Nokea
A nurse in a clinic is interviewing a client who has a possible diagnosis of endometriosis. Which of the following findings in the client's history should the nurse recognize as consistent with a diagnosis of endometriosis?
- A. Dysmenorrhea that is unresponsive to NSAIDs
- B. Heavy menstrual bleeding
- C. Positive family history of fibroids
- D. Pelvic pain after intercourse
Correct Answer: A
Rationale: The correct answer is A: Dysmenorrhea that is unresponsive to NSAIDs. Endometriosis is characterized by severe menstrual pain that is not relieved by NSAIDs. This is due to the abnormal growth of endometrial tissue outside the uterus. Heavy menstrual bleeding (B) is a common symptom but not specific to endometriosis. Positive family history of fibroids (C) is unrelated to endometriosis. Pelvic pain after intercourse (D) can be a symptom of endometriosis but is not as specific as unresponsive dysmenorrhea.
You may also like to solve these questions
A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?
- A. Reposition the client
- B. Check the chest tube for kinks
- C. Increase the suction pressure
- D. Administer pain medication
Correct Answer: A
Rationale: Repositioning the client can help alleviate chest burning caused by the chest tube.
A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?
- A. Cold and numbness distal to the fistula site
- B. Swelling around the fistula
- C. Bleeding from the fistula
- D. Pain at the site of fistula
Correct Answer: A
Rationale: The correct answer is A: Cold and numbness distal to the fistula site. This is indicative of venous insufficiency, which can occur when the arteriovenous fistula is not functioning properly. When there is inadequate blood flow through the fistula, it can result in reduced circulation to the distal part of the arm, leading to coldness and numbness. Swelling around the fistula (choice B) is more commonly associated with infection or inadequate drainage. Bleeding from the fistula (choice C) is a potential complication but not a typical manifestation of venous insufficiency. Pain at the site of the fistula (choice D) may indicate infection or clotting issues rather than venous insufficiency.
A nurse is monitoring a client who is receiving a blood transfusion. Which of the following findings indicates an allergic transfusion reaction?
- A. Chest pain
- B. Hypotension
- C. Generalized urticaria
- D. Fever
Correct Answer: C
Rationale: The correct answer is C: Generalized urticaria. This finding indicates an allergic transfusion reaction because urticaria, or hives, is a common symptom of an allergic response. It is caused by histamine release in response to the foreign blood product. Chest pain (A) is more indicative of a possible cardiac issue. Hypotension (B) may suggest a hemolytic reaction due to rapid destruction of red blood cells. Fever (D) is a common symptom of a febrile non-hemolytic transfusion reaction. Other choices are incorrect as they are not specific to an allergic reaction.
A nurse is caring for a client receiving TPN. What action should the nurse take?
- A. Monitor serum sodium levels daily.
- B. Check the client's capillary blood glucose level every 4 hr.
- C. Administer the solution at room temperature.
- D. Discontinue abruptly if the client reports nausea.
Correct Answer: B
Rationale: The correct answer is B: Check the client's capillary blood glucose level every 4 hr. This is crucial because TPN can cause hyperglycemia due to its high glucose content. Monitoring blood glucose levels helps in detecting and managing hyperglycemia.
Incorrect answers:
A: Monitoring serum sodium levels is not directly related to TPN administration.
C: Administering the solution at room temperature is not necessary for TPN administration.
D: Discontinuing TPN abruptly can lead to serious complications; it should be gradually tapered off.
Overall, monitoring blood glucose levels is essential in TPN therapy to prevent complications related to hyperglycemia.
A nurse is caring for a middle adult client who has just received the diagnosis of endometrial cancer. In taking a nursing history, which of the following manifestations is likely to be reported by this client?
- A. Postmenopausal bleeding
- B. Weight loss
- C. Increased appetite
- D. Abnormal hair growth
Correct Answer: A
Rationale: The correct answer is A: Postmenopausal bleeding. Endometrial cancer commonly presents with postmenopausal bleeding as a key manifestation due to abnormal growth of the endometrial tissue. This occurs because the cancerous cells disrupt the normal shedding process of the endometrium, leading to bleeding after menopause. Weight loss (B) is often associated with advanced stages of cancer, but it is not a specific early manifestation of endometrial cancer. Increased appetite (C) and abnormal hair growth (D) are not typically associated with endometrial cancer.