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A primiparous client who is breast-feeding develops endometritis on the third postpartum day. Which of the following instructions should the nurse give to the mother?
- A. The neonate will need to be bottle-fed for the next few days.
- B. The condition typically is treated with I.V. antibiotic therapy.
- C. The client's uterus may become 'boggy,' requiring frequent massage and oxytocics.
- D. The client needs to remain in bed in a side-lying position as much as possible.
Correct Answer: B
Rationale: Endometritis is typically treated with I.V. antibiotics to address the infection.
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A client with the diagnosis of pneumonia experiences dyspnea when engaging activities. Which action should the nurse implement to help address client safety?
- A. Encourage deep, rapid breathing during activity.
- B. Provide stimulation in the environment to maintain client alertness.
- C. Observe vital signs and oxygen saturation periodically during activity.
- D. Schedule activities before giving respiratory medications or treatments.
Correct Answer: C
Rationale: Monitoring vital signs and oxygen saturation during activity ensures the nurse can detect early signs of respiratory distress or hypoxia, promoting client safety. Encouraging deep, rapid breathing may exacerbate dyspnea and is not safe. Providing environmental stimulation is unrelated to respiratory safety. Scheduling activities before respiratory medications or treatments could worsen dyspnea, as these interventions improve breathing capacity.
Which of the following theories of pain are you utilizing when you recognize the fact that some of the factors that open this 'gate' to pain are low endorphins and anxiety and that some of the factors that close this 'gate' to pain are decreased anxiety and fear?
- A. Moritz Schiff's theory of pain
- B. The Intensive Theory of Pain
- C. Melzack and Wall's theory of pain
- D. The Specificity Theory of Pain
Correct Answer: C
Rationale: Melzack and Wall's Gate Control Theory posits that pain perception is modulated by factors like anxiety (opening the gate) and reduced anxiety or endorphins (closing the gate).
The nurse is caring for a client who has just undergone a mastectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Encourage arm exercises on the affected side.
- B. Keep the affected arm dependent.
- C. Apply heat to the surgical site.
- D. Restrict fluid intake.
Correct Answer: A
Rationale: Encouraging arm exercises prevents lymphedema and promotes circulation post-mastectomy.
You assess your family as having a deficit in terms of their instrumental activities of daily living (ADLs). Which healthcare professional would you most likely refer this family to in order to address this deficit?
- A. A social worker
- B. A physical therapist
- C. An occupational therapist
- D. A speech therapist
Correct Answer: C
Rationale: Occupational therapists specialize in helping individuals improve their ability to perform instrumental activities of daily living (e.g., managing finances, cooking), making them the most appropriate referral for this deficit.
The nurse assesses a client with diverticulitis and suspects peritonitis when which of the following symptoms is noted?
- A. Hyperactive bowel sounds.
- B. Rigid abdominal wall.
- C. Explosive diarrhea.
- D. Excessive flatulence.
Correct Answer: B
Rationale: A rigid abdominal wall is a hallmark sign of peritonitis, indicating peritoneal inflammation, often due to perforation in diverticulitis.