Nokea
The nurse assesses a client who gave birth 24 hours earlier. Which of the following findings reveals the need for further evaluation?
- A. Chills
- B. Scant lochia rubra
- C. Thirst and fatigue
- D. Temperature of 100.2°F (37.9°C)
Correct Answer: B
Rationale: During the early postpartum period, lochia rubra should be moderate to significant. Scant lochia rubra suggests that large clots are blocking the lochial flow. After delivery, vasomotor changes may cause a shaking chill. Thirst, fatigue, and a temperature of up to 100.4°F (38°C) also are common at 24 hours postpartum.
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A client is sent to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial personality disorder. In reviewing the client's record, the nurse could expect to find:
- A. A history of consistent employment
- B. A below-average intelligence
- C. A history of cruelty to animals
- D. An expression of remorse for his actions
Correct Answer: C
Rationale: Antisocial personality disorder is associated with a history of cruelty to animals , reflecting disregard for others. Consistent employment and remorse are unlikely. Intelligence is typically average or above.
During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-left quadrant. The infant is most likely in which position?
- A. Left mentum anterior
- B. Left occipital anterior
- C. Left sacral anterior
- D. Left occipital transverse
Correct Answer: B
Rationale: Fetal heart tones loudest in the upper-left quadrant suggest a left occipital anterior position, where the fetus's back is aligned with the mother's left side. Other positions` positions are less likely.
A client with a history of Addison's disease and flulike symptoms accompanied by nausea and vomiting over the past week is brought to the facility. The client's wife reports that she noticed that he acted confused and was extremely weak when he woke up in the morning. The client's blood pressure is 90/58 mm Hg, his pulse is 116 beats/minute, and his temperature is 101°F (38.3°C). A diagnosis of acute adrenal insufficiency is made. Which of the following would the nurse expect to administer by I.V. infusion?
- A. Insulin
- B. Hydrocortisone
- C. Potassium
- D. Hypotonic saline
Correct Answer: B
Rationale: Emergency treatment for acute adrenal insufficiency (addisonian crisis) is I.V. infusion of hydrocortisone and saline solution. The client is usually given 100 mg of hydrocortisone in normal saline every 6 hours until his blood pressure returns to normal. Insulin isn't indicated in this situation because adrenal insufficiency is usually associated with hypoglycemia. Potassium isn't indicated because these clients are usually hyperkalemic. The client needs normal - not hypotonic - saline solution.
The incidence of spinal cord defects/ neural tube defects such as meningomyelocele
The incidence of spinal cord defects/ neural tube defects such as meningomyelocele has decreased because
- A. prenatal diagnosis by ultrasound and treatment in the uterus.
- B. maternal ingestion of folic acid prior and during pregnancy.
- C. decreased incidence of smoking and alcohol use during pregnancy.
- D. genetic testing prior to pregnancy.
Correct Answer: B
Rationale: Folic acid supplementation reduces neural tube defects by supporting neural tube closure.
The nurse is caring for a client with a spinal cord injury at the T4 level. Which of the following findings would be MOST concerning?
- A. Blood pressure of 80/50 mmHg with a pulse of 50.
- B. Temperature of 99°F (37.2°C).
- C. Spasticity in the lower extremities.
- D. Numbness in the hands and fingers.
Correct Answer: A
Rationale: A T4 spinal cord injury can cause autonomic dysreflexia or neurogenic shock, leading to severe hypotension (80/50) and bradycardia (pulse 50), which are life-threatening and require immediate intervention. Low-grade fever (B), spasticity (C), and numbness (D) are expected or less urgent.