Nokea
A client is admitted to the hospital with the diagnosis of sepsis secondary to pelvic inflammatory disease. Which transmission-based precaution will be initiated by the nurse?
- A. Standard precautions
- B. Protective precautions
- C. Contact precautions
- D. Droplet precautions
Correct Answer: C
Rationale: Contact isolation is a category of transmission-based precautions for controlling the spread of infectious microorganisms found in body fluids. Standard precautions are used in the care of all clients in the prevention of HIV and hepatitis. Protective precautions are instituted when a client is immune compromised and needs protected from others. Droper precautions are not indicated with PID.
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The nurse is caring for a client with polycystic ovarian syndrome. On which associated problem(s) will the nurse focus teaching? Select all that apply.
- A. Hypertension
- B. Hyperlippiedemia
- C. Infertility
- D. Absence of body hair
- E. Weight loss
- F. Decreased Insulin
Correct Answer: A,B,C
Rationale: Polycystic ovarian syndrome is associated with multiple endocrine abnormalities such as abnormal lipid levels, hypertension, and difficulty with conceaving due to interference of ovulation. Other symptoms include excessive body hair, weight gain, and overproduction and inefficient use of insulin.
Which assessment finding will most likely influence the treatment regimen selected by a client with endometriosis?
- A. Presence of pain
- B. Family planning
- C. Dysmenorrhea
- D. Presence of chocolate cyst
Correct Answer: B
Rationale: Selection of a more conservative option may be indicated to preserve the possibility for future childbearing. Pain, dysmenorrhea, and chocolate cysts are all symptoms associated with endometriosis and can influence decision for treatment.
A client who wishes to preserve childbearing ability asks the nurse to explain how taking oral contraceptives will work in the management of endometriosis. Which is the best response by the nurse?
- A. Symptoms of endometriosis are increased during normal menstrual cycle.
- B. Conraceptives will allow blood to be diverted to the peritoneal cavity.
- C. Trapping blood causes less pain and discomfort for clients with endometriosis.
- D. Endometriosis is usually cured with surgical menopause.
Correct Answer: A
Rationale: The use of estrogen-progestin contraceptives keeps the client in a non-bleeding phase of the menstrual cycle, therefore decreasing ectopic tissue from shedding and causing extra uterine bleeding. Blood that is trapped in the peritoneal cavity causes more pain or adhesions form. Endometriosis is cured by natural or surgical menopause but can be medically instituted for periods of time with the use of oral contraceptives.
The nurse is caring for a young adult client who reports excessive menstrual flow with menses lasting 10 days each month. Which treatment option does the nurse anticipate the physician will order for symptomatic relief for this client?
- A. Dilation and curettage (D and C)
- B. Hormonal contraceptives
- C. Endometrial ablation
- D. Uterine balloon therapy
Correct Answer: B
Rationale: When combination hormonal contraceptives are administered, they produce a light menstrual period and are helpful in the management of menorrhagia. Dilation and curettage can provide symptomatic relief, however, the effectiveness is limited. Endometrial ablation and uterine balloon therapy cause the endometrium to slough and are cost-effective but are only used after childbearing has completed.
The nurse is teaching a client about the use of a pessary. Which statement by the client indicates the need for additional instruction?
- A. A white or yellow vaginal discharge is expected and normal.
- B. I need to apply a sterile lubricant to the pessary before reinserting it.
- C. After removal, I should wash the pessary with warm soapy, water, rinse, and dry it.
- D. I should call the physician if I notice any discomfort with the pessary.
Correct Answer: A
Rationale: A white or yellow discharge from the vagina is not a normal finding and should be reported to the physician because it may indicate an infection. A sterile lubricant is applied to the pessary before it is reinserted. After removal, the pessary should be washed thoroughly with warm soapy water, followed by rinsing and drying. Discomfort may indicate that a pessary has been inserted incorrectly, it has moved, or that it is causing irritation. These problems should be reported to the physician.