A nurse is caring for an adolescent.
The Correct Answer is []
- Pelvic Inflammatory Disease (PID): The client’s mucopurulent cervical discharge, pelvic pain, recent multiple sexual partners, fever, and urinary discomfort point strongly toward PID, a common infection of the upper genital tract in sexually active adolescents.
- Administer acetaminophen 650 mg PO every 6 hr PRN pain: Acetaminophen is appropriate for managing PID-associated fever and cramping pain without interfering with diagnostic assessments.
- Place the adolescent on bedrest in semi-Fowler's position: Semi-Fowler's positioning facilitates pelvic drainage, reduces the risk of abscess formation, and supports comfort.
- Temperature greater than 38.3°C (100.9°F): Ongoing fever indicates systemic infection or lack of response to treatment, making it a key marker for disease progression or resolution.
- Vaginal bleeding: Monitoring for abnormal bleeding is important, as PID can involve endometrial inflammation or complications like ectopic pregnancy or miscarriage if not promptly managed.
Rationale for Incorrect Choices:
- Urinary tract infection: UTIs typically cause dysuria, frequency, and suprapubic pain, but PID presents with more systemic symptoms and pelvic tenderness, along with sexual history risk factors.
- Ectopic pregnancy: Though a possibility, the client recently had her period 7 days ago, making active ectopic pregnancy less likely; there is also no mention of missed periods or positive pregnancy test.
- Acute appendicitis: This usually involves right lower quadrant pain and rebound tenderness; cervical discharge and bilateral pelvic pain make PID more likely.
- Instruct the adolescent about the use of sitz baths: Sitz baths help with localized perineal discomfort but are not primary management for PID.
- Administer an enema: This is unrelated to PID and could worsen abdominal discomfort or cause unnecessary complications.
- Maintain an NPO status: NPO is reserved for surgical cases or procedures requiring sedation; PID is typically managed with medications and does not require dietary restrictions.
- Rebound tenderness: While it can indicate peritonitis as a result of peritoneal irritation, it's more typical of appendicitis than PID.
- Presence of a Cullen’s sign: Cullen’s sign (periumbilical bruising) is associated with intra-abdominal bleeding such as pancreatitis or ruptured ectopic pregnancy, not PID.
- Irritation of the phrenic nerve: This is associated with upper abdominal pathology like gallbladder disease, not with PID.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","F"]
Explanation
- Capillary refill 4 seconds: Prolonged capillary refill indicates poor peripheral perfusion, often due to dehydration or shock in toddlers. This requires urgent assessment and intervention to prevent further circulatory compromise.
- Extremities cool: Cool extremities suggest vasoconstriction caused by decreased circulating volume or shock. Immediate evaluation is necessary to prevent progression of hypovolemia.
- Reports no tears: Lack of tears while crying is a hallmark sign of moderate to severe dehydration, signaling the need for urgent fluid replacement therapy.
- Lethargic: Lethargy reflects altered mental status and possible systemic compromise, requiring immediate medical evaluation to address underlying causes such as severe dehydration or infection.
- Hyperactive bowel sounds: Hyperactive bowel sounds correlate with diarrhea and fluid loss, which can worsen dehydration. Prompt monitoring and management are necessary to prevent complications.
Rationale for Incorrect Choices:
- Respiratory rate 26/min: This respiratory rate falls within the normal toddler range (20–30/min) and does not indicate respiratory distress or need for urgent intervention.
- Heart rate 112/min: A mild tachycardia can be expected in a toddler with mild dehydration or distress but is not an isolated sign of immediate concern.
- Diaper area reddened: Diaper rash is a common irritation due to frequent stools and requires routine skin care, not urgent clinical action unless worsened.
Correct Answer is D
Explanation
A. Hematemesis: Vomiting blood is not a typical finding in celiac disease; it usually indicates gastrointestinal bleeding from other causes such as ulcers or esophageal varices. Celiac disease primarily affects nutrient absorption rather than causing direct bleeding.
B. Redcurrant, jelly-like stools: This type of stool is characteristic of intussusception, a condition where part of the intestine telescopes into itself causing obstruction and bleeding. It is unrelated to the malabsorption seen in celiac disease.
C. Increased hemoglobin level: Celiac disease commonly causes malabsorption leading to iron deficiency anemia, which results in decreased hemoglobin levels. An increased hemoglobin level would not be expected because nutrient deficiencies impair red blood cell production.
D. Pale, oily stools: Steatorrhea, characterized by pale, bulky, and oily stools, occurs due to fat malabsorption in celiac disease. This reflects damage to the intestinal villi by gluten, which impairs digestion and absorption of fats and other nutrients. It is one of the hallmark clinical features of celiac disease.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.