Nokea
An obstetrical client is admitted in active labor. During examination,the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
- A. Document the finding
- B. Report the finding to the physician
- C. Prepare the client for a C-section
- D. Continue primary care as prescribed
Correct Answer: B
Rationale: A papular lesion on the perineum during labor could indicate an infectious condition (e.g. herpes simplex virus) which poses risks to the newborn. Reporting to the physician is the most appropriate initial action to determine management such as the need for a C-section.
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The nurse is caring for a client with a diagnosis of oligohydramnios. Which finding is most likely to be present?
- A. Decreased fetal movement
- B. Increased fetal heart rate
- C. Uterine size larger than expected
- D. Fetal macrosomia
Correct Answer: A
Rationale: Oligohydramnios (low amniotic fluid) can restrict fetal movement due to limited space making decreased fetal movement a likely finding. Fetal heart rate may be normal or show distress uterine size is smaller and macrosomia is unrelated.
An obstructing stone in the renal pelvis or upper ureter causes:
- A. Radiating pain into the urethra with labia pain experienced in females or testicular pain in males
- B. Urinary frequency and dysuria
- C. Severe flank and abdominal pain with nausea, vomiting, diaphoresis, and pallor
- D. Dull, aching, back pain
Correct Answer: C
Rationale: Radiating pain in the urethra in both sexes, extending into the labia in females and into the testicle or penis in the male, indicates a stone in the middle or lower segment of the ureter. Urinary frequency and dysuria are caused by a stone in the terminal segment of the ureter within the bladder wall. An obstructing stone in the renal pelvis or upper ureter causes severe flank and abdominal pain with nausea, vomiting, diaphoresis, and pallor. Dull and aching pain may indicate early stages of hydronephrosis. Also, a stone in the renal pelvis or upper ureter causes severe flank and abdominal pain.
A client with a history of chronic renal failure is receiving hemodialysis. Which assessment finding indicates a complication during dialysis?
- A. Mild fatigue
- B. Hypotension
- C. Slight headache
- D. Stable weight
Correct Answer: B
Rationale: Hypotension during dialysis suggests fluid removal too rapid or disequilibrium syndrome, a serious complication. Fatigue (A), headache (C), and stable weight (D) are less concerning.
The nurse is caring for a 6-week-old girl with meningitis. To help her develop a sense of trust, the nurse should:
- A. Give her a small soft blanket to hold
- B. Give her good perineal care after each diaper change
- C. Leave the door open to her room
- D. Pick her up when she cries
Correct Answer: D
Rationale: A soft blanket may be comforting, but it is not directed toward developing a sense of trust. Good perineal care is important, but it is not directed toward developing a sense of trust. An infant with meningitis needs frequent attention, but leaving the door open does not foster trust. Consistently picking her up when she cries will help the child feel trust in her caregivers.
A male client has been an insulin-dependent diabetic for approximately 30 years. He frequently indulges in high-sugar foods and forgets to take his insulin. He has not experienced acute diabetic emergencies over the years but is now beginning to demonstrate symptoms of diabetic peripheral neuropathy. This distresses him because dancing is one of his favorite pastimes. He decides to question his wife's home health nurse about diabetic peripheral neuropathy. The nurse points out his noncompliance to his diabetic diet and insulin regimen. The client answers the nurse, 'It has been my experience that the diabetic diet is very difficult to follow. As far as the insulin, isn't a fellow allowed to forget now and then?' The client's actions and response best demonstrate:
- A. Depression
- B. Anger
- C. Denial
- D. Bargaining
Correct Answer: C
Rationale: Depression may be an underlying feature, but it is not evident from limited data presented here. Anger is not exhibited in his response. Denial is evident in the client's actions; through the years, he has had a casual approach to his illness. He only becomes concerned when bodily changes affect his present lifestyle, when in fact he should have been concerned all along. His verbal response also reflects denial. There is no evidence of bargaining in the client's actions or verbal response.