A nurse is assessing a client who has been taking oral contraceptives for the past 6 months. Which of the following findings should the nurse immediately report to the provider?

Persistent headache.

Weight gain 2.3 kg (5 lb).

Frequent nausea.

Breast tenderness.

Answer and Explanation

The Correct Answer is A

Choice A reason: Persistent headache on oral contraceptives may indicate serious complications like stroke or hypertension, requiring immediate reporting to prevent life-threatening events. This is critical for timely intervention, ensuring client safety, and guiding potential medication adjustments in women using hormonal contraception for 6 months.

Choice B reason: Weight gain of 2.3 kg is common with oral contraceptives and not urgent, unlike persistent headache, which signals serious risks. Assuming weight gain requires reporting risks overlooking critical neurological symptoms, critical to avoid in ensuring safe monitoring of contraceptive side effects.

Choice C reason: Frequent nausea is a common contraceptive side effect, typically managed with counseling, not urgent like headache. Assuming nausea is priority risks delaying serious symptom evaluation, critical to prevent in ensuring timely reporting of potentially life-threatening complications in contraceptive users.

Choice D reason: Breast tenderness is a common, non-urgent side effect of oral contraceptives, unlike persistent headache, which may indicate stroke risk. Assuming tenderness is urgent risks missing critical symptoms, critical to avoid in ensuring proper monitoring and safety in clients on hormonal contraception.

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Correct Answer is D

Explanation

Choice A reason: TENS units are effective for chronic pain but less practical 4 hours post-knee arthroplasty due to incision sensitivity; cold packs reduce swelling. Assuming TENS is ideal risks discomfort, critical to avoid in early postoperative pain management, ensuring comfort in acute recovery phases.

Choice B reason: Walking 4 hours post-knee arthroplasty is premature, risking strain or bleeding; cold packs are safer. Assuming walking is appropriate risks complications, critical to prevent in early postoperative care, ensuring pain relief and surgical site protection in clients recovering from knee surgery.

Choice C reason: Lidocaine gel is pharmacological, not nonpharmacological, and inappropriate near fresh incisions; cold packs are correct. Assuming gel is nonpharmacological risks misapplication, potentially causing irritation, critical to avoid in ensuring safe, nonpharmacological pain relief in early post-knee arthroplasty recovery.

Choice D reason: Placing a cold pack reduces swelling and pain 4 hours post-knee arthroplasty, a safe nonpharmacological therapy promoting comfort. This is critical for early recovery, minimizing inflammation, supporting healing, and ensuring effective pain management without medications in clients post-total knee arthroplasty.

A. Hold a critical incident debriefing about the client. B. Observe the client’s range of movement. C. Maintain sensory stimulation for the client. D. Identify stressors that caused the client’s aggression.

Correct Answer is B

Explanation

Choice A reason: Holding a debriefing is post-incident, not a priority during restraint use; observing movement ensures safety. Assuming debriefing is immediate risks neglecting client monitoring, potentially causing injury, critical to avoid in ensuring safe restraint use and client well-being in acute behavioral situations.

Choice B reason: Observing range of movement during restraints ensures proper application, preventing injury like nerve damage or circulation issues, critical for client safety. This ongoing assessment adheres to restraint protocols, essential for minimizing harm, ensuring ethical care, and supporting de-escalation in aggressive clients.

Choice C reason: Maintaining sensory stimulation is inappropriate during restraints, as it may escalate agitation; observing movement is priority. Assuming stimulation is needed risks worsening aggression, potentially prolonging restraint use, critical to avoid in ensuring calm and safe management of clients in mechanical restraints.

Choice D reason: Identifying stressors is important but secondary to ensuring physical safety by observing movement during restraints. Assuming stressors are the immediate focus risks neglecting restraint safety, potentially causing injury, critical to prevent in ensuring proper monitoring and care in aggressive client situations.

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A nurse is assessing a client who has been taking oral contraceptives for the past 6 months. Which of the following findings should the nurse immediately report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is 4 hours postoperative following a total knee arthroplasty. The client reports a pain level of 3 on a scale from 0 to 10. Which of the following nonpharmacological pain management therapies should the nurse recommend?

Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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