Nokea
A 32-year-old woman comes into the clinic for a well-woman exam and asks for information on an intrauterine device (IUD) for contraception. The nurse should explain that all of the following are potential risks EXCEPT
- A. stroke.
- B. pelvic infections.
- C. abnormal menstrual bleeding.
- D. ectopic pregnancy.
Correct Answer: A
Rationale: IUD risks include pelvic infections, abnormal bleeding, and ectopic pregnancy. Stroke is not a recognized risk associated with IUD use.
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A client's wife states that her elderly husband has begun to slightly slur his words and drop word endings, he has become increasingly withdrawn socially, and he is irritable, accusing her of talking behind his back and whispering at him. The nurse suspects that the client should be initially evaluated for which of the following?
- A. Depression.
- B. Alzheimer's disease.
- C. Hearing loss.
- D. Stroke.
Correct Answer: C
Rationale: Slurred speech, social withdrawal, and irritability with accusations of whispering suggest hearing loss (C), which can cause communication difficulties and paranoia. Depression (A), Alzheimer's (B), and stroke (D) are less likely to present with this specific combination.
A neurological consult has been ordered for a pediatric client with suspected absence seizures. The client with absence seizures can be expected to have:
- A. Short, abrupt muscle contractions
- B. Quick, severe bilateral jerking movements
- C. Abrupt loss of muscle tone
- D. Brief lapse in consciousness
Correct Answer: D
Rationale: Absence seizures cause brief lapses in consciousness, often appearing as staring spells, without motor symptoms.
The client presents to the emergency room with a hyphema. Which action by the nurse would be best?
- A. Elevate the head of the bed and apply ice to the eye
- B. Place the client in a supine position and apply heat to the knee
- C. Insert a Foley catheter and measure the intake and output
- D. Perform a vaginal exam and check for a discharge
Correct Answer: A
Rationale: Elevating the head and applying ice reduces intraocular pressure and swelling in hyphema, a bleed in the eye.
While obtaining information about the client's current medication use, the nurse learns that the client takes ginkgo to improve mental alertness. The nurse should tell the client to:
- A. Report signs of bruising or bleeding to the doctor
- B. Avoid sun exposure while using the herbal
- C. Purchase only those brands with FDA approval
- D. Increase daily intake of vitamin E
Correct Answer: A
Rationale: Ginkgo can increase bleeding risk by affecting platelet function, so clients should report signs of bruising or bleeding to their physician.
The nurse has inserted a nasogastric tube and aspirated gastric contents to check the pH with color-coded pH paper. The aspirate is dark brown, and pH measures slightly less than 5 according to the color chart. What does this pH usually indicate?
- A. Gastric aspirate
- B. Intestinal aspirate
- C. Respiratory aspirate
- D. Inconclusive results
Correct Answer: A
Rationale: A pH < 5 with dark brown aspirate indicates gastric placement (A). Intestinal aspirate (B) has pH > 6, respiratory (C) is > 7, and results are conclusive (D).