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What response should the nurse make to a client complaining of headaches and leg pain while taking birth control pills?
- A. Continue the pill, but take one aspirin tablet with it each day from now on.
- B. Stop taking the pill, and start using a condom for contraception.
- C. Come to the clinic this afternoon so that we can see what is going on.
- D. Those are common side effects that should disappear in a month or so.
Correct Answer: C
Rationale: Headaches and leg pain may indicate a clotting disorder requiring immediate evaluation.
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What client statement would most influence the nurse's teaching regarding contraceptive choices?
- A. I have 2 children.
- B. My partner and I have sex twice a week.
- C. I am 25 years old.
- D. I feel funny touching my private parts.
Correct Answer: D
Rationale: Comfort with intimate touch influences method selection.
To prevent the kidnapping of newborns from the hospital, the nurse should:
- A. instruct the mother not to give her infant to anyone except the one nurse assigned to her that day.
- B. question anyone who is seen walking in the hallways carrying an infant.
- C. allow no visitors in the maternity area except those who have identification bracelets.
- D. restrict the amount of time infants are out of the nursery.
Correct Answer: B
Rationale: Questioning individuals carrying infants ensures security.
The nurse is caring for a pregnant person who is living in an underserved area of town with a history of childhood abuse, opioid use disorder, and asthma. What can the nurse do to decrease the risk of maternal mortality?
- A. Connect the patient to a counselor.
- B. Educate the patient on the risk factors for maternal mortality.
- C. Give prn albuterol for asthma.
- D. Discuss how they need to move out of the poor area of town.
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Connecting the patient to a counselor addresses the underlying issues of childhood abuse and opioid use disorder, which can contribute to maternal mortality.
2. Counseling can provide support, coping strategies, and mental health assistance crucial for at-risk individuals.
3. Addressing mental health concerns can improve overall well-being and increase the likelihood of seeking appropriate prenatal care.
Summary:
B: While education on risk factors is important, it may not directly address the patient's specific mental health and trauma history.
C: Giving albuterol for asthma is essential but does not directly address the underlying factors contributing to maternal mortality.
D: Moving out of the poor area is not a feasible or realistic solution and does not address the patient's mental health and substance abuse issues.
What signs/symptoms should the nurse suspect in a bulimic client?
- A. Significant weight loss and hyperkalemia.
- B. Respiratory acidosis and hypoxemia.
- C. Dental caries and scars on her knuckles.
- D. Hyperglycemia and large urine output.
Correct Answer: C
Rationale: Dental erosion and scars from induced vomiting are classic signs of bulimia.
The nursing assessment of an infant reveals expiratory grunting, substernal retractions, and a temperature of 99° F (32.2° C). What is the first nursing action?
- A. Place the infant in Trendelenburg position.
- B. Begin administration of 40% humidified oxygen via hood.
- C. Increase the temperature of the environment
- D. Perform a complete assessment for congenital anomalies.
Correct Answer: B
Rationale: Oxygen administration addresses potential respiratory distress.