Nokea
A client is admitted to the hospital with a suspected diagnosis of Graves' disease. On assessment, which manifestation related to the client's menstrual cycle should the nurse expect the client to report?
- A. Amenorrhea
- B. Menorrhagia
- C. Metrorrhagia
- D. Dysmenorrhea
Correct Answer: A
Rationale: Amenorrhea or a decreased menstrual flow is common in the client with Graves' disease. Menorrhagia, metrorrhagia, and dysmenorrhea are also disorders related to the female reproductive system; however, they do not manifest in the presence of Graves' disease.
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The nurse is performing an assessment on a female client who is suspected of having mittelschmerz. Which subjective finding supports the possibility of this condition?
- A. Experiences pain during intercourse
- B. Has pain at the onset of menstruation
- C. Experiences profuse vaginal bleeding
- D. Has sharp pelvic pain during ovulation
Correct Answer: D
Rationale: Mittelschmerz (middle pain) refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain is caused by a growth follicle within the ovary, or rupture of the follicle and subsequent spillage of follicular fluid and blood into the peritoneal space. The pain is fairly sharp and is felt on the right or left side of the pelvis. It generally lasts 1 to 3 days, and slight vaginal bleeding may accompany the discomfort.
The nurse prepares the client for the removal of a nasogastric tube. During the tube removal, the nurse instructs the client to take which action?
- A. Inhale deeply.
- B. Exhale slowly.
- C. Hold in a deep breath.
- D. Pause between breaths.
Correct Answer: C
Rationale: Just before removing the tube, the client is asked to take a deep breath and hold it because breath-holding minimizes the risk of aspirating gastric contents spilled from the tube during removal. The maneuver partially occludes the airway during tube removal; afterward, the client exhales as soon as the tube is out and thus avoids drawing the gastric contents into the trachea.
The nurse assessing the apical heart rates of several different newborn infants notes that which heart rate is normal for this newborn population?
- A. 90 beats per minute
- B. 140 beats per minute
- C. 180 beats per minute
- D. 190 beats per minute
Correct Answer: B
Rationale: The normal heart rate in a newborn infant is approximately 100 to 160 beats per minute. Options 1, 3, and 4 are incorrect. Option 1 indicates bradycardia, and options 3 and 4 indicate tachycardia (greater than 100 beats per minute).
A client has developed atrial fibrillation resulting in a ventricular rate of 150 beats per minute. The nurse should assess the client for which effects of this cardiac occurrence? Select all that apply.
- A. Dyspnea
- B. Flat neck veins
- C. Nausea and vomiting
- D. Chest pain or discomfort
- E. Hypotension and dizziness
- F. Hypertension and headache
Correct Answer: A,D,E
Rationale: The client with uncontrolled atrial fibrillation with a ventricular rate over 100 beats per minute is at risk for low cardiac output caused by loss of atrial kick. The nurse should assess the client for palpitations, chest pain or discomfort, hypotension, pulse deficit, fatigue, weakness, dizziness, syncope, shortness of breath, and distended neck veins. Neither headache nor nausea and vomiting are associated with the effects of uncontrolled atrial fibrillation.
What should the nurse consider when determining whether a client diagnosed with a respiratory disease could tolerate and benefit from active progressive relaxation? Select all that apply.
- A. Social status
- B. Financial status
- C. Functional status
- D. Medical diagnosis
- E. Ability to expend energy
- F. Motivation of the individual
Correct Answer: C,D,E,F
Rationale: Active progressive relaxation training teaches the client how to effectively rest and reduce tension in the body. Some important considerations when choosing the type of relaxation technique are the client's physiological and psychological status. Because active progressive relaxation training requires a moderate expenditure of energy, the nurse needs to consider the client's functional status, medical diagnosis, and ability to expend energy. For example, a client with advanced respiratory disease may not have sufficient energy reserves to participate in active progressive relaxation techniques. The client needs to be motivated to participate in this form of alternative therapy to obtain beneficial results. The client's social or financial status has no relationship with her or his ability to tolerate and benefit from active progressive relaxation.