Nokea
A nurse is caring for a 14-year-old child with appendicitis who has a pain rating of 8 on a scale of 1 to 10. The child has just returned to the unit after a computed tomography (CT) scan of the abdomen and tells the nurse the pain just stopped. Which of the following should the nurse do first?
- A. "The illness requires careful attention to fluid balance since hyperglycemia contributes to dehydration."'
- B. "Exercise requires additional insulin since glucose will be released from the cells during activity."'
- C. "Urine glucose must be monitored because there is a correlation between simultaneous glycosuria and blood glucose concentrations."'
- D. "The diet needs to include fewer complex carbohydrates because they quickly raise blood glucose."'
Correct Answer: A
Rationale: The correct answer is A because in this scenario, the child's sudden relief from pain after a CT scan could indicate a possible rupture of the appendix. This is a critical situation that requires immediate attention to prevent complications such as peritonitis. Monitoring fluid balance is crucial to prevent dehydration, especially if surgery is needed. Choices B, C, and D are incorrect and not the priority as they focus on managing diabetes, which is not the primary concern in this case. Monitoring glucose levels, adjusting insulin, or modifying the diet are not immediate actions required for a child with suspected appendicitis.
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A client in active labor receives a regional anesthetic. Which is the main purpose of regional anesthetics?
- A. To relieve pain by decreasing the client's level of consciousness
- B. To provide general loss of sensation by blocking sensory nerves to an area
- C. To provide pain relief by blocking descending impulses from the central nervous system
- D. To relieve pain by decreasing the perception of pain leading to the pain centers in the brain
Correct Answer: B
Rationale: The correct answer is B: To provide general loss of sensation by blocking sensory nerves to an area. Regional anesthetics work by blocking specific nerve pathways in a targeted area, leading to loss of sensation while maintaining consciousness. This is ideal for laboring clients as it allows pain relief without affecting consciousness or motor function. Choice A is incorrect as regional anesthetics do not aim to decrease consciousness. Choice C is incorrect as regional anesthetics block sensory nerves locally, not descending impulses. Choice D is incorrect as the goal is to block sensation locally, not perception in the brain.
A nurse in a prenatal clinic who reports that her menstrual period is 2 wks late. The client appears anxious and asks the nurse if she is pregnant. Which of the following responses should the nurse make?
- A. You can miss your period for several other reasons, describe your typical menstrual cycle.
- B. If you have been sexually active and haven't used protection, it is likely that you are pregnant.
- C. Let's check to see if you have any other signs of pregnancy, have you noticed any abdominal enlargement yet?
- D. Because you have missed your period, you should try taking a home pregnancy test before you start worrying.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Response A is the most appropriate because it addresses the client's concerns while also gathering more information. By asking the client to describe her typical menstrual cycle, the nurse can explore other potential reasons for the missed period, such as stress or hormonal imbalances. This approach shows empathy and helps the nurse to provide personalized care based on the client's individual situation.
Summary of Other Choices:
B: This response assumes pregnancy without gathering more information or considering other possibilities, potentially causing unnecessary worry or anxiety.
C: Asking about abdominal enlargement is a specific sign of pregnancy and may not be relevant at this early stage. It also does not address the client's anxiety directly.
D: While suggesting a home pregnancy test is important, it does not address the client's anxiety or gather more information about her menstrual cycle.
A client comes to the clinic to confirm that she is pregnant. Her last menstrual period was January 31st. According to Naegele's rule, when should the client expect to deliver?
- A. November 31
- B. December 7
- C. November 7
- D. December 24
Correct Answer: C
Rationale: The correct answer is C: November 7. Naegele's rule estimates the due date by adding 7 days to the first day of the last menstrual period (LMP), subtracting 3 months, and adding 1 year. LMP is January 31, so adding 7 days gives February 7. Subtracting 3 months gives November 7. Other choices are incorrect as there is no November 31, December 7 is too far ahead, and December 24 is also too far from the estimated due date.
The physician performs an amniotomy for a woman in labor. Which nursing action should follow the procedure?
- A. Check the client's capillary refill and oxygenation.
- B. Monitor the maternal pulse and blood pressure.
- C. Inspect the perineum for lacerations, bleeding, and hematoma.
- D. Assess the fluid for color, odor, and amount.
Correct Answer: D
Rationale: The correct answer is D: Assess the fluid for color, odor, and amount. After an amniotomy, it is important to assess the amniotic fluid to ensure it is clear, odorless, and of the appropriate amount, as changes in these characteristics may indicate fetal distress or infection. Checking capillary refill and oxygenation (Choice A) is not directly related to an amniotomy. Monitoring maternal pulse and blood pressure (Choice B) is important but not the immediate priority post-amniotomy. Inspecting the perineum for lacerations, bleeding, and hematoma (Choice C) is important for overall assessment but not specific to the procedure.
A woman in the transition stage of labor is using paced breathing to relieve pain. She complains of blurred vision, numbness, and tingling of her hands and mouth. Which condition is indicated by these signs and symptoms?
- A. Anoxia
- B. Hyperventilation
- C. Anxiety
- D. Hypertension
Correct Answer: B
Rationale: The correct answer is B: Hyperventilation. The symptoms of blurred vision, numbness, and tingling in the hands and mouth are indicative of hyperventilation. During paced breathing, if the woman breathes too quickly or deeply, it can lead to a decrease in carbon dioxide levels in the blood, causing these symptoms. To address this, the woman should be guided to slow down her breathing and breathe into a paper bag to rebreathe some carbon dioxide. Anoxia (A) is a severe lack of oxygen, which would present with different symptoms. Anxiety (C) may cause similar symptoms but is not the primary issue here. Hypertension (D) does not typically lead to these specific symptoms.