A nurse is assessing a client two weeks postpartum. Which of the following statements by the client indicates a need for further evaluation?

"I really wish I had a girl instead."

"I am so relieved the baby looks like my mother."

"My labor was so long I'm glad it's over."

"My appetite has really increased”

Answer and Explanation

The Correct Answer is A

A. "I really wish I had a girl instead.": Expressing disappointment in the baby's gender may indicate difficulty bonding with the infant or potential postpartum emotional concerns. This statement warrants further evaluation to assess for postpartum depression or attachment issues.

B. "I am so relieved the baby looks like my mother.": Feeling relieved that the baby resembles a family member is a normal emotional reaction and does not typically require further psychological evaluation unless associated with more concerning behaviors.

C. "My labor was so long I'm glad it's over.": Expressing relief after a long labor is a normal reaction and does not indicate emotional distress or dysfunction that would need further mental health evaluation.

D. "My appetite has really increased.": An increased appetite two weeks postpartum is a normal physiological response as the body recovers from childbirth, particularly if the client is breastfeeding. It does not suggest a need for further emotional or physical evaluation.

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Correct Answer is B

Explanation

A. Dry skin: Dry skin is not typically associated with the disulfiram-alcohol reaction. The primary concerns involve cardiovascular and gastrointestinal symptoms rather than dermatologic effects.

B. Hypotension: Disulfiram causes an intense physical reaction when alcohol is consumed, including symptoms like flushing, nausea, vomiting, hypotension, and potentially life-threatening cardiovascular collapse. Monitoring for hypotension is critical during this reaction.

C. Constipation: Constipation is not a typical side effect of disulfiram-alcohol interaction. Gastrointestinal symptoms such as nausea and vomiting are much more common and more clinically significant.

D. Urinary retention: Urinary retention is not a known reaction to the combination of disulfiram and alcohol. The body’s response focuses more on vascular changes and gastrointestinal distress.

A. Medication B. Route C. Dosage D. Time

Correct Answer is B

Explanation

A. Medication: The medication, erythromycin, is clearly stated and appropriately spelled. There is no confusion about what drug the provider intended to prescribe, so there is no immediate need to clarify the medication name itself.

B. Route: The prescription does not specify the route of administration, which is essential for safe medication delivery. Erythromycin can be given orally or intravenously, and using the wrong route could lead to serious complications. Clarifying the route ensures proper technique and absorption.

C. Dosage: The dosage of 500 mg is within the standard therapeutic range for erythromycin, depending on the severity and type of infection. Since the dose appears appropriate, it does not require immediate clarification unless clinical concerns arise.

D. Time: Although "four times per day" is broad, it is generally understood as approximately every six hours. While more exact times can improve consistency, missing the route of administration is a more critical and urgent issue to clarify for client safety.

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A nurse is assessing a client two weeks postpartum. Which of the following statements by the client indicates a need for further evaluation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

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