Nokea
An adolescent client hospitalized with anorexia nervosa is described by her parents as 'the perfect child.' When planning care for the client, the nurse should:
- A. Allow her to choose what foods she will eat
- B. Provide activities to foster her self-identity
- C. Encourage her to participate in morning exercise
- D. Provide a private room near the nurse's station
Correct Answer: B
Rationale: Anorexia nervosa is often linked to issues of control and identity; activities fostering self-identity help address underlying psychological factors.
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A 19-year-old primigravida is admitted to the labor and delivery suite of the hospital. Her husband is accompanying her. The couple tells the nurse that this is the first hospital admission for her. The client's vaginal exam indicates she is 3 cm dilated, 80% effaced, and at -0 station. Based on the vaginal exam, she is in:
- A. Stage 2, latent phase
- B. Stage 1, active phase
- C. Stage 3, transition phase
- D. Stage 1, latent phase
Correct Answer: D
Rationale: The second stage of labor is from full cervical dilation through birth of the baby. The three phases of this stage include latency or resting, descent, and final transition. The client is less than fully dilated so she is not in stage 2. The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor. The third stage of labor is from the birth of the baby until the delivery of the placenta. The client is less than fully dilated. The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor.
The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:
- A. Feet
- B. Neck
- C. Hands
- D. Sacrum
Correct Answer: D
Rationale: In left-sided congestive heart failure, fluid backs up into the lungs, but dependent edema is assessed in the sacrum in bedridden clients or feet in ambulatory clients. The sacrum is the most appropriate site for hospitalized clients, as they are often recumbent.
A female client at 30 weeks' gestation is brought into the emergency department after falling down a flight of stairs. On examination, the physician notes a rigid, boardlike abdomen; FHR in the 160s; and stable vital signs. Considering possible abdominal trauma, which obstetric emergency must be anticipated?
- A. Abruptio placentae
- B. Ectopic pregnancy
- C. Massive uterine rupture
- D. Placenta previa
Correct Answer: A
Rationale: Abruptio placentae, the complete or partial separation of the placenta from the uterine wall, can be caused by external trauma. When hemorrhage is concealed, one sign is a rapid increase in uterine size with rigidity. Ectopic pregnancy occurs when the embryo implants itself outside the uterine cavity. Massive uterine rupture occurs during labor when the uterine contents are extruded through the uterine wall. It is usually due to weakness from a pre-existing uterine scar and trauma from instruments or an obstetrical intervention. Placenta previa is the condition in which the placenta is implanted in the lower uterine segment and either completely or partially covers the cervical os.
A postpartum client complains of rectal pressure and severe pain in her perineum; this may be indicative of:
- A. Afterbirth pains
- B. Constipation
- C. Cystitis
- D. A hematoma of the vagina or vulva
Correct Answer: D
Rationale: Afterbirth pains are a common complaint in the postpartum client, but they are located in the uterus. Constipation may cause rectal pressure but is not usually associated with 'severe pain.' Cystitis may cause pain, but the location is different. Hematomas are frequently associated with severe pain and pressure. Further assessments are indicated for this client.
The nurse asks a patient about current medications. Which one of the patient's medications is most likely to cause abdominal pain?
- A. Norco (hydrocodone/APAP)
- B. Erythrocin (erythromycin)
- C. Zyrtec (cetirizine)
- D. Aldactone (spironolactone)
Correct Answer: B
Rationale: Erythromycin commonly causes gastrointestinal side effects, including abdominal pain, due to its motility-stimulating effects. Norco may cause constipation, Zyrtec is less likely to affect the GI tract, and Aldactone’s side effects are primarily electrolyte-related.