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Client postoperative following a mastectomy, expresses concern about attractiveness to partner.
A nurse is caring for a client who is postoperative following a mastectomy. The client expresses concern that they will no longer be attractive to their partner. Which of the following actions should the nurse take?
- A. Discourage the client from looking at their breasts.
- B. Recommend a support group for the client to attend.
- C. Tell the client you are so sorry for how devastated they must feel.
- D. Tell the client to focus on their postoperative recovery for now.
Correct Answer: B
Rationale: Recommending a support group provides psychosocial support, enabling clients to share experiences and gain insights from peers, which can alleviate feelings of inadequacy and encourage acceptance of body image changes.
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Client at 31 weeks of gestation.
A nurse is assessing a client who is at 31 weeks of gestation. Which of the following findings should the nurse identify as an indication of a potential prenatal complication?
- A. Periodic tingling of fingers.
- B. Absence of clonus.
- C. Leg cramps.
- D. Blurred vision.
Correct Answer: D
Rationale: Blurred vision may result from severe preeclampsia or elevated blood pressure, signifying potential end-organ damage. It requires immediate medical evaluation to prevent progression to eclampsia.
Client reports feeling well, findings include: General: No acute distress. Cardiovascular: No murmur or rub. Respiratory: Bilateral breath sounds clear. Abdomen: Fundal height 38 cm. Genitourinary: Purulent cervical discharge.
A nurse conducts a physical exam of a client who reports feeling well. Which finding requires clinical intervention?
- A. No acute distress.
- B. No murmur or rub.
- C. Bilateral breath sounds clear.
- D. Fundal height 38 cm.
- E. Purulent cervical discharge.
Correct Answer: E
Rationale: Purulent cervical discharge suggests an ongoing infection, likely bacterial cervicitis. It reflects leukocyte accumulation due to pathogenic invasion, requiring clinical intervention to prevent complications.
For each body system below, specify the potential complications that can occur. Match the body system with the potential complications.
- A. Hypotonia
- B. Seizures
- C. Hearing loss
Correct Answer: B
Rationale: Neurologic: Seizures (B) - due to potential neurological dysfunction. Musculoskeletal: Hypotonia (A) - indicating muscle weakness. Head, ears, eyes, nose, and throat: Hearing loss (C) - from auditory nerve or structural damage.
Client who is Rh-negative.
A nurse is teaching a pregnant client who is Rh-negative about Rho(D) immune globulin. Which of the following statements by the client indicates an understanding of the teaching?
- A. This shot may be given after birth to protect future pregnancies.
- B. If my partner is Rh-negative, I will not receive the shot.
- C. I will receive the shot after delivery if my baby is Rh-negative.
- D. I should not receive any immunizations for 3 months after the shot.
Correct Answer: A
Rationale: Rho(D) immune globulin administered postpartum prevents maternal sensitization to Rh-positive fetal blood cells, reducing risks of hemolytic disease in subsequent pregnancies by suppressing maternal immune response.
Newborn born two hours ago at 36 weeks gestation, findings: Bruising noted over occiput, yellowish hue on sclera and skin blanching, transcutaneous bilirubin level 12.5 mg/dL, phototherapy initiated.
A newborn born two hours ago at 36 weeks gestation has noted findings. Which findings are consistent with neonatal jaundice?
- A. Bruising noted over occiput.
- B. Yellowish hue on sclera and skin blanching.
- C. Transcutaneous bilirubin level 12.5 mg/dL (less than 12 mg/dL).
- D. Phototherapy initiated at 08:45.
Correct Answer: B,C,D
Rationale: Yellowish sclera and blanching skin (B), transcutaneous bilirubin level of 12.5 mg/dL (C), and phototherapy initiation (D) indicate neonatal jaundice from elevated bilirubin levels due to immature hepatic conjugation, requiring monitoring and treatment to prevent kernicterus.