Nokea
A woman presents at the ED with sharp, colicky pain in her right abdomen that radiates to her right shoulder. She tells the nurse that she has been spotting lightly for the past few days. The patient is subsequently diagnosed with an ectopic pregnancy. What major nursing diagnosis most likely relates to this patients needs?
- A. Anxiety related to potential treatment options and health outcomes
- B. Chronic sorrow related to spontaneous abortion
- C. Chronic pain related to genitourinary trauma
- D. Impaired tissue integrity related to keloid scarring
Correct Answer: A
Rationale: A diagnosis of ectopic pregnancy is likely to cause significant anxiety due to treatment uncertainties and health risks. Chronic sorrow, chronic pain, and impaired tissue integrity (keloid scarring) are less applicable to the acute presentation of ectopic pregnancy.
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The nurse is working with a couple who have been unable to conceive despite more than 2 years of trying to get pregnant. The couple has just learned that in vitro fertilization (IVF) was unsuccessful and they are both tearful. What nursing diagnosis is most likely to apply to this couple?
- A. Hopelessness related to failed IVF
- B. Acute confusion related to reasons for failed IVF
- C. Compromised family coping related to unsuccessful IVF
- D. Moral distress related to unsuccessful IVF
Correct Answer: A
Rationale: The couple's tearful response to a failed IVF suggests hopelessness, a likely emotional reaction to the loss of a promising intervention. Acute confusion implies cognitive impairment, compromised coping is less specific, and moral distress is unrelated to the scenario.
A patient who is in the first trimester of pregnancy has experienced an incomplete abortion. The obstetric nurse should prepare the patient for what possible intervention?
- A. Dilation and evacuation
- B. Several days of bed rest
- C. Administration of hydromorphone
- D. IV administration of clomiphene
Correct Answer: A
Rationale: If only some of the tissue is passed, the abortion is referred to as incomplete. An emptying or evacuation procedure (D&C, or dilation and evacuation [D&E]) or administration of oral misoprostol (Cytotec) is usually required to remove the remaining tissue. Bed rest will not necessarily result in the passing of all the tissue. Clomiphene is used for ovulation induction, not abortion management, and hydromorphone is for pain relief, not a primary intervention.
A community health nurse is leading a health education session addressing menopause and other aspects of womens health. What dietary supplements should the nurse recommend to prevent morbidity associated with osteoporotic fractures?
- A. Vitamin B12 and vitamin C
- B. Vitamin A and potassium
- C. Vitamin B6 and phosphorus
- D. Calcium and vitamin D
Correct Answer: D
Rationale: Calcium and vitamin D supplementation are recommended to reduce bone loss and prevent osteoporotic fractures, a key concern in menopause. Other listed supplements do not address bone health effectively.
A 36-year-old woman comes to the clinic complaining of premenstrual syndrome (PMS) that is disrupting her quality of life. What signs and symptoms are associated with this health problem? Select all that apply.
- A. Loss of appetite
- B. Breast tenderness
- C. Depression
- D. Fluid retention
- E. Headache
Correct Answer: B,C,D,E
Rationale: Physiologic symptoms of PMS include headache, breast tenderness, and fluid retention, along with affective symptoms like depression. Loss of appetite is not a common symptom of PMS.
The nurse is being trained to perform assessment screenings for abuse on patients who come into the walk-in clinic where the nurse works. Which of the following assessment questions is most appropriate?
- A. Would you describe your relationship as healthy and functional?
- B. Have you ever been forced into sexual activity?
- C. Do you make your husband uncontrollably angry?
- D. How is conflict usually handled in your home?
Correct Answer: B
Rationale: Asking about abuse directly, such as inquiring about forced sexual activity, is effective in identifying the presence of abuse and should be included in the health history of the patients. Oblique questions that relate to the character of the relationship or conflict resolution are less useful clinically. Asking about making a partner angry is inappropriate as it implies blame and does not directly screen for abuse.