Nokea
Assessment of a nulligravid client in active labor reveals the following: complaints of moderate discomfort; cervix dilated $3 \mathrm{~cm}, 0$ station and completely effaced; fetal heart rate of $136 \mathrm{bpm}$. Which of the following should the nurse plan to do next?
- A. Assist the client with comfort measures and breathing techniques.
- B. Turn the client from the left side-lying position to the right side-lying position.
- C. Prepare the client for epidural anesthesia to relieve pain.
- D. Instruct the client that internal fetal monitoring is necessary.
Correct Answer: A
Rationale: Moderate discomfort in early labor is managed with non-pharmacologic comfort measures and breathing techniques to promote coping.
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A client with a history of depression is prescribed bupropion (Wellbutrin). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Seizures.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Bupropion lowers the seizure threshold, and seizures are a serious side effect requiring immediate reporting.
Select the member of the multidisciplinary team that you would most likely collaborate with when the client can benefit from the use of adaptive devices for cutting food?
- A. The physical therapist
- B. The occupational therapist
- C. The dietician
- D. The podiatrist
Correct Answer: B
Rationale: An occupational therapist specializes in helping clients use adaptive devices to perform activities of daily living, such as cutting food, making them the most appropriate team member for this need.
The nurse is teaching a 17-year-old girl who has a severe gonorrheal infection. The nurse realizes that the girl needs further teaching when she states:
- A. Once I'm treated, I'll have immunity.'
- B. My partner doesn't need treatment.'
- C. I won't have any more problems once I learn to protect myself.'
- D. I could have trouble getting pregnant.'
Correct Answer: A,B
Rationale: Gonorrhea does not confer immunity, and partners require treatment to prevent reinfection. Potential infertility is a correct understanding, but believing protection eliminates all problems is overly optimistic.
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).
Which of the following nursing diagnoses should the nurse implement as part of the long-term care for a child with hemophilia?
- A. Deficient knowledge
- B. Risk for injury
- C. Situational low self-esteem
- D. Acute pain
Correct Answer: B
Rationale: Risk for injury is a priority nursing diagnosis for a child with hemophilia due to the risk of bleeding from minor trauma. Other diagnoses may apply but are less critical long-term.