Nokea
Before giving methergine postpartum, the nurse should assess the client for:
- A. Decreased amount of lochial flow
- B. Elevated blood pressure
- C. Flushing
- D. Afterpains
Correct Answer: B
Rationale: Methergine is given to contract the uterus and to control postpartal hemorrhage; therefore, lochial flow should decrease. Methergine may elevate the blood pressure. A client with an elevated blood pressure should not receive methergine, but she could be given oxytocin if necessary. Flushing is not a side effect of methergine. Afterpains are increased with methergine usage. The client should be informed that this is a normal response.
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The nurse is caring for a client with a history of hypothyroidism. The nurse should expect the client to have:
- A. Fatigue
- B. Tachycardia
- C. Weight loss
- D. Diarrhea
Correct Answer: A
Rationale: Hypothyroidism slows metabolism, causing fatigue, weight gain, and cold intolerance.
A burn client's care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?
- A. Wound culture results showing minimal bacteria
- B. Cloudy, foul-smelling urine
- C. White blood cell count of 14,000/mm3
- D. Temperature elevation of 101°F
Correct Answer: A
Rationale: Minimal bacteria in wound cultures indicates no localized infection, supporting the outcome. Cloudy urine (B), elevated WBC (C), and fever (D) suggest possible infection.
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.
A 56-year-old client is admitted to the psychiatric unit in a state of total despair. She feels hopeless and worthless, has a flat affect and very sad appearance, and is unable to feel pleasure from anything. Her husband has been assisting her at home with the housework and cooking; however, she has not been eating much, lies around or sits in a chair most of the day, and is becoming confused and thinks her family does not want her around anymore. In assessing the client, the nurse determines that her behavior is consistent with:
- A. Transient depression
- B. Mild depression
- C. Moderate depression
- D. Severe depression
Correct Answer: D
Rationale: Transient depression manifests as sadness or the 'blues' as seen with everyday disappointments and is not necessarily dysfunctional. Mild depression manifests as symptoms seen with grief response, such as denial, sadness, withdrawal, somatic symptoms, and frequent or continuous thoughts of the loss. Moderate depression manifests as feelings of sadness, negativism; low self-esteem; rumination about life's failures; decreased interest in grooming and eating; and possibly sleep disturbances. These symptoms are consistent with dysthymia. Severe depression manifests as feelings of total despair, hopelessness, emptiness, inability to feel pleasure; possibly extreme psychomotor retardation; inattention to hygiene; delusional thinking; confusion; self-blame; and suicidal thoughts. These symptoms are consistent with major depression.
A client is medically cleared for ECT and is tentatively scheduled for six treatments over a 2-week period. Her husband asks, 'Isn't that a lot?' The nurse's best response is:
- A. Yes, that does seem like a lot.'
- B. You'll have to talk to the doctor about that. The physician knows what's best for the client.'
- C. Six to 10 treatments are common. Are you concerned about permanent effects?'
- D. Don't worry. Some clients have lots more than that.'
Correct Answer: C
Rationale: The most common range for affective disorders is 6-10 treatments. This response confirms and reinforces the physician's plan for treatment. It also opens communication with the husband to identify underlying fears and knowledge deficits.