Nokea
A client is admitted to the postpartum floor after a vaginal birth. Which finding indicates the need for immediate intervention?
- A. Lochia that soaks a perineal pad every 2 hours
- B. Persistent headache with blurred vision
- C. Red, painful nipple on one breast
- D. Strong-smelling vaginal discharge
Correct Answer: B
Rationale: Headache with blurred vision (B) suggests preeclampsia, a life-threatening condition requiring immediate intervention. Lochia (A), nipple pain (C), and discharge (D) are normal or less urgent postpartum findings.
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In assessing a post partum client, the nurse palpates a firm fundus and observes a constant trickle of bright red blood from the vagina. What is the most likely cause of these findings?
- A. Uterine atony
- B. Genital lacerations
- C. Retained placenta
- D. Clotting disorder
Correct Answer: B
Rationale: Genital lacerations. Continuous bleeding in the absence of a boggy fundus indicates undetected genital tract lacerations.
The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended?
- A. Seizures
- B. Withdrawal
- C. Craving
- D. Marked tolerance
Correct Answer: B
Rationale: Withdrawal. Early withdrawal symptoms, including nausea and tremor, appear within hours of reducing alcohol intake.
The nurse is discussing dementia with the families of older adults. All of the following behaviors are reported. Which behavior is most suggestive of dementia?
- A. The woman can't remember the birth year of each of her six children.
- B. A woman walked to the store and got lost on the way home.
- C. A woman forgot where she put her purse.
- D. A man is wearing one green sock and one red sock and doesn't see the difference.
Correct Answer: B
Rationale: Getting lost in a familiar area indicates significant spatial disorientation, a hallmark of dementia. Forgetting details, misplacing items, or color oversight are less specific.
The nurse is reviewing a depressed client's history from an earlier admission. Documentation of anhedonia is noted. The nurse understands that this finding refers to
- A. Reports of difficulty falling and staying asleep
- B. Expression of persistent suicidal thoughts
- C. Lack of enjoyment in usual pleasures
- D. Reduced senses of taste and smell
Correct Answer: C
Rationale: Lack of enjoyment in usual pleasures. Anhedonia, a common finding in depression, is the lack of enjoyment in usual pleasures.
Prior to administering a tube feeding, the nurse obtains 50 mL of aspirant. The nurse should:
- A. Discard the aspirant and begin the tube feeding.
- B. Replace the aspirant and begin the tube feeding.
- C. Discard the aspirant and hold the tube feeding.
- D. Replace the aspirant and hold the tube feeding.
Correct Answer: B
Rationale: Replacing the aspirant prevents fluid/electrolyte loss, and feeding can proceed if pH confirms placement. Discarding aspirant risks dehydration, and holding the feeding is unnecessary unless placement is uncertain.