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Which of the following is a primary consideration in planning for her care?
- A. To prevent problems related to immobility
- B. To prevent infection
- C. Planning for client`s eventual inability communicate
- D. To prevent complications
Correct Answer: A
Rationale: When planning for a client's care, a primary consideration is to prevent problems related to immobility. Immobility can lead to a range of complications such as pressure ulcers, muscle weakness, joint contractures, and decreased circulation. To maintain the client's overall health and well-being, it is essential to address mobility issues and implement strategies to prevent complications associated with immobility. By prioritizing interventions that promote movement and prevent immobility-related problems, the client's quality of life can be improved and potential health risks mitigated.
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A pregnant woman presents with lower abdominal pain, fever, and vaginal discharge. On examination, cervical motion tenderness and bilateral adnexal tenderness are noted. Which of the following conditions is the most likely cause of these symptoms?
- A. Ectopic pregnancy
- B. Pelvic inflammatory disease
- C. Placenta previa
- D. Ovarian torsion
Correct Answer: B
Rationale: Pelvic inflammatory disease (PID) is the most likely cause of the symptoms described in the pregnant woman. PID is an infection of the female reproductive organs, typically caused by sexually transmitted bacteria like Chlamydia or Gonorrhea. The classic presentation includes lower abdominal pain, fever, vaginal discharge, cervical motion tenderness, and bilateral adnexal tenderness on examination. This condition can lead to serious complications if not promptly treated, including infertility, ectopic pregnancy, and chronic pelvic pain. Therefore, it is crucial to diagnose and manage PID promptly, especially in pregnant women, to prevent adverse outcomes.
A postpartum client reports severe headache, visual disturbances, and epigastric pain. Which nursing action is most appropriate?
- A. Encouraging the client to rest in a dark, quiet room
- B. Providing acetaminophen for headache relief
- C. Assessing blood pressure and other vital signs
- D. Offering a massage to relieve muscle tension
Correct Answer: C
Rationale: The most appropriate nursing action in this situation is to assess the client's blood pressure and other vital signs. The client's symptoms of severe headache, visual disturbances, and epigastric pain could be indicative of preeclampsia or eclampsia, which are serious conditions that require immediate medical attention. Checking the blood pressure and other vital signs will help determine if the client's symptoms are related to abnormal blood pressure levels, which is critical in identifying and managing hypertensive disorders in postpartum clients. Once the assessment is completed, appropriate medical interventions can be initiated promptly if necessary.
A patient presents with multiple, dome-shaped, translucent papules with central umbilication on the face and trunk. The lesions are asymptomatic and have been gradually increasing in number. Which of the following conditions is most likely responsible for this presentation?
- A. Basal cell carcinoma
- B. Molluscum contagiosum
- C. Sebaceous hyperplasia
- D. Keratoacanthoma
Correct Answer: B
Rationale: Molluscum contagiosum is a viral skin infection caused by the poxvirus. It typically presents as multiple dome-shaped, translucent papules with central umbilication on the face and trunk. The lesions are usually asymptomatic but can be itchy. Molluscum contagiosum is a common infection in children but can also occur in adults, especially those who are immunocompromised. The lesions can gradually increase in number over time. Basal cell carcinoma, sebaceous hyperplasia, and keratoacanthoma do not typically present with the characteristic features of molluscum contagiosum.
One evening, Sonny complained of dyspnea despite continuous oxygen therapy. What should be the FIRST action of the nurse?
- A. Reassess the client.
- B. Give PRN medication.
- C. Assess the patency of the tubing.
- D. Refer client to the physician.
Correct Answer: A
Rationale: The FIRST action of the nurse should be to reassess the client experiencing dyspnea despite continuous oxygen therapy. Reassessment would involve checking the client's respiratory status, oxygen saturation levels, vital signs, and overall condition to gather more information about the situation. This will help the nurse identify any potential causes of the dyspnea and determine the appropriate next steps for intervention. Assessing the client before proceeding with any other actions is crucial in providing safe and effective care.
You cannot open Claudia's eyes due to dried crust. Which of the following actions would you do?
- A. Apply the eye drops the next day
- B. Apply eye ointment to soften the crust
- C. Instill eye drops
- D. Place a warm wet wash cloth over her eyes for at least three minutes
Correct Answer: D
Rationale: The best course of action in this scenario is to place a warm wet washcloth over Claudia's eyes for at least three minutes. This will help soften and loosen the dried crust, making it easier to gently clean her eyes and open them. Applying eye drops or ointment may not be effective if the crust is blocking her eyes completely. By using a warm wet washcloth, you can improve the ability to clean her eyes effectively and without causing discomfort.