Nokea
A postpartum client who experienced a perineal laceration reports pain and discomfort during defecation. What nursing intervention should be prioritized to alleviate symptoms?
- A. Recommending the use of stool softeners or laxatives
- B. Encouraging the client to increase fluid and fiber intake
- C. Providing perineal care using peri-bottles with warm water
- D. Instructing the client on proper positioning for defecation
Correct Answer: A
Rationale: The priority nursing intervention for a postpartum client who experienced a perineal laceration and reports pain and discomfort during defecation is to recommend the use of stool softeners or laxatives. Perineal lacerations can lead to pain and discomfort during bowel movements due to the strain that passing stools may cause on the tender area. Stool softeners or laxatives can help soften the stool, making it easier and less painful for the client to have bowel movements. It is important to alleviate the discomfort and promote bowel regularity to prevent complications such as constipation, which can further exacerbate the pain and delay healing of the perineal laceration.
You may also like to solve these questions
A patient with a tibial shaft fracture undergoes surgical fixation with an intramedullary nail. What postoperative complication should the healthcare team monitor for in the immediate postoperative period?
- A. Wound infection
- B. Nonunion
- C. Fat embolism syndrome
- D. Compartment syndrome
Correct Answer: C
Rationale: Following surgical fixation of a tibial shaft fracture with an intramedullary nail, healthcare providers should monitor for the development of fat embolism syndrome (FES) in the immediate postoperative period. FES is a serious complication that occurs when fat droplets from the bone marrow enter the bloodstream and cause respiratory and neurological symptoms. Clinical manifestations of FES may include dyspnea, tachypnea, petechial rash, altered mental status, and hypoxemia. Prompt recognition and treatment are essential in managing fat embolism syndrome to prevent serious complications such as respiratory failure and neurological deficits. Monitoring for signs and symptoms of FES is crucial in the postoperative care of patients undergoing surgical fixation of long bone fractures.
A patient with a history of heart failure is prescribed spironolactone. Which electrolyte imbalance is the patient at risk for developing with spironolactone therapy?
- A. Hypernatremia
- B. Hyperkalemia
- C. Hypokalemia
- D. Hyponatremia
Correct Answer: B
Rationale: Spironolactone is a potassium-sparing diuretic commonly used in the management of heart failure. One of the significant side effects of spironolactone is hyperkalemia, which is an elevated level of potassium in the bloodstream. Spironolactone works by blocking the action of aldosterone, a hormone that regulates potassium and sodium balance in the body. By inhibiting aldosterone, spironolactone reduces potassium excretion in the urine, leading to potential accumulation of potassium in the body.
A pregnant woman presents with severe lower abdominal pain and vaginal bleeding. On examination, cervical motion tenderness and unilateral adnexal tenderness are noted, along with an adnexal mass on the affected side. Which of the following conditions is the most likely cause of these symptoms?
- A. Ectopic pregnancy
- B. Pelvic inflammatory disease
- C. Placenta previa
- D. Ovarian torsion
Correct Answer: A
Rationale: The clinical presentation of severe lower abdominal pain and vaginal bleeding in a pregnant woman, along with cervical motion tenderness, unilateral adnexal tenderness, and an adnexal mass on the affected side, is highly concerning for an ectopic pregnancy. Ectopic pregnancy occurs when a fertilized egg implants outside the uterus, most commonly in the fallopian tube. The presence of an adnexal mass and tenderness on one side is indicative of potential tubal involvement and can mimic symptoms of pelvic inflammatory disease. Prompt evaluation and management are crucial in ectopic pregnancy to prevent life-threatening complications associated with rupture of the fallopian tube.
A patient presents with multiple, flesh-colored, papular lesions with a central dell on the face and trunk. The lesions have a tendency to bleed upon minor trauma and have been increasing in number over time. Which of the following conditions is most likely responsible for this presentation?
- A. Basal cell carcinoma
- B. Squamous cell carcinoma
- C. Seborrheic keratosis
- D. Actinic keratosis
Correct Answer: A
Rationale: The presentation described in the question is classic for basal cell carcinoma (BCC). BCC typically presents as multiple, flesh-colored, papular lesions with a central dell (resembling a pearl-like appearance) on sun-exposed areas such as the face and trunk. These lesions are known to bleed easily upon minor trauma and tend to increase in number over time. BCC is the most common type of skin cancer, often triggered by sun exposure. On the other hand, seborrheic keratosis (choice C) presents as benign, pigmented, stuck-on, waxy, or warty lesions with a rough surface, true bumpy appearance. Squamous cell carcinoma (choice B) usually presents as a scaly, erythematous, rapidly growing nodule, ulcer, or plaque. Actinic keratosis (choice D) presents as rough, scaly patches on sun-exposed areas that can progress to
Nurse Reese is preparing the patient assignment t for the day and needs to assign patients to a midwife and nursing assistant. Which patient should the nurse assign to the midwife because of patient needs that cannot be met by the nursing assistant? A patient requiring________.
- A. dressing change of post caesarian Surgery
- B. Collecting of urine specimen for urinalysis testing
- C. performing range-of-motion exercises twice a day
- D. taking of vital signs measurement every hour
Correct Answer: A
Rationale: The patient requiring a dressing change of post-caesarian surgery should be assigned to the midwife because this task involves specialized knowledge and skills related to wound care and post-operative care. Performing a dressing change for a post-caesarian surgery patient requires expertise to ensure proper hygiene, wound healing, and prevention of post-operative complications. This task goes beyond the scope of practice for a nursing assistant and should be done by a healthcare professional with higher qualifications and training, such as a midwife.