Nokea
The nurse is caring for a client with a diagnosis of abruptio placenta. Which intervention is most appropriate?
- A. Monitor fetal heart tones
- B. Administer tocolytics
- C. Place the client in Trendelenburg position
- D. Administer antibiotics
Correct Answer: A
Rationale: Abruptio placenta can cause fetal hypoxia making fetal heart tone monitoring critical to assess fetal well-being. Tocolytics are contraindicated Trendelenburg may worsen bleeding and antibiotics are not indicated unless infection is present.
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A male client had a right below-the-knee amputation 4 days ago. His incision is healing well. He has gotten out of bed several times and sat at the side of the bed. Each time after returning to bed, he has experienced pain as if it were located in his right foot. Which nursing measure indicates the nurse has a thorough understanding of phantom pain and its management?
- A. Phantom pain is entirely in the client's mind. The client should be instructed that the pain is psychological and should not be treated.
- B. The basis for phantom pain may occur because the nerves still carry pain sensation to the brain even though the limb has been amputated. The pain is real, intense, and should be treated.
- C. The cause of phantom pain is unknown. The nurse should provide the client with support, promote sleep, and handle the injured limb smoothly and gently.
- D. Phantom pain is caused by trauma, spasms, and edema at the incisional site. It will decrease when postoperative edema decreases. It should be treated with nonnarcotic medication whenever possible.
Correct Answer: B
Rationale: This statement is entirely false. Phantom pain may be caused by nerves continuing to carry sensation to the brain even though the limb is removed. It is real, intense, and should be treated as ordinary pain would. Although the cause of phantom pain is still unknown, these measures may promote the relief of any type of pain, not just phantom pain. Phantom pain is not caused by trauma, spasms, and edema and will not be relieved by decreasing edema.
Which measure helps reduce nipple soreness associated with breastfeeding?
- A. Feeding the baby during the first 48 hours after delivery
- B. Placing a finger between the baby's mouth and the breast to break suction after feeding
- C. Applying warm, moist soaks to the breast several times per day
- D. Wearing a support bra during the day
Correct Answer: B
Rationale: Breaking suction by placing a finger between the baby’s mouth and the breast prevents trauma to the nipple, reducing soreness. Feeding early promotes latch but doesn’t address soreness directly, warm soaks may increase inflammation, and a bra supports but doesn’t prevent nipple trauma.
The nurse is assessing an adult female client for hypovolemia.
- A. Hematocrit 55%
- B. Potassium 5.0 mEq/L
- C. Urine specific gravity 1.016
- D. BUN 18 mg/dL
Correct Answer: A
Rationale: Elevated hematocrit (55%) indicates hemoconcentration due to fluid loss in hypovolemia. Potassium (B) and BUN (D) are within normal ranges, and urine specific gravity (C) is normal, not elevated as expected in hypovolemia.
A 67-year-old man had a physical examination prior to beginning volunteer work at the hospital. A routine chest x-ray demonstrated left ventricular hypertrophy. His blood pressure was 180/110. He is 45 lb overweight. His diet is high in sodium and fat. He has a strong family history of hypertension. The client is placed on antihypertensive medication; a low-sodium, low-fat diet; and an exercise regimen. On his next visit, compliance would best be determined by:
- A. A blood pressure reading of 130/70 with a 5-lb weight loss
- B. No side effects from antihypertensive medication and an accurate pill count
- C. No evidence of increased left ventricular hypertrophy on chest x-ray
- D. Serum blood levels of the antihypertensive medication within therapeutic range
Correct Answer: A
Rationale: A blood pressure within acceptable range best demonstrates compliance, but weight loss cannot be accomplished without adherence to medication, diet, and exercise. Absence of side effects does not indicate compliance with medication. Pill counts can be misleading because the client can alter pill counts prior to visit. Left ventricular hypertrophy is not an accurate measure of compliance because hypertrophy frequently does not decrease even with pharmacological management. Therapeutic blood levels measure the drug level at the time of the test. There is no indication of compliance several days before testing.
An elderly client has been noted to have increasing confusion late in the afternoon and before bedtime. The nurse is aware that the client is experiencing:
- A. Proprioception
- B. Agnosia
- C. Sundowning
- D. Confabulation
Correct Answer: C
Rationale: Sundowning is increased confusion or agitation in the late afternoon or evening common in elderly patients with dementia. Proprioception agnosia and confabulation do not describe this time-specific behavior.