Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
When caring for a postpartum client the nurse notes that the client's perineal pad is saturated with bright red blood. What is the priority question to ask the client?
A. Have you passed any clots?
Have you passed any clots? This is important to assess for potential postpartum hemorrhage, which can be indicated by passage of large clots.
B. Do you have to go to the bathroom?
Do you have to go to the bathroom? This does not directly address the issue of excessive bleeding.
C. When was the last time you changed your pad?
When was the last time you changed your pad? This provides information about the amount of bleeding but does not address clotting.
D. Are you having any cramping?
Are you having any cramping? Cramping is common postpartum but does not directly assess for hemorrhage.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Nur 209 Reproductive Health Proctored Exam. Take the full exam now
Full Explanation
A. Have you passed any clots? This is important to assess for potential postpartum hemorrhage, which can be indicated by passage of large clots.
B. Do you have to go to the bathroom? This does not directly address the issue of excessive bleeding.
C. When was the last time you changed your pad? This provides information about the amount of bleeding but does not address clotting.
D. Are you having any cramping? Cramping is common postpartum but does not directly assess for hemorrhage.
Similar Questions
A nurse is discussing postpartum depression with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of this condition?
A. "The most common manifestation of postpartum depression is harming the infant."
"The most common manifestation of postpartum depression is harming the infant." This is incorrect; harming the infant is a severe complication but not the most common manifestation.
B. "It's common for clients who have postpartum depression to exhibit psychotic behavior."
"It's common for clients who have postpartum depression to exhibit psychotic behavior." Psychotic behavior is a rare but serious complication of postpartum depression.
C. "Postpartum depression usually begins 48 hours after childbirth."
"Postpartum depression usually begins 48 hours after childbirth." Postpartum blues may start within this timeframe, but postpartum depression typically manifests later.
D. "Postpartum depression is more likely to occur in women who have a history of depression."
"Postpartum depression is more likely to occur in women who have a history of depression." This statement correctly identifies a significant risk factor for postpartum depression.
Full Explanation
A. "The most common manifestation of postpartum depression is harming the infant." This is incorrect; harming the infant is a severe complication but not the most common manifestation.
B. "It's common for clients who have postpartum depression to exhibit psychotic behavior." Psychotic behavior is a rare but serious complication of postpartum depression.
C. "Postpartum depression usually begins 48 hours after childbirth." Postpartum blues may start within this timeframe, but postpartum depression typically manifests later.
D. "Postpartum depression is more likely to occur in women who have a history of depression." This statement correctly identifies a significant risk factor for postpartum depression.
Which statements made by the parent indicate that appropriate care is being provided to a 4-year-old who has spastic type cerebral palsy? (Select All that Apply.)
A. I perform range of motion exercises every 4 hours to help prevent contractures
I perform a range of motion exercises every 4 hours to help prevent contractures. This helps prevent the tightening of muscles and joints, reducing the risk of contractures common in spastic cerebral palsy.
B. I make sure that I use toys and activities that are appropriate for my child's chronological age
I make sure that I use toys and activities that are appropriate for my child's chronological age. While important, this does not specifically address the care needs related to spastic cerebral palsy.
C. I have utensils with large, padded handles to make it easier for my child to feed himself
I have utensils with large, padded handles to make it easier for my child to feed himself. Adaptive utensils promote independence in self-care activities.
D. I play games with my child every day to keep them as independent as possible
I play games with my child every day to keep them as independent as possible. Engaging in activities that promote independence and social interaction is beneficial for children with cerebral palsy.
E. I give my child carbidopa so that he will stop drooling
I give my child carbidopa so that he will stop drooling. Medications like carbidopa are not typically used to manage drooling associated with cerebral palsy and are not a primary care measure.
Full Explanation
A. I perform a range of motion exercises every 4 hours to help prevent contractures. This helps prevent the tightening of muscles and joints, reducing the risk of contractures common in spastic cerebral palsy.
B. I make sure that I use toys and activities that are appropriate for my child's chronological age. While important, this does not specifically address the care needs related to spastic cerebral palsy.
C. I have utensils with large, padded handles to make it easier for my child to feed himself. Adaptive utensils promote independence in self-care activities.
D. I play games with my child every day to keep them as independent as possible. Engaging in activities that promote independence and social interaction is beneficial for children with cerebral palsy.
E. I give my child carbidopa so that he will stop drooling. Medications like carbidopa are not typically used to manage drooling associated with cerebral palsy and are not a primary care measure.
A nurse in an outpatient setting is caring for a client.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
Full Explanation
Potential Condition
Bulimia nervosa: The client has a BMI of 18.5, which is on the lower end of normal, indicating possible weight issues, but not the severe underweight typical of anorexia nervosa. The client describes cycles of binge eating followed by compensatory behaviors such as purging (using laxatives), which are characteristic of bulimia nervosa. The client expresses a preoccupation with food and body weight, and feelings of embarrassment about their eating habits, which align with bulimia nervosa.
Actions to Take
1. Assess binging and purging patterns: It's crucial to understand the frequency, triggers, and methods of binging and purging to tailor interventions effectively and to monitor the severity and progression of bulimia.
2. Encourage client to identify triggers for overeating: Identifying triggers for binging can help the client develop healthier coping mechanisms and reduce the occurrence of binge eating episodes.
Parameters to Monitor
1. Electrolyte levels: Frequent use of laxatives and purging behaviors can lead to electrolyte imbalances, which are potentially life-threatening and must be monitored regularly.
2. Frequency of compensatory behaviors: Tracking the frequency of purging behaviors (such as laxative use) helps assess the effectiveness of interventions and the client’s progress in reducing harmful behaviors.
Incorrect answers:
Actions to Take:
- Assess for and discourage provocative or seductive behaviour: This is more relevant to histrionic personality disorder, not bulimia nervosa.
- Weigh daily for the first week: While weighing the client can be part of the monitoring process, daily weigh-ins can increase anxiety and may not directly address the core issues of bulimia.
- Assess for consumption of right food items: While dietary intake is important, focusing solely on food items without addressing the psychological aspects may not be effective for treating bulimia.
Parameters to Monitor:
- Attention-seeking behaviours: More relevant to histrionic personality disorder than bulimia nervosa.
- Signs of infection: Not directly relevant unless there is evidence of a related health issue or a compromised immune system, which is not indicated in the provided information.
- Presence of lanugo: Lanugo is more commonly associated with anorexia nervosa due to severe malnutrition, not bulimia.