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Questions 158

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Question 1 of 5

A client with a history of a burn injury is being discharged. The nurse should teach the client to:

Correct Answer: A

Rationale: Avoiding sun exposure protects healing burn skin from UV damage and hyperpigmentation. Harsh soaps, petroleum lotions, and tight clothing can irritate or delay healing.

Question 2 of 5

A client with a history of endometriosis is admitted with complaints of pelvic pain. The nurse should expect the client to have:

Correct Answer: A

Rationale: Endometriosis causes pelvic pain and dysmenorrhea due to ectopic endometrial tissue responding to hormonal changes.

Question 3 of 5

A 27-year-old primigravida stated that she got up from the chair to fix dinner and bright red blood was running down her legs. She denies any pain previously or currently. The client is very concerned about whether her baby will be all right. Her vital signs include P 120 bpm, respirations 26 breaths/min, BP 104/58 mm Hg, temperature 98.2_F, and fetal heart rate 146 bpm. Laboratory findings revealed hemoglobin 9.0 g/dL, hematocrit 26%, and coagulation studies within normal range. On admission, the peripad she wore was noted to be half saturated with bright red blood. A medical diagnosis of placenta previa is made. The priority nursing diagnosis for this client would be:

Correct Answer: A

Rationale: Based on the client's history, presence of bright red vaginal bleeding, and hemoglobin value on admission, the priority nursing diagnosis would be decreased cardiac output related to excessive bleeding. This nursing diagnosis is a potential problem that does not exist at the present time, and therefore is not the priority problem. The client's expressed anxiety is for her child. The fetus will remain physiologically safe if the decreased cardiac output is resolved. Initial spontaneous bleeding with placenta previa is rarely life threatening to the mother or the fetus. Delivery of the fetus will be postponed until fetal maturity is achieved and survival is likely.

Question 4 of 5

The client is prescribed ciprofloxacin (Cipro) for a urinary tract infection. Which instruction should the nurse include?

Correct Answer: B

Rationale: Ciprofloxacin can cause photosensitivity, so avoiding sun exposure prevents skin reactions. Dairy products reduce absorption, and the full course must be completed, regardless of symptoms.

Question 5 of 5

The initial focus when providing nursing care for a child with rheumatic fever during the acute phase of the illness should be to:

Correct Answer: B

Rationale: This goal is helpful, but rest is essential during the acute phase. Rest is essential for healing to occur and for pain to be relieved. This goal is important, but rest is essential. This goal should be part of the plan of care, but it is not the priority during the acute phase.

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