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A postpartum client presents with persistent, severe abdominal pain, distention, and absent bowel sounds. Which nursing action is most appropriate?
- A. Encouraging the client to ambulate to promote bowel function
- B. Providing a heating pad to alleviate abdominal discomfort
- C. Notifying the healthcare provider immediately
- D. Administering a laxative to promote bowel evacuation
Correct Answer: C
Rationale: The most appropriate nursing action in this situation is to notify the healthcare provider immediately. The symptoms the postpartum client is experiencing - persistent, severe abdominal pain, distention, and absent bowel sounds - are concerning and could indicate a serious underlying issue such as bowel obstruction or other complications. Prompt communication with the healthcare provider is crucial to ensure the client receives the necessary assessment, intervention, and treatment. Encouraging ambulation, providing a heating pad, or administering a laxative are not appropriate actions in this case without first consulting with the healthcare provider due to the severity and potential complexity of the client's symptoms.
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In the performance of her role and functions a school nurse, which guiding principle should be consider very IMPORTANT?
- A. Health is an integral part of the education process.
- B. The nurse is in full authority over the children
- C. The local health authority supervises the school health
- D. School nursing is more focused on socialization
Correct Answer: A
Rationale: The guiding principle that health is an integral part of the education process is of utmost importance for a school nurse in performing their role and functions. This principle emphasizes the interconnectedness of health and academic success, highlighting that healthy students are better able to learn and succeed in school. As a school nurse, understanding and prioritizing this principle means focusing on promoting health and wellness, providing healthcare services, and implementing health education programs to support the overall well-being and academic achievement of students. By recognizing the significance of this principle, school nurses can effectively contribute to creating a healthy and supportive school environment that fosters student growth and development.
A client is admitted with acute gouty arthritis. Which medication does the nurse anticipate the health care provider may prescribe to prevent and treat an acute attack of gout?
- A. Ibuprofen (Motrin)
- B. Probenecid (Benemid)
- C. Colchicine (Colsalide)
- D. Hydrocortisone (Cortef)
Correct Answer: C
Rationale: Colchicine is a medication commonly prescribed to prevent and treat acute attacks of gout. It works by reducing inflammation caused by the buildup of uric acid crystals in the joints. Colchicine is effective in relieving pain and reducing swelling during gout attacks. It is important to follow the prescribed dosage due to potential side effects such as gastrointestinal upset. Ibuprofen is a nonsteroidal anti-inflammatory drug that can be used for pain relief but is not specific for gout treatment. Probenecid is used for chronic gout by helping the kidneys remove uric acid, not for acute gout attacks. Hydrocortisone is a steroid that may be used in some cases but is not a first-line treatment for acute gouty arthritis.
Which of the following is a common complication associated with long-term corticosteroid use in patients with rheumatoid arthritis?
- A. Osteoporotic fracture
- B. Osteonecrosis of the femoral head
- C. Avascular necrosis of the talus
- D. Septic arthritis
Correct Answer: A
Rationale: Long-term corticosteroid use in patients with rheumatoid arthritis can lead to osteoporosis, which is a common complication. Osteoporosis causes weakening of the bones, increasing the risk of fractures, particularly in weight-bearing bones such as the hip, spine, and wrist. Osteoporotic fractures are a significant concern in patients on long-term corticosteroid therapy, highlighting the importance of monitoring bone health and considering preventive measures such as calcium, Vitamin D supplementation, and regular bone density testing. While osteonecrosis of the femoral head and avascular necrosis of the talus can also occur as complications of corticosteroid use, osteoporotic fractures are more commonly associated with this type of therapy in patients with rheumatoid arthritis. Septic arthritis, on the other hand, is not directly related to corticosteroid use but can occur due to other factors such as joint infections.
A patient with a history of chronic obstructive pulmonary disease (COPD) is experiencing respiratory distress. Which nursing intervention is the priority for managing the patient's respiratory status?
- A. Administering bronchodilators
- B. Positioning the patient in high Fowler's position
- C. Performing chest physiotherapy
- D. Administering oxygen therapy
Correct Answer: D
Rationale: Administering oxygen therapy is the priority nursing intervention for managing a patient with COPD experiencing respiratory distress. In COPD, the patient's lungs are less efficient at oxygen exchange, leading to hypoxemia. Oxygen therapy helps improve oxygenation in the body and alleviates respiratory distress in these patients. Positioning the patient in high Fowler's position can also help improve lung expansion, but providing supplemental oxygen takes precedence in addressing the underlying hypoxemia. Administering bronchodilators and performing chest physiotherapy aim to manage airway obstruction and promote airway clearance, but ensuring the patient has adequate oxygenation is crucial in the immediate management of respiratory distress in COPD.
A patient receiving palliative care for end-stage heart failure experiences severe fatigue and limited mobility. What intervention should the palliative nurse prioritize to promote the patient's comfort and quality of life?
- A. Recommend initiating physical therapy to improve mobility and strength.
- B. Encourage the patient to conserve energy and avoid unnecessary activities.
- C. Prescribe stimulant medications to alleviate fatigue and increase energy levels.
- D. Refer the patient to a nutritionist for dietary modifications to boost energy.
Correct Answer: B
Rationale: In this scenario, the palliative nurse should prioritize encouraging the patient to conserve energy and avoid unnecessary activities (Option B). End-stage heart failure can lead to severe fatigue and limited mobility, making it essential for the patient to conserve energy to prevent exacerbating symptoms and improve quality of life. Engaging in physical therapy (Option A) may not be suitable for a patient experiencing severe fatigue, as it can further drain energy reserves. Prescribing stimulant medications (Option C) may have limited effectiveness and potential side effects. Referring the patient to a nutritionist for dietary modifications (Option D) is important for overall health but may not directly address the immediate comfort and quality of life concerns related to fatigue and limited mobility. Helping the patient prioritize energy conservation will allow them to use their limited energy for essential activities, leading to a more comfortable and fulfilling experience while receiving palliative care for end-stage heart failure.