Nokea
The nurse on the antenatal unit is planning care for four clients. The nurse should assess which of the following clients first?
- A. A 29-year-old G3 P2 carrying twins, being treated for preterm labor at 29 weeks' gestation. She is receiving magnesium sulfate @ 2 g\hour. She has had no contractions for the past 2 hours and both twins appear stable, according to the nurse's shift report
- B. A 19-year-old 18 weeks' IUP who is now 12 hours post motor vehicle accident with bright red vaginal bleeding
- C. A G8 P4 Ab3 at 38 weeks' gestation hospitalized frequently during this pregnancy for placenta previa. Two days ago she was admitted with severe bright red vaginal bleeding that has tapered off now
- D. A 9-week IUP hospitalized for hyperemesis gravidarum who has not vomited for the last 12 hours
Correct Answer: B
Rationale: The 19-year-old with bright red vaginal bleeding post-accident at 18 weeks is at high risk for miscarriage or placental abruption, requiring immediate assessment. The other clients are stable or less acute.
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A nurse is about to conduct a sexual history for a 16-year-old female who is accompanied by her mother. What is an appropriate question for the nurse to ask this client or her mother?
- A. What do you think about having your mother leave the room?'
- B. Mother, do you think your daughter is sexually active?'
- C. Mother, I am going to ask you to wait a few minutes in the waiting room now so I can complete the health history with your daughter.'
- D. The two of you seem like you share everything. I am going to ask questions about sexual history now.'
Correct Answer: C
Rationale: Requesting the mother to leave ensures privacy for the teen, promoting honest responses during the sexual history.
A newborn infant is diagnosed with imperforate anus. Which description of this disorder should the nurse provide to the parents?
- A. The presence of fecal incontinence
- B. Incomplete development of the anus
- C. The infrequent and difficult passage of dry stools
- D. Invagination of a section of the intestine into the distal bowel
Correct Answer: B
Rationale: Imperforate anus (anal atresia, anal agenesis) is the incomplete development or absence of the anus in its normal position in the perineum. Option 1 describes encopresis. Encopresis generally affects preschool and school-age children. Option 3 describes constipation. Constipation can affect any child at any time, although it peaks at age 2 to 3 years. Option 4 describes intussusception.
The nurse is caring for a 25-year-old client who will undergo bilateral orchiectomy for testicular cancer. Considering the nature of the illness, the nurse should make it a priority to explore which potential psychological concern with this client?
- A. Postoperative pain
- B. Postoperative swelling
- C. Loss of reproductive ability
- D. Length of recuperative period
Correct Answer: C
Rationale: Although the client will need factual information about the postoperative period and recuperation, the nurse should place priority on addressing loss of reproductive ability as a psychological concern. The radical effects of this surgery in the reproductive area make it likely that the client may have some difficulty in adjustment to this consequence of surgery.
The nurse is assessing a client with a diagnosis of polycythemia vera. Which clinical manifestation should the nurse expect to note in this client?
- A. Pallor
- B. Hypertension
- C. A low hematocrit level
- D. Pale mucous membranes
Correct Answer: B
Rationale: Polycythemia vera is a myeloproliferative disease that causes increased blood viscosity and blood volume. Manifestations of polycythemia vera include a ruddy complexion, dusky red mucosa, hypertension, dizziness, headache, and a sense of fullness in the head. Signs of heart failure may also be present. The hematocrit level is usually greater than 54% in men and 49% in women.
A client who has Ménière's disease is experiencing an acute attack of vertigo. Which of the following interventions should the nurse include in the plan of care?
- A. Darken the client's room and provide a quiet environment.
- B. Provide a low-sodium, bland diet.
- C. Administer an opioid to relieve headache.
- D. Encourage fluid intake to prevent dehydration.
Correct Answer: A
Rationale: A dark, quiet environment reduces stimuli that can exacerbate vertigo in Ménière's disease.