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A postpartum client presents with calf pain, swelling, and warmth. Which nursing action is most appropriate?
- A. Applying a warm compress to the affected calf
- B. Encouraging ambulation to promote circulation
- C. Notifying the healthcare provider immediately
- D. Administering a nonsteroidal anti-inflammatory drug (NSAID) for pain relief
Correct Answer: C
Rationale: The most appropriate nursing action in this scenario is to notify the healthcare provider immediately. The client's presentation of calf pain, swelling, and warmth could be indicative of a deep vein thrombosis (DVT), which is a serious condition that requires prompt evaluation and intervention by the healthcare provider. DVT is a blood clot that forms in a deep vein, often in the leg, and if left untreated, it can lead to life-threatening complications such as pulmonary embolism. Therefore, timely communication with the healthcare provider is critical to ensure that the client receives the appropriate diagnostic testing and treatment to address the potential DVT. Applying warm compresses, encouraging ambulation, or administering NSAIDs would not be the first-line interventions for a suspected DVT and may even worsen the condition.
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Applying multidisciplinary approach of patient care, which among the members of the multidisciplinary team that the nurse would MOST likely collaborate with when the patient is at risk of fall due to an impaired gait?
- A. Podiatrist
- B. Speech therapist
- C. Physica l therapist
- D. Nutritionist
Correct Answer: C
Rationale: When a patient is at risk of falls due to an impaired gait, a physical therapist would be the most appropriate member of the multidisciplinary team for the nurse to collaborate with. Physical therapists specialize in improving mobility, balance, and coordination through exercises, gait training, and other interventions. They can assess the patient's gait pattern, strength, and balance, and develop a personalized plan to address the impairments contributing to the fall risk. By working closely with a physical therapist, the nurse can help the patient improve their gait and reduce the risk of falls, ultimately promoting safety and independence.
The diagnostic examination for osteoporosis is geared towards measuring
- A. Bone density
- B. Weight
- C. Blood volume
- D. Height
Correct Answer: A
Rationale: The diagnostic examination for osteoporosis typically involves measuring bone density. This is usually done through a dual-energy x-ray absorptiometry (DEXA) scan, which is considered the gold standard for assessing bone density. Osteoporosis is characterized by decreased bone mass and deterioration of bone tissue, leading to increased bone fragility and risk of fractures. Measuring bone density helps in diagnosing osteoporosis by identifying areas of low bone density, assessing the risk of fractures, and monitoring the effectiveness of treatment. Weight, blood volume, and height are not directly used as primary indicators for diagnosing osteoporosis.
Which of the following structures is responsible for propelling food from the oral cavity to the stomach through coordinated muscular contractions?
- A. Tongue
- B. Pharynx
- C. Esophagus
- D. Epiglottis
Correct Answer: C
Rationale: The esophagus is responsible for propelling food from the oral cavity to the stomach through a series of coordinated muscular contractions. These contractions are known as peristalsis. The esophagus is a muscular tube connecting the throat (pharynx) to the stomach and plays a crucial role in moving food bolus from the mouth to the stomach for digestion. The tongue helps in the chewing and swallowing of food, the pharynx is involved in the passage of food and air, and the epiglottis helps prevent food from entering the airways during swallowing. However, it is the esophagus that actively moves the food to the stomach.
A pregnant woman presents with severe lower abdominal pain, fever, and vaginal discharge. On examination, cervical motion tenderness and adnexal tenderness are noted, along with bilateral adnexal masses. Which of the following conditions is the most likely cause of these symptoms?
- A. Ectopic pregnancy
- B. Pelvic inflammatory disease
- C. Placenta previa
- D. Ovarian torsion
Correct Answer: B
Rationale: The constellation of severe lower abdominal pain, fever, and vaginal discharge in a pregnant woman raises suspicion for pelvic inflammatory disease (PID). Cervical motion tenderness and adnexal tenderness are classic physical exam findings for PID. The presence of bilateral adnexal masses further supports the diagnosis, as PID can lead to the formation of tubo-ovarian abscesses. Ectopic pregnancy may present with similar symptoms but is less likely in this case as bilateral adnexal masses suggest a more diffuse inflammatory process. Placenta previa would typically present with painless vaginal bleeding in the third trimester, which is not consistent with the symptoms described. Ovarian torsion would present with sudden severe unilateral lower abdominal pain and is less likely to involve both ovaries simultaneously.
A woman in active labor is diagnosed with uterine rupture. What is the priority nursing action?
- A. Preparing for immediate cesarean section
- B. Administering intravenous oxytocin to augment contractions
- C. Assisting the mother into a hands-and-knees position
- D. Initiating cardiopulmonary resuscitation (CPR)
Correct Answer: A
Rationale: The priority nursing action for a woman diagnosed with uterine rupture during labor is to prepare for immediate cesarean section. Uterine rupture is a serious obstetric emergency that can lead to severe maternal and fetal complications, including hemorrhage, fetal distress, and injury to both mother and baby. A cesarean section is necessary to deliver the baby promptly and address any potential complications, such as controlling bleeding and ensuring the safety of both the mother and the baby. Time is critical in these situations, and prompt surgical intervention is essential to optimize outcomes. Administering intravenous oxytocin or assisting the mother into a hands-and-knees position would not address the immediate risks associated with uterine rupture. Initiating cardiopulmonary resuscitation (CPR) is only necessary if the mother's condition deteriorates to the point of cardiac or respiratory arrest, which may occur as a result of significant hemorrhage or other complications associated with uterine