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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Indirect lighting aids visual impairment, not hearing loss, where attention-getting is key. Assuming lighting is relevant risks ineffective communication, potentially frustrating the client, critical to avoid in ensuring clear, respectful interaction for clients with total hearing loss in care settings.
Choice B reason: Speech therapists address speech, not hearing loss communication, where attention-getting is essential. Assuming therapist collaboration is primary risks overlooking direct communication strategies, critical to prevent in ensuring effective, tailored interaction for clients with total hearing loss in healthcare settings.
Choice C reason: Getting the client’s attention before speaking (e.g., tapping or waving) ensures effective communication for total hearing loss, facilitating lip-reading or sign language. This is critical for clarity, promoting inclusion, and ensuring accurate information exchange, essential for care delivery in hearing-impaired clients.
Choice D reason: Using a loud tone is ineffective for total hearing loss, where visual cues are needed. Assuming loudness helps risks miscommunication, potentially isolating the client, critical to avoid in ensuring respectful, effective communication strategies for clients with complete hearing loss in care.
Correct Answer is D
Explanation
Choice A reason: A semi-sitting position for meals is impractical in a hip spica cast, risking discomfort or aspiration; turning every 2 hours prevents pressure injuries. Assuming semi-sitting is correct risks complications, critical to avoid in ensuring safe positioning and care for children in spica casts.
Choice B reason: Maintaining dependent lower extremities increases edema risk in a hip spica cast; turning every 2 hours promotes circulation. Assuming dependent positioning is correct risks swelling, critical to prevent in ensuring proper cast care and comfort for children with hip spica casts.
Choice C reason: A bedside commode is unsuitable for a hip spica cast, which covers the pelvis; bedpans are used. Turning every 2 hours is key. Assuming a commode is appropriate risks impracticality, critical to avoid in ensuring proper toileting and care in spica cast management.
Choice D reason: Turning every 2 hours prevents pressure ulcers and promotes circulation in a child with a hip spica cast, critical for skin integrity and comfort. This ensures proper cast care, reducing complications, supporting healing, and maintaining safety in pediatric orthopedic management.
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