Nokea
Intrapartum nursing care for a woman who has sickle cell disease focuses on:
- A. Maintaining oxygenation and preventing dehydration
- B. Controlling pain and avoiding unnecessary movement
- C. Preventing excess exertion and limiting visitors
- D. Increasing calorie intake and avoiding internal monitoring
Correct Answer: A
Rationale: The correct answer is A because maintaining oxygenation is crucial due to the risk of vaso-occlusive crisis in sickle cell disease. Dehydration can worsen sickling of red blood cells. Choice B is incorrect because pain control is important but not the primary focus. Choice C is incorrect as excess exertion can trigger a crisis, and limiting visitors is not a priority. Choice D is incorrect as calorie intake and internal monitoring are not directly related to intrapartum care for sickle cell disease.
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The client receives zidovudine (Retrovir) for treatment of HIV infection. Which assessment data indicates an adverse reaction to the drug?
- A. Cough
- B. Enlarged lymph nodes
- C. Decreased WBC count
- D. Fever
Correct Answer: C
Rationale: The correct answer is C: Decreased WBC count. Zidovudine is known to cause bone marrow suppression which can lead to a decrease in white blood cell count. This is an adverse reaction as it increases the risk of infections.
A: Cough is not a common adverse reaction to zidovudine.
B: Enlarged lymph nodes are not directly associated with zidovudine adverse reactions.
D: Fever is a non-specific symptom and can occur due to various reasons, not specifically related to zidovudine.
Therefore, the most concerning and relevant assessment data indicating an adverse reaction to zidovudine is a decreased white blood cell count.
The nurse is providing education to parents of a child with cleft palate. What will the nurse instruct the parents to report immediately?
- A. Facial paralysis
- B. Ear infections
- C. Increasing intracranial pressure (ICP)
- D. Drooling
Correct Answer: B
Rationale: The correct answer is B: Ear infections. Parents of a child with a cleft palate should report ear infections immediately because children with cleft palate are at higher risk for developing ear infections due to issues with Eustachian tube function. Ear infections can lead to hearing loss if left untreated. Facial paralysis (A) is not directly related to cleft palate. Increasing ICP (C) is not typically associated with cleft palate. Drooling (D) is common in children with cleft palate and does not require immediate reporting unless there are other concerning symptoms present.
The nurse is assessing a client who has a suspected cystocele. Which signs and symptoms should the nurse expect? Select all that apply.
- A. Frequent bladder infections
- B. Sense of fullness in the vaginal area
- C. Leaking of urine
- D. Irregular vaginal bleeding
Correct Answer: D
Rationale: The correct answer is D: Irregular vaginal bleeding. A cystocele is a condition where the bladder protrudes into the vagina. This can cause pressure on surrounding tissues and lead to irregular vaginal bleeding. A, B, and C are incorrect as they are more commonly associated with other conditions such as urinary tract infections (A), pelvic organ prolapse (B), and urinary incontinence (C). Irregular vaginal bleeding is a key sign specific to cystocele due to the physical displacement of organs.
A 20-year-old college student expresses concern over the recent appearance of genital warts, an assessment finding her primary care provider confirms as attributable to HPV infection. Which client education should be included?
- A. It's important to start treatment as soon as possible, so you will receive a prescription for pills today.
- B. There is a chance that the genital warts will clear up on their own without any treatment.
- C. I recommend receiving an HPV vaccination today.
- D. Unfortunately, this is going to greatly increase your chance of developing pelvic inflammatory disease.
Correct Answer: B
Rationale: The correct answer is B: There is a chance that the genital warts will clear up on their own without any treatment.
Rationale:
1. Genital warts caused by HPV can sometimes resolve spontaneously without treatment.
2. This option emphasizes the possibility of self-resolution, which is a common occurrence.
3. Encouraging observation without immediate treatment aligns with current guidelines for managing HPV-related genital warts.
4. Avoiding unnecessary treatment helps prevent potential side effects and reduces healthcare costs.
Summary of Incorrect Choices:
A: Incorrect because immediate treatment is not always necessary for genital warts caused by HPV.
C: Incorrect because HPV vaccination does not treat existing HPV infections, including genital warts.
D: Incorrect because developing pelvic inflammatory disease is not directly related to the presence of genital warts caused by HPV.
Which pharmacological preparation is the least effective in relieving symptoms of dysmenorrhea?
- A. Ibuprofen
- B. Acetaminophen
- C. Oral contraceptive pills
- D. Naproxen sodium
Correct Answer: B
Rationale: The correct answer is B: Acetaminophen. Acetaminophen is not an anti-inflammatory medication, unlike Ibuprofen and Naproxen sodium, which are more effective in reducing inflammation and pain associated with dysmenorrhea. Oral contraceptive pills (Choice C) can help regulate hormones to reduce menstrual cramps. Ibuprofen and Naproxen sodium (Choices A and D) are nonsteroidal anti-inflammatory drugs (NSAIDs) that target prostaglandins, which play a role in causing menstrual cramps. Acetaminophen, being a mild pain reliever, lacks the anti-inflammatory properties needed to effectively alleviate dysmenorrhea symptoms.