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 B
Explanation
A. Ask her if she is ready to eat her sandwich for lunch: This question is closed-ended and might prompt resistance, as toddlers often respond negatively to direct commands or yes/no questions that limit their sense of control.
B. Ask her if she would like to have her favorite sandwich for lunch: Offering a choice with a positive option gives the toddler a sense of autonomy while guiding them toward a preferred food. This approach can reduce negativism by providing limited, acceptable choices.
C. Tell her she is having her favorite sandwich for lunch: This directive removes the toddler’s ability to choose, which may increase resistance or oppositional behavior during mealtime.
D. Tell her that she may have a sandwich or soup for lunch: While offering choices is good, this statement is more authoritative than inviting and may not engage the toddler’s cooperation as effectively as phrasing it as a question.
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"E"}
Explanation
Rationale for Correct Answers:
- Preparing for a lumbar puncture: The child exhibits symptoms consistent with possible bacterial meningitis, including headache, lethargy, irritability, and nuchal rigidity. A lumbar puncture is necessary to obtain cerebrospinal fluid for diagnostic confirmation.
- Neurological findings: Signs like lethargy, nuchal rigidity, and severe headache strongly suggest central nervous system involvement. These findings indicate increased risk of meningitis, warranting immediate evaluation via lumbar puncture.
Rationale for Incorrect Choices:
- Administering potassium chloride: The child's potassium level is 3.8 mEq/L, which falls within the normal range. There is no indication of hypokalemia or need for potassium supplementation.
- Initiating airborne precautions: Bacterial meningitis requires droplet precautions, not airborne. Airborne precautions are reserved for illnesses like tuberculosis or measles.
- Administering acyclovir: There is no indication of viral infection such as herpes simplex or varicella. The presentation and history align more with bacterial meningitis than a viral cause.
- Increasing environmental stimuli: The child is irritable and lethargic, so increased stimuli would be contraindicated. A quiet, low-stimulation environment is more appropriate for neurologically compromised children.
- Pain level: Although pain is present (7/10 headache), the more critical finding prompting a lumbar puncture is the constellation of neurological symptoms rather than pain alone.
- WBC: An elevated WBC supports infection but is nonspecific. It should be interpreted alongside neurologic symptoms to justify a lumbar puncture.
- Lymph node findings: Slightly enlarged cervical nodes could be residual from a prior URI and are not the primary reason for a lumbar puncture in this context.
- Potassium level: The potassium is normal and unrelated to the need for a lumbar puncture or the child’s presenting concerns.
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