Nokea
The nurse is collecting data on a client who has arrived at the clinic for pregnancy confirmation and prenatal evaluation. Which of the following findings indicate diagnostic evidence (positive signs) of pregnancy? Select all that apply.
- A. Cervical softening upon examination
- B. Fetal heart tones detected by Doppler device
- C. Positive serum human chorionic gonadotropin test
- D. Report of fetal movement felt by client
- E. Visualization of fetus via ultrasound
Correct Answer: B,E
Rationale: Positive signs of pregnancy are objective, provider-verified findings: fetal heart tones by Doppler and ultrasound visualization . Cervical softening and hCG test are probable signs, and fetal movement is subjective.
You may also like to solve these questions
A client comes to the emergency department with diplopia and recent onset of nausea. Which statement by the client would indicate to the nurse that this is an emergency?
- A. I am very tired, and it's hard for me to keep my eyes open.'
- B. I don't feel good, and I want to be seen.'
- C. I have not taken my blood pressure medicine in over a week.'
- D. I have the worst headache I've ever had in my life.'
Correct Answer: D
Rationale: A severe headache described as the worst ever with diplopia and nausea suggests a possible subarachnoid hemorrhage or aneurysm, requiring emergency evaluation. Other statements (A, B, C) are less specific.
A client is scheduled for a myelogram. Which of the following medications orders should be questioned?
- A. Ampicillin (Pencipen) $250 \mathrm{mg} \mathrm{PO} \mathrm{q} 6$ hours
- B. Motrin (Ibuprofen) $400 \mathrm{mg} \mathrm{PO} \mathrm{q} 4$ hours PRN for headache
- C. Secobarbital (Seconal) $50 \mathrm{mg}$ HS PRN for sleep
- D. Propoxyphene (Darvon) $65 \mathrm{mg} \mathrm{PO} \mathrm{q} 4$ hours for pain
Correct Answer: B
Rationale: Ibuprofen (Motrin) has anticoagulant properties, increasing bleeding risk during a myelogram, a procedure involving spinal puncture. Other medications are safer.
The nurse manager hears a provider loudly criticize one of the staff nurses within the hearing range of others. The nurse manager's next action should be to
- A. Walk up to the provider and quietly state: 'Stop this unacceptable behavior.'
- B. Allow the staff nurse to handle this situation without interference
- C. Notify the chief of the other administrative persons of a breech of professional conduct
- D. Request an immediate private meeting with the provider and staff nurse
Correct Answer: D
Rationale: Assertive communication respects the needs of all parties to express themselves, but not at the expense of others. The nurse manager needs to protect clients and staff from this display and assist the nurse employee.
A client with Cushing's syndrome should be instructed to:
- A. Avoid alcoholic beverages
- B. Limit the sodium in her diet
- C. Increase servings of dark green vegetables
- D. Limit the amount of protein in her diet
Correct Answer: B
Rationale: A client with Cushing's syndrome has adrenocortical hypersecretion, so she retains sodium and water. The client may drink alcohol in moderation, so answer A is incorrect, and there is no need to eat more green vegetables or limit protein, so answers C and D are incorrect.
The nurse in the outpatient clinic is caring for a client with heart failure who reports increased ankle swelling and a 3-lb (1.4-kg) weight gain over the past 2 days. The nurse reviews the client's current medications and anticipates the need for an increase in the dosage of which of the following medications?
- A. Bumetanide
- B. Candesartan
- C. Carvedilol
- D. Isosorbide
Correct Answer: A
Rationale: A 3-lb weight gain and ankle swelling in heart failure indicate fluid retention, requiring an increased dose of a diuretic like bumetanide . Candesartan , carvedilol , and isosorbide manage other aspects but do not directly address acute fluid overload.