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A nurse is performing a vaginal exam on a client in active labor. An important landmark to assess during labor and delivery are the ischial spines because:
- A. Ischial spines are the narrowest diameter of the pelvis
- B. Ischial spines are the widest diameter of the pelvis
- C. They represent the inlet of birth canal
- D. They measure pelvic floor
Correct Answer: A
Rationale: The ischial spines mark the narrowest diameter of the pelvis, critical for assessing fetal descent during labor.
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A 44-year-old client had an emergency cholecystectomy 3 days ago for a ruptured gallbladder. She complains of severe abdominal pain. Assessment reveals abdominal rigidity and distention, increased temperature, and tachycardia. Diagnostic testing reveals an elevated WBC count. The nurse suspects that the client has developed:
- A. Gastritis
- B. Evisceration
- C. Peritonitis
- D. Pulmonary embolism
Correct Answer: C
Rationale: Assessment findings for gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort. Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision. Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity. This causes infection and irritation. Assessment findings of pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing often accompanied by blood-tinged sputum.
Which information should be given to the client using a TENS unit?
- A. Electrocution may occur if you use water with this unit.'
- B. Skin irritation may occur with prolonged use of the unit.'
- C. The unit can be placed anywhere on the body without fear of adverse reactions.'
- D. A cream or lotion should be applied to the skin before applying the unit.'
Correct Answer: B
Rationale: Prolonged use of a TENS unit can cause skin irritation due to electrode adhesion or electrical stimulation. Electrocution is not a risk with battery-operated units, placement requires specific guidance, and lotions may interfere with electrode contact.
A female client is exhibiting signs of respiratory distress. Which of the following signs indicate a possible pneumothorax?
- A. Crackles or rales on the affected side
- B. Bradypnea and bradycardia
- C. Shortness of breath and sharp pain on the affected side
- D. Increased breath sounds on the affected side
Correct Answer: C
Rationale: With a pneumothorax, air occupies the pleural space. Crackles or rales are heard with increased fluid or secretions and would not be present with air in the space. With a pneumothorax, the client would experience tachypnea and tachycardia to compensate for the decrease in oxygenation. Symptoms of pneumothorax include shortness of breath, sharp pain on the affected side with movement or coughing, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. With a pneumothorax, breath sounds would be decreased on the affected side (indicates air in the pleural space).
The nurse is caring for a client with a history of Sjögren’s syndrome. The nurse should expect the client to have:
- A. Dry eyes and mouth
- B. Joint swelling
- C. Fever
- D. Chest pain
Correct Answer: A
Rationale: Sjögren’s syndrome is an autoimmune condition causing reduced salivary and lacrimal gland function, leading to dry eyes and mouth.
A 43-year-old client is admitted to the hospital with a diagnosis of peripheral vascular disorder. She arrives in her room via stretcher and requires assistance to move to her bed. The nurse notes that her left leg is cold to touch. She complains of having recently experienced muscle spasms in that leg. To determine if these muscle spasms are indicative of intermittent claudication, the nurse would begin her assessment with the following question:
- A. Would you describe the intensity, duration, and symptoms associated with your pain?
- B. Do you experience swelling at the end of the day in the affected and unaffected leg?
- C. Have you had any lesions of the affected leg that have been difficult to heal?
- D. Do your muscle spasms occur following rest, walking, or exercising?
Correct Answer: D
Rationale: Describing pain is an important aspect of the assessment; however, assessing activity preceding muscle spasms is equally important. Edema may occur with peripheral vascular disease, but it is not of particular importance in assessing intermittent claudication. Lesions may be present with peripheral vascular disease, but they are not an indication of intermittent claudication. With intermittent claudication, muscle spasms occur intermittently, mainly with walking and after exercising. Rest may relieve muscle spasms.