When obtaining a health history on a menopausal woman, which information is a contraindication for hormone replacement therapy?

Correct Answer: D

Rationale: The correct answer is D - unexplained vaginal bleeding. This is a contraindication for hormone replacement therapy as it could indicate a serious underlying condition such as endometrial cancer. Hormone replacement therapy can increase the risk of endometrial cancer, so it should not be used in the presence of unexplained vaginal bleeding. A, B, and C are incorrect: A: Family history of stroke is not a direct contraindication for hormone replacement therapy. It may influence the decision-making process, but it is not a definitive contraindication. B: Ovaries removed before age 45 may actually be an indication for hormone replacement therapy to manage symptoms of menopause. C: Frequent hot flashes and/or night sweats are common symptoms of menopause and are not contraindications for hormone replacement therapy.

Correct Answer: A

Rationale: The correct first step is to administer pain relief (Choice A) because addressing the client's pain is a top priority to ensure their comfort and well-being. Pain management is crucial post-surgery to prevent complications and aid in recovery. Monitoring vital signs (Choice B) is important but should follow pain relief to ensure the client's stability. Assessing the wound (Choice C) is necessary but not the immediate priority when the client is in acute pain. Applying a warm compress (Choice D) may provide temporary relief but does not address the underlying cause of the pain. Therefore, administering pain relief is the most appropriate initial action to alleviate the client's discomfort and start the healing process effectively.

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. This is the first step in the care of a client with acute chest pain because nitroglycerin helps dilate blood vessels, improving blood flow to the heart. This can relieve chest pain associated with angina or heart attack. Administering aspirin (choice B) is important as well, but nitroglycerin is prioritized due to its immediate effect in reducing chest pain. Administering opioids (choice C) and morphine (choice D) are not recommended as first-line treatments for acute chest pain, as they can mask symptoms and delay the diagnosis of potentially life-threatening conditions.

Correct Answer: A

Rationale: The correct answer is A: Administer antiepileptics. Administering antiepileptics is the priority nursing action for a client with a history of seizures to prevent seizure recurrence. Antiepileptics help control and manage seizure activity effectively. Monitoring vital signs (B) and placing the client in a lateral position (C) are important actions during a seizure but are not the priority over administering antiepileptics. Providing seizure precautions (D) is also important but does not directly address the immediate need of administering antiepileptics to prevent a seizure.

Correct Answer: A

Rationale: The correct answer is A: Administer nitroglycerin. Nitroglycerin is the priority action for a client with a suspected myocardial infarction as it helps dilate coronary arteries, improving blood flow to the heart muscle. This helps reduce chest pain and minimize myocardial damage. Administering fluids (B) may be necessary but not the priority. Placing the client in a sitting position (C) could worsen symptoms. Administering aspirin (D) is important but not as immediate as nitroglycerin for acute pain relief.

Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. After a craniotomy, the client may experience decreased oxygen levels due to the surgical procedure, anesthesia, or potential complications. Administering oxygen helps ensure adequate oxygenation to the brain and tissues. Placing the client in a supine or Trendelenburg position can increase intracranial pressure, which is contraindicated post-craniotomy. Monitoring for arrhythmias is important, but ensuring oxygenation takes precedence as hypoxia can have immediate detrimental effects on brain function.

Correct Answer: C

Rationale: The correct answer is C: Objective. Objective data in a physical assessment refers to measurable and observable information obtained through physical examination, laboratory tests, and diagnostic procedures. This type of data is crucial as it is based on facts and can be quantified. Subjective data (A) is based on the patient's feelings and experiences, while patient-centered (B) refers to care that is tailored to the individual's preferences. Diagnostic (D) data refers to information obtained through tests to determine a specific condition, which is different from the general data collected during a physical assessment.

Correct Answer: A

Rationale: The correct answer is A: Place the client on their side. This is the first nursing action for a client who develops a seizure to prevent aspiration and maintain an open airway. Placing the client on their side helps to keep their airway clear and prevents them from choking on saliva or vomit. Choice B, loosening clothing, is important but not the first priority. Choice C, placing the client in a Trendelenburg position, is not recommended as it may increase intracranial pressure. Choice D, placing the client in a sitting position, can increase the risk of injury during a seizure.

Correct Answer: D

Rationale: The correct answer is D - unexplained vaginal bleeding. This is a contraindication for hormone replacement therapy as it could indicate a serious underlying condition such as endometrial cancer. Hormone replacement therapy can increase the risk of endometrial cancer, so it should not be used in the presence of unexplained vaginal bleeding. A, B, and C are incorrect: A: Family history of stroke is not a direct contraindication for hormone replacement therapy. It may influence the decision-making process, but it is not a definitive contraindication. B: Ovaries removed before age 45 may actually be an indication for hormone replacement therapy to manage symptoms of menopause. C: Frequent hot flashes and/or night sweats are common symptoms of menopause and are not contraindications for hormone replacement therapy.