EAQ #3 Health and Illness

Which client statement leads the nurse to conclude that the client has been experiencing menorrhagia? 'It hurts when I have intercourse.' 'I have a foul-smelling vaginal discharge.' 'I have bleeding between my menstrual periods.' 'I have severe bleeding during my menstrual periods.'

Menorrhagia is severe bleeding during a menstrual period. Painful intercourse is the definition of dyspareunia. Foul-smelling vaginal discharge is a sign of a vaginal infection. Metrorrhagia is uterine bleeding that occurs at any time other than during the menstrual period.

A client informs the nurse that her home pregnancy test was positive and that her last menstrual period began on June 18. According to Naegele's rule, which is the estimated date of birth (EDB)? March 8 March 11 March 1 March 25

March 25 is the EDB. Using Naegele's rule, take the first day of the last menstrual period (June 18), subtract 3 months, and then add 7 days. March 8, March 11, and March 1 are incorrect calculations according to Naegele's rule.

The nurse teaches a new mother how to position her newborn during feedings. Which is the best way to evaluate if the teaching is effective? Develop a basic teaching plan. Ask the mother if she understands. Observe the mother feeding the infant. Determine the mother's readiness to learn.

A return demonstration can confirm that the desired learning from earlier teaching has taken place. Developing a teaching plan is part of the planning of the nursing process, not evaluating. A return demonstration is a more effective way of evaluating than asking the mother if she understands. Determining the mother's readiness to learn is part of planning in the nursing process, not evaluating.

Which sign in the newborn infant would reflect an Apgar score of 1 in the category of respiration? Good cry Grimace Absent respiration Slow, weak cry

A slow, weak cry would be scored as a 1 in the category of respiration in the Apgar scoring system. A good cry would receive a score of 2. A grimace is a sign that is evaluated in the category of reflex irritability, not respiration. Absent respiration would receive a score of 0 in the respiration category of the Apgar score system.

Which medication is safe to take during pregnancy? Select all that apply. One, some, or all responses may be correct. Metronidazole Aspirin Codeine Acetaminophen Diphenhydramine HCl

Acetaminophen may be taken safely during all stages of pregnancy. Metronidazole should not be used during the first trimester of pregnancy. Salicylates like aspirin, codeine, and antihistamines like diphenhydramine HCl should be avoided throughout pregnancy.

Which information about nausea and vomiting in the first trimester would the nurse provide to the pregnant client? It is always present during early pregnancy. It will disappear when lightening occurs. It is a common response to an unwanted pregnancy. It may be related to an increased human chorionic gonadotropin level.

An increased level of human chorionic gonadotropin, or hCG, may cause nausea and vomiting, but the exact reason is unknown. Some pregnant women do not experience nausea and vomiting. Lightening occurs at the end of the third trimester; nausea and vomiting usually cease at the end of the first trimester. Nausea and vomiting are unrelated to whether a pregnancy is desired or unwanted.

Which client care activity may the nurse safely delegate to an unlicensed health care worker? Assessing a client's mastectomy incision for signs of inflammation Assisting a client who is recovering from an abdominal hysterectomy to the bathroom Providing information about side effects to a client receiving chemotherapy for breast cancer Evaluating the effectiveness of an antiemetic that was administered to a client to relieve nausea

An unlicensed health care worker is taught how to safely ambulate clients; this activity does not require extensive nursing knowledge or expert clinical judgment. Assessment, teaching, and evaluation of client responses to care all require clinical judgment and a license to practice nursing.

Morning sickness generally disappears by the end of which month? Fifth month Third month Fourth month Second month

Because of a decrease in chorionic gonadotropin, morning sickness seldom persists beyond the first trimester. Morning sickness usually ends at the end of the third month, not the second month, when the chorionic gonadotropin level falls. It is still present in the second month because of the high level of chorionic gonadotropin but has usually diminished by the fifth month.

Which finding in a newborn is a behavioral response to pain? Select all that apply. One, some, or all responses may be correct. Crying Tachypnea Diaphoresis Tachycardia Hypertension

Crying is a behavioral response. Tachypnea, diaphoresis, tachycardia, and hypertension are physiological responses to pain.

Which statement is an accurate description of dysmenorrhea? Pain with menses Endometrial hyperplasia Bleeding between menses Heavy bleeding with menses

Dysmenorrhea is defined as pain with menses. Endometrial hyperplasia results from anovulation and persistent estrogen stimulation. Bleeding between menses is metrorrhagia. Heavy bleeding with menses is menorrhagia.

Which conditions are risk factors that may place infants at a higher risk for developing jaundice? Select all that apply. One, some, or all responses may be correct. Infection African-American race Prematurity Breast-feeding Formula feeding Maternal diabetes

Infants are at a higher risk of jaundice if they have an infection, are born prematurely, are exclusively breast-fed, or if their mothers have diabetes. Newborns of East Asian race have a higher risk factor than African-Americans to develop jaundice. Infants who are fed formula do not develop jaundice as often as breast-fed babies do.

The nurse plans to delegate some of the tasks for the discharge of a postpartum client to an unlicensed health care worker. Which activity must be performed by the nurse? Taking the neonate's picture Calling to arrange the client's postpartum appointment Comparing the identification bands of mother and infant Preparing the discharge packets and distributing them to the parents

It is the nurse's professional responsibility to compare the mother's and infant's identification bands one last time before discharge. This ensures that the correct infant is discharged with the mother. Taking the neonate's picture, arranging the client's postpartum appointment, and preparing the discharge packets and distributing them to parents are all within the role of the nursing assistant and may be delegated safely.

Which information would the nurse include in the discharge teaching of a postpartum client? The prenatal Kegel tightening exercises should be continued. A bowel movement may not occur for up to a week after the birth. The episiotomy sutures will be removed at the first postpartum visit. A postpartum checkup should be scheduled as soon as menses returns.

Kegel exercises may be resumed immediately and should be done for the rest of the client's life because they help strengthen muscles needed for urinary continence and may enhance sexual intercourse. Episiotomy sutures do not have to be removed. Bowel movements should spontaneously return in 2 to 3 days after the client gives birth; a delay of bowel movements promotes constipation, perineal discomfort, and trauma. The usual postpartum examination is 6 weeks after birth; the menses may return earlier or later than this and should not be a factor when the client is scheduling a postpartum examination.

A client at the fertility clinic is being treated for hypertension and obesity and has lost 8 lb (3.6 kg) in the past month, and her blood pressure has decreased to 154/98 mmHg. She states she is using self-control strategies to achieve these improvements. Which would be a therapeutic response by the nurse? Explaining to the client that her current program needs revision to improve results Acknowledging the client's achievement while encouraging continuation of her current program Emphasizing to the client the importance of exercise in addition to reduced sodium and caloric intake Recommending that the client ask her health care practitioner about a prescription for an antihypertensive or a diuretic

Acknowledging the client's achievement while encouraging continuation of her current program recognizes achievement and reinforces the client's behavior. Explaining to the client that her current program needs revision to improve results focuses on the negative rather than the positive; small gains should be reinforced. Emphasizing to the client the importance of exercising in addition to reducing sodium and caloric intake implies that the client is not doing enough; the focus should be on the positive, and the gains should be reinforced. The client may need an antihypertensive medication because her blood pressure is still elevated, and that would require discussion and consultation with her health care provider, but focusing on that rather than on her successes would not be a therapeutic response.

Which factor distinguishes true labor from false labor? Cervical dilation is evident. Contractions stop when the client walks around. The client's contractions progress only when she is in a side-lying position. Contractions occur immediately after the membranes rupture.

Progressive cervical dilation is the most accurate indication of true labor. With true labor, contractions will increase with activity. Contractions of true labor persist in any position. Contractions may not begin until 24 to 48 hours after the membranes rupture.

Which is the most important parameter for the nurse to monitor during the first 24 hours after the birth of an infant at 36 weeks' gestation? Duration of cry Respiratory distress Frequency of voiding Poor nutritional intake

Respiratory distress is a common response in the preterm infant, related to possible immaturity of the newborn's respiratory tract, manifesting as a small lumen, weakness of the respiratory musculature, paucity of functional alveoli, or insufficient calcification of the bony thorax. The tone of the cry is more pertinent than its duration. Frequency of voiding is not the priority because the newborn's intake is limited during the first 24 hours. If the infant is in respiratory distress, the nutritional intake is not important.

Which response would the nurse give to a postpartum client who asks if she can drink a small glass of wine before breast-feeding the first time to help her relax? 'I think drinking 1 glass of wine won't be a problem. Go ahead.' 'You seem a little tense. Tell me how you feel about breast-feeding.' 'You seem to find it relaxing, but you should try to find another way to relax.' 'I think drinking 1 glass of wine is alright, but you had better check with your health care provider first.'

Stating that the client seems tense and initiating a discussion honors the client's feelings and encourages expression of them; there is no reference to alcohol consumption and its relaxing effects. Alcohol ingestion should not be encouraged, because it enters the breast milk. Stating that the client needs to find another way to relax reflects the client's statement but not her underlying feelings. Suggesting that she find another way to relax may make the client defensive and shut off communication. Although alcohol ingestion should not be encouraged because it enters breast milk, the primary health care provider need not be involved because health education is within the role of the nurse.

A 16-year-old high school student comes to a community health center because of the fear of having contracted herpes. The teenager is upset and shares this information with the community health center nurse. Which response would the nurse provide? 'Let me get a brief health history now.' 'Try not to worry until you know whether you have herpes.' 'You sound worried. Let me make arrangements to have you examined.' 'Herpes has received too much attention in the media; let's be realistic.'

Telling the client that she sounds worried and offering to arrange an examination immediately identifies the client's fear as real and offers a service to meet the need for information about the client's physical status. Obtaining the health history ignores the client's concern and focuses on the nurse's need to complete the task of obtaining a history. Telling the client not to worry minimizes the client's concern about having a sexually transmitted infection. Saying that herpes has received too much attention in the media minimizes the client's concern and implies that the client is being unrealistic.

At her first prenatal visit, the client informs the nurse that her last menstrual period started on June 10. Which is her expected date of birth (EDB), according to Naegele's rule? March 3 March 10 March 17 March 24

The EDB is March 17 of the following year. Using Naegele's rule, subtract 3 months from the first day of the last menstrual period and add 7 days. March 3 and March 10 are too early. March 24 is too late.

A client who recently was told by her primary health care provider that she has extensive terminal metastatic carcinoma of the breast tells the nurse that she believes an error has been made. She states that she does not have breast cancer, and she is not going to die. Which stage of death and dying is the client experiencing? Anger Denial Bargaining Acceptance

The client has difficulty accepting the inevitability of death and is attempting to deny the reality of it. In the anger stage the client strikes out with 'Why me?' and 'How could God do this?' types of statements. The client is angry at life and still angrier to be removed from it by death. In the bargaining stage the client tries to bargain for more time. The reality of death is no longer denied, but the client attempts to manipulate and extend the remaining time. In the acceptance stage the client accepts the inevitability of death and peacefully awaits it.