A nurse is caring for a client who is 4 days postpartum following a cesarean birth
For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process
Painful, tender breast
Temperature
Chills
Foul-smelling lochia
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}
Mastitis: A, B, C
Endometritis: B, C, D
Rationale:
A. This finding is consistent with mastitis. Mastitis is characterized by inflammation of the breast tissue, often presenting with pain, tenderness, warmth, and redness in the affected breast.
B. This finding can be indicative of both mastitis and endometritis. A fever, as indicated by an elevated temperature (38.8°C or 101.9°F), is a common symptom of both mastitis and endometritis. It suggests an inflammatory response or infection in the body.
C. This finding is also consistent with both mastitis and endometritis. Chills often accompany fever and can be a sign of systemic infection or inflammation.
D. This finding is more indicative of endometritis. Endometritis involves infection or inflammation of the uterine lining, which can result in foul-smelling lochia. Foul- smelling lochia may indicate the presence of infection within the uterus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: Feeling light-headed upon standing is a common side effect of many psychotropic medications, indicating orthostatic hypotension but not necessarily requiring immediate provider intervention unless it persists or worsens.
B: Mumbling quietly could be related to the client’s schizophrenia rather than a direct effect of the medication.
C: Photosensitivity can be a side effect of some antipsychotic medications, but it is less concerning than neurological symptoms and usually manageable with lifestyle adjustments.
D: A shuffling gait can indicate the development of parkinsonism, a serious side effect of antipsychotic medications, which involves motor impairments mimicking symptoms of Parkinson's disease. This is significant and should be reported to the provider immediately for potential medication adjustment.
Correct Answer is A
Explanation
A: A client who is scheduled for a colonoscopy and is taking sodium phosphate requires follow-up care because sodium phosphate can cause colonic mucosal damage and electrolyte imbalances that may affect the safety and accuracy of the colonoscopy. Sodium phosphate is a bowel preparation agent that empties the colon before the procedure, but it can also cause dehydration, kidney injury, and cardiac arrhythmias.
B: Induration following a Mantoux test indicates a reaction that may suggest tuberculosis exposure, but this is an expected result that requires assessment rather than immediate follow-up.
C: Bumetanide is a diuretic, and an increase in urination is an expected effect of this medication.
D: Warfarin is considered safe during lactation since it is not excreted in breastmilk to any measurable degree.
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