A nurse at the family planning clinic triages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic?
A client who uses a diaphragm for contraception and has lost 30 lb in the past 6 months dieting
A client who had an intrauterine device (IUD) inserted yesterday and has cramping and bleeding
A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding
A client who has sharp pain in her shoulder following a laparoscopic tubal ligation yesterday
The Correct Answer is D
A. Weight loss while using a diaphragm is not typically an urgent concern and may be related to dieting; the client should be advised to follow up with her primary care provider for further
evaluation.
B. Cramping and bleeding are common side effects following an IUD insertion and typically do not require immediate attention unless severe or accompanied by other concerning symptoms;
the client should be advised to monitor her symptoms and follow up if they worsen.
C. Breakthrough bleeding is a common side effect of starting oral contraceptives and may resolve on its own after a few cycles; the client should be advised to continue taking her pills as prescribed and to follow up if the bleeding persists or worsens.
D. Shoulder pain following a laparoscopic procedure may indicate a potential complication such as referred pain from gas used during the procedure or more serious issues such as internal bleeding or organ injury; the client should be instructed to come to the clinic for further
evaluation and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Administer an antitoxin: There is no specific antitoxin available for anthrax. Treatment primarily involves antibiotics and supportive care.
B. Quarantine the client: Quarantine may not be necessary unless the client is confirmed to have an active infection or poses a risk of spreading the disease to others.
C. Monitor the client for a productive cough: While respiratory symptoms can occur in inhalation anthrax, monitoring for a productive cough alone may not be sufficient for management.
D. Begin prophylactic treatment with ciprofloxacin: Prophylactic antibiotic treatment with ciprofloxacin or doxycycline is recommended following exposure to anthrax to prevent the development of the disease.
Correct Answer is B
Explanation
A. Constipation: While constipation can be uncomfortable, it is not typically considered an immediate threat to a patient's health in a cardiac unit setting. It requires assessment and intervention but is not the highest priority.
B. Indigestion can be a subtle symptom of myocardial infarction (MI) or acute coronary syndrome (ACS), particularly in older adults, women, or clients with diabetes. Clients experiencing "indigestion" may be describing chest discomfort, which requires immediate assessment to rule out a cardiac event. Early identification and intervention for cardiac symptoms are critical to prevent further complications.
C. Swollen ankles can indicate fluid retention, which is a common sign of heart failure. While this symptom requires attention, it does not typically indicate an immediate life-threatening issue compared to potential cardiac ischemia associated with "indigestion."
D. Urinary frequency: This could be related to medications or other conditions. While it should be addressed, it is not the most critical issue compared to potential acute cardiac symptoms.
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