people or situations as either all good or all bad, is frequently used by persons experiencing a disruption in self-concept. This ego defense mechanism is reflective of the individual's inability to integrate the positive and negative aspects of self. (D) Sublimation, the channeling of socially unacceptable impulses and behaviors into more acceptable patterns of behavior, is another ego defense mechanism. The client's comment reveals that she is not engaging in sublimation.

Section: Questions Set A
Explanation:
(A) She is probably not compliant with her diet and exercise program. Recommended weight gain during second and third trimesters is approximately 12 lb. (B) Because of her excessive weight gain of 10 lb in 2 months, she needs re-evaluation of her eating habits and reinforcement of proper dietary habits for pregnancy.
A 2200-calorie diet is recommended for most pregnant women with a weight gain of 27-30 lb over the 9-month period. With rapid and excessive weight gain, PIH should also be suspected. (C) She does not need to increase her caloric intake, but she does need to re-evaluate dietary habits. Ten pounds in 2 months is excessive weight gain during pregnancy, and health teaching is warranted. (D) Restrictive dieting is not recommended during pregnancy.