Nokea
A nurse is conducting health promotion education regarding contraindications to combination oral contraceptive use to a group of women. Which of the following conditions should the nurse include in the teaching?
- A. Hypertension
- B. Fibromyalga
- C. Renal calculi
- D. Fibrocystic breast disease
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Hypertension is a contraindication to combination oral contraceptive use due to the increased risk of cardiovascular events. Hypertension can be exacerbated by hormonal contraceptives, leading to serious complications like stroke or heart attack. It is crucial for women with hypertension to avoid estrogen-containing contraceptives.
B: Fibromyalgia, C: Renal calculi, D: Fibrocystic breast disease are not contraindications to combination oral contraceptive use. Fibromyalgia is a chronic pain disorder, renal calculi are kidney stones, and fibrocystic breast disease is a benign breast condition. These conditions do not impact the safety or efficacy of hormonal contraceptives.
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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress
- A. Teach the client to use self-talk. Ask, “What kind of drugs have you been taking?â€. Reduce external stimuli. Ask,Have you been sick recently?" Engage with the client several times each day to establish trust"
- B. Brief psychotic disorder. Delirium. Anxiety. Substance use disorder.
- C. Ability to care for self. Fearfulness. Suicide risk. Tremulousness. Temperature
- D. Brief psychotic disorder
Correct Answer:
Rationale: Action to Take: Teach the client to use self-talk, Engage with the client several times each day to establish trust; Potential Condition: Anxiety; Parameter to Monitor: Fearfulness, Suicide risk.
Rationale: The correct actions to take for addressing anxiety would be teaching self-talk and building trust through engagement. Fearfulness and suicide risk are relevant parameters to monitor in assessing the client's progress and response to interventions. These choices align with addressing anxiety and ensuring client safety and well-being.
Incorrect Choices:
- A: "Ask, 'What kind of drugs have you been taking?' and 'Have you been sick recently?' are not appropriate actions for addressing anxiety.
- B: Brief psychotic disorder and delirium are not the potential conditions the client is most likely experiencing.
- C: Monitoring ability to care for self and tremulousness are not the most relevant parameters for assessing anxiety.
A nurse is setting up a sterile field to perform wound irrigation for a client. Which of the following actions should the nurse take when pouring the sterile solution?
- A. Remove the cap and place it stenile-side up on a clean surface.
- B. Place sterile gauze over areas of spilled solution within the sterile field.
- C. Hold the bottle in the center of the sterile field when pouring the solution.
- D. Hold the irrigation solution bottle with the label facing away from the palm of the hand
Correct Answer: A
Rationale: The correct answer is A. When setting up a sterile field, it is essential to maintain sterility. By removing the cap and placing it sterile-side up on a clean surface, the nurse ensures that the inside of the cap, which will come into contact with the sterile solution, remains uncontaminated. Placing the cap sterile-side up prevents any potential contaminants from coming into contact with the solution. This practice follows aseptic technique guidelines to prevent the introduction of pathogens.
Choices B, C, and D are incorrect because they do not address the key principle of maintaining sterility. Placing sterile gauze over spilled solution (B) can introduce contaminants to the field, holding the bottle in the center (C) does not prevent contamination, and the orientation of the label (D) does not affect sterility.
Which of the following should the nurse identify as an expected finding?
- A. Weak femoral pulses
- B. Frequent nosebleeds
- C. Upper extremity hypotension
- D. Increased intracranial pressure
Correct Answer: A
Rationale: Coarctation causes weak or absent femoral pulses.
For which of the following therapeutic effects should the nurse monitor the client?
- A. Deep tendon reflexes 2+
- B. Pulse rate 100/min
- C. Urine output 20 mL/hr
- D. 1+ proteinuria via urine dipstick
Correct Answer: A
Rationale: The correct answer is A: Deep tendon reflexes 2+. Monitoring deep tendon reflexes is essential in assessing neurological function and detecting abnormalities such as hyperreflexia or hyporeflexia. A normal response of 2+ indicates intact neurological pathways. Abnormal reflexes could be indicative of various neurological conditions. Pulse rate, urine output, and proteinuria are important parameters to monitor but are not specifically related to therapeutic effects. Monitoring deep tendon reflexes is crucial for detecting early signs of neurological complications and guiding appropriate interventions.
A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care?(Select all that apply.)
- A. Give the client one simple direction at a time
- B. Refute the client's delusions using logic
- C. Allow the client to choose among a variety of activities each day
- D. Reinforce orientation to time, place, and person
- E. Establish eye contact when communicating with the client.
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
A: Giving the client one simple direction at a time is essential for someone with dementia to reduce confusion and facilitate understanding.
D: Reinforcing orientation to time, place, and person helps maintain the client's sense of reality and reduce disorientation.
E: Establishing eye contact when communicating with the client enhances connection and understanding, aiding in effective communication.
Incorrect Choices:
B: Refuting the client's delusions using logic may lead to frustration and agitation, as individuals with dementia may not be able to understand or accept logical arguments.
C: Allowing the client to choose among a variety of activities each day may overwhelm them with choices, leading to increased confusion and agitation.