Nokea
Which statement by the woman indicates that she does not understand the teaching provided about postmastectomy breast reconstruction home care?
- A. I will avoid trauma to my breasts.
- B. I will need to wear a tight bra immediately.
- C. I have to empty my drains every 8 hours.
- D. I must notify the doctor if I notice any skin ulceration or changes in breast color such as redness.
Correct Answer: B
Rationale: The correct answer is B because wearing a tight bra immediately after postmastectomy breast reconstruction is not recommended as it can restrict blood flow and cause discomfort. A is correct because avoiding trauma is important. C is correct because draining is necessary. D is correct because skin changes should be reported.
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A client has severe preeclampsia. The nurse would expect the primary health care practitioner to order tests to assess the fetus for which of the following?
- A. Severe anemia.'
- B. Hypoprothrombinemia.'
- C. Craniosynostosis.'
- D. Intrauterine growth restriction.'
Correct Answer: D
Rationale: The correct answer is D: Intrauterine growth restriction (IUGR). In severe preeclampsia, there is a risk of placental insufficiency leading to reduced blood flow to the fetus, resulting in IUGR. The primary concern is monitoring the fetus's growth and well-being.
A: Severe anemia is not typically a direct result of severe preeclampsia and is not a primary concern in this situation.
B: Hypoprothrombinemia refers to a deficiency in blood clotting factors and is not directly related to fetal well-being in the context of severe preeclampsia.
C: Craniosynostosis is a condition where the bones in an infant's skull fuse too early, which is a congenital issue and not typically related to preeclampsia.
In summary, the primary concern in severe preeclampsia is assessing fetal growth and well-being due to placental insufficiency, making IUG
The primary fetal risk when the mother has any type of anemia is for:
- A. Neonatal anemia
- B. Elevated bilirubin level
- C. Limited infection defenses
- D. Reduced oxygen delivery
Correct Answer: D
Rationale: The correct answer is D: Reduced oxygen delivery. Anemia in the mother can lead to decreased oxygen-carrying capacity in the blood, resulting in reduced oxygen delivery to the fetus. This can lead to fetal hypoxia, affecting the baby's growth and development. Neonatal anemia (choice A) is a consequence of the mother's anemia affecting the baby after birth, not the primary risk. Elevated bilirubin level (choice B) is not directly related to maternal anemia but may occur in conditions like Rh incompatibility. Limited infection defenses (choice C) is not the primary fetal risk associated with maternal anemia, although it can be a concern in severe cases due to decreased immune response.
A male client is being seen by a physician at a community clinic regarding a painless ulcer on his penis. The provider will be communicating his diagnosis of syphilis and prescribing treatment. In the primary stage of syphilis, what is the time between infection and development of symptoms?
- A. 7 days
- B. 10 days
- C. 21 days
- D. 35 days
Correct Answer: C
Rationale: The correct answer is C: 21 days. The primary stage of syphilis typically occurs around 21 days after infection when a painless ulcer, known as a chancre, appears at the site of infection. This is due to the multiplication of the bacterium Treponema pallidum. Choice A (7 days) is too short for the development of symptoms. Choice B (10 days) is also too short. Choice D (35 days) is too long for the primary stage of syphilis.
A nurse is developing a plan of care for a 16-year-old female client experiencing her first outbreak of genital herpes. The client states that she contracted the disease by holding hands with someone who has syphilis. Which nursing diagnosis should the nurse identify as the priority?
- A. Acute pain related to the development of genital lesions
- B. Lack of knowledge about the disease and its transmission
- C. Ineffective coping related to the increased stress associated with the infection
- D. Noncompliance with treatment related to age of the client
Correct Answer: B
Rationale: The correct answer is B: Lack of knowledge about the disease and its transmission. This is the priority nursing diagnosis because the client's statement about contracting herpes by holding hands with someone who has syphilis indicates a lack of understanding about how genital herpes is transmitted. The nurse should prioritize educating the client about the disease, its transmission, and prevention to empower the client to make informed decisions about her health.
Choices A, C, and D are incorrect:
A: Acute pain may be a symptom of genital herpes, but addressing the lack of knowledge about the disease and its transmission is more essential for the client's well-being.
C: While coping with the stress of the infection is important, addressing the lack of knowledge should take precedence to prevent further transmission and help the client manage the condition effectively.
D: Noncompliance with treatment may be a concern, but addressing the client's lack of knowledge about the disease and its transmission is crucial in promoting understanding and adherence to treatment.
A client with a history of herpes simplex virus (HSV-2) infection asks the nurse about future sexual activity. Which response is most appropriate?
- A. If the infection has healed, you do not have to use a condom.
- B. Refrain from all sexual activity.
- C. Use a condom during sexual activity only if the infection becomes active again.
- D. Inform all potential sexual partners about the infection, even if it is inactive.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Informing all potential sexual partners about the HSV-2 infection, even if inactive, is crucial to ensure transparency and promote informed decision-making.
2. HSV-2 can be transmitted even when symptoms are not present, so partners need to be aware of the risk.
3. This approach demonstrates respect for the partners' autonomy and enables them to make choices regarding their own health.
Summary:
A: Incorrect. Using a condom is important even when the infection is inactive to prevent transmission.
B: Incorrect. Refraining from all sexual activity may not be necessary if proper precautions are taken.
C: Incorrect. Using a condom only when the infection is active does not fully address the risk of transmission during asymptomatic periods.