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A postpartum client complains of rectal pressure and severe pain in her perineum; this may be indicative of:
- A. Afterbirth pains
- B. Constipation
- C. Cystitis
- D. A hematoma of the vagina or vulva
Correct Answer: D
Rationale: Afterbirth pains are a common complaint in the postpartum client, but they are located in the uterus. Constipation may cause rectal pressure but is not usually associated with 'severe pain.' Cystitis may cause pain, but the location is different. Hematomas are frequently associated with severe pain and pressure. Further assessments are indicated for this client.
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A client with a stroke and malnutrition has been placed on Total Parenteral Nutrition (TPN). The nurse notes air entering the client via the central line. Which initial action is most appropriate?
- A. Notify the physician.
- B. Elevate the head of the bed.
- C. Place the client in the left lateral decubitus position.
- D. Stop the TPN and hang D5 1/2 NS.
Correct Answer: C
Rationale: Air embolism is suspected. Placing the client in the left lateral decubitus position traps air in the right atrium, preventing pulmonary embolism. Notifying the physician (A), elevating the bed (B), or changing fluids (D) is secondary.
A client on the psychiatric unit is threatening other clients and staff,and interventions to distract him have not been successful. What action should the nurse take?
- A. Call security for assistance and administer PRN medication to calm the client
- B. Tell the client to calm down and ask him again if he would like to play cards
- C. Tell the client that if he continues this behavior he will lose recreational privileges
- D. Ignore the client since it is unlikely he will actually harm anyone
Correct Answer: A
Rationale: Threatening behavior that persists despite de-escalation attempts requires immediate intervention. Calling security ensures safety and PRN medication may help calm the client. The other options are unsafe or ineffective in managing acute agitation.
The nurse is caring for a client with a history of Raynaud’s disease. The nurse should expect the client to have:
- A. Color changes in fingers
- B. Joint swelling
- C. Fever
- D. Chest pain
Correct Answer: A
Rationale: Raynaud’s disease causes vasospasms, leading to color changes (white, blue, red) in the fingers triggered by cold or stress.
The nurse working in a prenatal clinic needs to be alert to the cardinal signs and symptoms of PIH because:
- A. Immediate treatment of mild PIH includes the administration of a variety of medications
- B. Psychological counseling is indicated to reduce the emotional stress causing the blood pressure elevation
- C. Self-discipline is required to control caloric intake throughout the pregnancy
- D. The client may not recognize the early symptoms of PIH
Correct Answer: D
Rationale: Mild PIH is not treated with medications. Emotional stress is not the cause of blood pressure elevation in PIH. Excessive caloric intake is not the cause of weight gain in PIH. The client most frequently is not aware of the signs and symptoms in mild PIH.
A client with a history of bipolar disorder is receiving Lithium. The nurse should teach the client to:
- A. Avoid salty foods
- B. Increase fluid intake
- C. Take the medication with meals
- D. Monitor for weight loss
Correct Answer: B
Rationale: Lithium can cause dehydration and toxicity, so increasing fluid intake is essential. Salty foods are not contraindicated, meals are optional, and weight loss is not a primary concern.