A postpartum client who delivered vaginally reports difficulty emptying the bladder completely and experiences urinary frequency. What nursing intervention should be prioritized to address this issue?

Correct Answer: A

Rationale: The priority nursing intervention in this situation is to first assess the client for signs of urinary retention or bladder distention. Difficulty in emptying the bladder completely and experiencing urinary frequency can be indications of urinary retention, which can lead to bladder distention and possible complications such as urinary tract infection. By assessing the client, the nurse can determine the cause of the issue and implement appropriate interventions. It is crucial to address potential complications promptly to promote the client's health and well-being postpartum. Once the assessment is completed, further interventions such as recommending appropriate measures, like warm compresses or pelvic floor exercises, can be considered based on the assessment findings.

Correct Answer: A

Rationale: Patients with nephrotic syndrome who are ordered corticosteroids need to avoid close contact with individuals who have infections or illnesses, as corticosteroids can suppress the immune system and increase the risk of infections. Therefore, it is important to prioritize the safety and well-being of the patient by minimizing potential sources of infection. While diabetes itself does not pose a direct risk to the patient with nephrotic syndrome, individuals with diabetes may have a compromised immune system or be at higher risk for infections, which could potentially be transmitted to the patient. This precaution helps to minimize the risk of infection and maximize the effectiveness of the treatment for nephrotic syndrome.

Correct Answer: A

Rationale: This statement indicates a need for further instructions because drinking milk between meals may worsen heartburn for some individuals. Milk can temporarily neutralize stomach acid, but it can also stimulate acid production in the stomach leading to increased heartburn symptoms. Therefore, Nurse Harper should provide more guidance on appropriate dietary choices for managing heartburn, such as avoiding trigger foods like fatty or spicy foods, eating small, frequent meals, and not lying down immediately after eating.

Correct Answer: B

Rationale: The best approach for the nurse in this situation is to listen actively to the patient's religious beliefs, respect their autonomy, and explore alternative treatment options. It is important for the nurse to understand and acknowledge the patient's perspective, even if it conflicts with the recommended treatment plan. By showing respect for the patient's beliefs and involving them in the decision-making process, the nurse can work collaboratively with the patient to find a solution that aligns with their religious beliefs while also addressing their medical needs. This approach promotes patient-centered care and helps build a trusting and therapeutic relationship between the nurse and the patient.

Correct Answer: A

Rationale: Acute pyelonephritis is the most likely condition based on the patient presentation and urinalysis findings described. Acute pyelonephritis is an infection of the renal parenchyma and pelvis, typically caused by ascending bacteria from the lower urinary tract. The classic symptoms include fever, chills, flank pain, and costovertebral angle tenderness (tenderness over the kidneys). The presence of pyuria (pus in the urine) and bacteriuria (bacteria in the urine) on urinalysis further supports the diagnosis of acute pyelonephritis. It is crucial to diagnose and treat acute pyelonephritis promptly to prevent complications and recurrent infections.

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.

Correct Answer: B

Rationale: The gallbladder is the structure responsible for storing and concentrating bile produced by the liver until it is needed for digestion. Bile is a digestive fluid that helps in the breakdown of fats during the digestive process. When food containing fats enters the small intestine, the gallbladder contracts and releases bile into the small intestine to aid in the digestion and absorption of fats. The gallbladder acts as a reservoir for bile, storing it until it is needed for digestion.

Correct Answer: C

Rationale: When encountering patients who are stressed due to their health condition, the best way for a nurse to communicate is through empathizing. Empathy involves understanding and sharing the feelings of another person, which can help the nurse connect with the patient on an emotional level. Empathizing allows the nurse to show genuine care and concern for the patient's well-being, fostering a trusting and supportive relationship. This approach can help alleviate the patient's stress and make them feel understood and supported during a difficult time. Sympathizing and sharing may come across as insincere or minimize the patient's experiences, while listening is important but combining it with empathy enhances the overall communication experience.

Correct Answer: C

Rationale: Uterine rupture is a severe obstetric complication that requires prompt and decisive management to prevent adverse outcomes for both the mother and the baby. In cases of uterine rupture leading to fetal distress and maternal hemorrhage, performing an emergency cesarean section is crucial. This intervention allows for rapid delivery of the baby, relieving the distress on the fetus and enabling immediate access to manage the maternal hemorrhage. By performing a timely cesarean section, healthcare providers can expedite the delivery process and effectively address both the fetal and maternal complications associated with uterine rupture. This intervention is essential in saving lives and reducing the risk of further complications in such a critical obstetric emergency.