Nokea
A postpartum client presents with persistent, severe headache, photophobia, and altered mental status. Which nursing action is most appropriate?
- A. Encouraging the client to rest in a dark, quiet room
- B. Providing acetaminophen for headache relief
- C. Notifying the healthcare provider immediately
- D. Offering a massage to relieve muscle tension
Correct Answer: C
Rationale: The most appropriate nursing action when a postpartum client presents with persistent, severe headache, photophobia, and altered mental status is to notify the healthcare provider immediately. These symptoms could be indicative of serious conditions such as postpartum preeclampsia or postpartum eclampsia, both of which require prompt medical evaluation and intervention. Delaying medical attention in such cases can lead to severe complications for the mother. Therefore, it is crucial to prioritize the client's safety and well-being by quickly involving the healthcare provider for further assessment and management.
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Which of the following is caused by the markedly distended uterus and intermittent uterine contractions within 2 to 3 days after birth?
- A. Retained placenta
- B. Uterine atony
- C. Afterpains
- D. Boggy uterus
Correct Answer: B
Rationale: Uterine atony is caused by the markedly distended uterus and intermittent uterine contractions within 2 to 3 days after birth. It is characterized by the inability of the uterus to contract after delivery, leading to excessive bleeding postpartum. This condition is a significant risk factor for postpartum hemorrhage. Treatment may involve massage of the uterus, administration of uterotonics, and in severe cases, surgical interventions such as a hysterectomy. Retained placenta refers to incomplete expulsion of the placenta after delivery. Afterpains are the discomfort felt by some women as their uterus contracts and returns to its normal size after childbirth. A boggy uterus is another term for a uterus that feels soft, lax, or lack firm tone, which can be a sign of uterine atony.
A 38-year-old woman presents with cyclic pelvic pain, dysmenorrhea, and dyspareunia. On pelvic examination, the uterus is retroverted and fixed. Which of the following conditions is most likely to be responsible for these findings?
- A. Endometriosis
- B. Adenomyosis
- C. Leiomyomas (uterine fibroids)
- D. Pelvic inflammatory disease (PID)
Correct Answer: A
Rationale: Endometriosis is the most likely condition responsible for the symptoms described in this scenario. Endometriosis is a chronic condition in which endometrial-like tissue grows outside the uterus, commonly affecting the pelvic structures such as the ovaries, fallopian tubes, and pelvic peritoneum. The main symptoms include cyclic pelvic pain, dysmenorrhea (painful periods), and dyspareunia (pain during intercourse). The retroverted and fixed uterus on examination may be due to adhesions from endometriosis, causing the uterus to be fixed in position. Endometriosis should be considered in women of reproductive age presenting with these symptoms and pelvic examination findings.
Which is the MOST important risk factor to osteoporosis
- A. Menopause
- B. With history of previous fracture
- C. Being male
- D. Short in height
Correct Answer: A
Rationale: Menopause is the most important risk factor for osteoporosis because it leads to a decrease in estrogen levels, which plays a crucial role in maintaining bone density. After menopause, women are at a higher risk of developing osteoporosis due to loss of estrogen's protective effects on bone mass. Other risk factors like history of previous fracture, being male, and short stature can also contribute to osteoporosis, but menopause has the strongest association with the development of the condition. It is essential for postmenopausal women to be aware of this risk factor and take preventive measures such as regular exercise, adequate calcium and vitamin D intake, and appropriate medical evaluation and treatment as needed.
Nurse Lina is on duty at the ER and has been very busy that morning resulting to the administration of a penicillin injection which is ordered to another patient. With this error, the nurse can be charged of _______.
- A. malpractice
- B. negligence
- C. assault
- D. battery
Correct Answer: B
Rationale: Negligence refers to the failure to act or perform duties according to the standard of care expected from a reasonable person in similar circumstances. In this case, Nurse Lina administering a penicillin injection that was ordered for another patient is a clear instance of negligence. It involves a breach of duty by not verifying the correct patient and medication before administration. While malpractice can also encompass negligence, it typically involves a broader scope of professional misconduct or harm caused by a healthcare provider. Assault and battery involve intentional harmful acts, which are not applicable in this situation.
what must the Emergency Room Nurse do FIRST?
- A. Start an intravenous line at once.
- B. Position with head lower than extremities.
- C. Request for laboratory examinations.
- D. Stop the bleeding immediately.
Correct Answer: B
Rationale: When a patient arrives in the emergency room, the nurse's first priority is to assess the patient's airway, breathing, and circulation, following the ABCs of emergency care. In this scenario, positioning the patient with the head lower than the extremities ensures proper blood flow to vital organs, especially the brain. This position helps to maintain perfusion to the brain and prevent complications such as hypotension and shock. Once the patient's position is optimized, the nurse can proceed with further interventions such as starting an intravenous line, stopping bleeding, and requesting laboratory examinations as needed.