Nokea
A nurse is providing care to a group of postpartum clients. Which client comment should prompt further investigation?
- A. I feel so exhausted that I started taking naps when the baby sleeps.
- B. I have trouble sleeping well at night because I worry that I won't hear the baby cry.
- C. My aunt has come over every day to care for the baby because the baby's cries bother me.
- D. My spouse thinks that I have been more emotional since I had the baby last week.
Correct Answer: C
Rationale: Being bothered by the baby's cries (C) may indicate postpartum depression, requiring investigation. Exhaustion (A), worry (B), and emotionality (D) are common postpartum experiences.
You may also like to solve these questions
A 4-year-old admitted with Wilms tumor is scheduled for a right nephrectomy in the morning. Which nursing action is a priority pre-operatively?
- A. Assessment of the child's emotional maturity level
- B. Auscultating for adventitious breath sounds
- C. Monitoring blood pressure closely
- D. Reinforcing instructions not to palpate the abdomen
Correct Answer: D
Rationale: Avoiding abdominal palpation (D) prevents tumor rupture in Wilms tumor, a critical pre-operative priority. Emotional assessment (A), lung sounds (B), and BP monitoring (C) are important but secondary.
The nurse has completed teaching the client about his low-sodium, low-fat diet. Which menu, if selected by the client, would indicate to the nurse that the client understands his diet?
- A. Mashed potatoes, spinach, and meatloaf
- B. Swordfish with Hollandaise sauce, carrots, and rice pilaf
- C. Baked chicken, wild rice, and broccoli
- D. Roast beef with gravy, baked potato with sour cream, and creamed peas
Correct Answer: C
Rationale: Baked chicken, wild rice, and broccoli are low in sodium and fat, aligning with the diet. Meatloaf, Hollandaise, and gravy/sour cream/creamed peas are high in sodium or fat.
A client diagnosed with heart failure has an 8-hour urine output of 200 mL. What is the nurse's first action?
- A. Auscultate the client's breath sounds
- B. Encourage the client to increase fluid intake
- C. Report the findings to the supervising registered nurse
- D. Start an IV line for diuretic administration
Correct Answer: C
Rationale: Low urine output (200 mL/8 hr) in heart failure suggests worsening fluid retention, requiring immediate reporting to the RN (C). Auscultation (A), fluids (B), and IV diuretics (D) require RN direction.
The nurse is monitoring a client who had an esophagogastroduodenoscopy 2 hours ago. Which finding requires an immediate report to the registered nurse?
- A. Blood pressure drop from 122/88 mm Hg to 106/72 mm Hg
- B. Gag reflex has not returned
- C. Sore throat when swallowing
- D. Temperature spike to 101.2 F (38.4 C)
Correct Answer: D
Rationale: A temperature spike to 101.2 F (D) suggests possible perforation or infection, requiring immediate reporting. BP drop (A) is mild, absent gag reflex (B) is expected, and sore throat (C) is normal post-procedure.
The practical nurse is reinforcing discharge teaching to a client seen for treatment of a second episode of acute gout. Which instructions should be included to prevent future exacerbations? Select all that apply.
- A. Achieve and maintain a healthy weight
- B. Avoid diet sodas
- C. Avoid foods containing protein
- D. Drink plenty of fluids
- E. Restrict alcohol consumption
Correct Answer: A,D,E
Rationale: Healthy weight (A), hydration (D), and limiting alcohol (E) reduce uric acid levels and gout risk. Diet sodas (B) are not directly linked, and avoiding all protein (C) is unnecessary.