A nurse is caring for an adolescent
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
Rationale for Correct Choices
• Pelvic inflammatory disease: The client’s fever, pelvic pain, mucopurulent cervical discharge, elevated WBC and CRP, and positive chlamydia test point to pelvic inflammatory disease, a complication of untreated sexually transmitted infection.
• Instruct the adolescent about the use of sitz baths: Sitz baths provide localized warmth and comfort, reducing pelvic and abdominal pain while promoting circulation and relaxation in the pelvic region.
• Administer acetaminophen 650 mg PO every 6 hr PRN pain: Acetaminophen helps relieve pelvic cramping, fever, and discomfort, improving the client’s ability to tolerate care and promoting rest.
• Vaginal bleeding: PID can damage reproductive tissue, increasing risk of abnormal vaginal bleeding, so monitoring helps detect complications such as worsening infection or endometrial involvement.
• Temperature greater than 38.3° C (100.9° F): Persistent fever indicates ongoing infection or ineffective antibiotic therapy, making temperature an essential marker for evaluating treatment response.
Rationale for Incorrect Choices
• Acute appendicitis: This condition presents with right lower quadrant pain, rebound tenderness, and elevated inflammatory markers, but mucopurulent cervical discharge and positive chlamydia culture make PID more likely.
• Urinary tract infection: A UTI typically causes dysuria, frequency, and pyuria in urinalysis, but this client’s urine shows no WBCs or nitrites, making this diagnosis unlikely.
• Ectopic pregnancy: The negative hCG rules out pregnancy-related causes such as ectopic pregnancy, despite the abdominal pain.
• Maintain an NPO status: This is appropriate for appendicitis or surgical conditions, not PID, which is treated with antibiotics and comfort measures.
• Administer an enema: This is unrelated to PID management and could worsen discomfort without addressing the infection.
• Place the adolescent on bedrest in semi-Fowler’s position: This is more appropriate for appendicitis or abdominal surgery; PID management focuses on antibiotics, comfort, and symptom control instead.
• Rebound tenderness: While possible in appendicitis, this is not a priority assessment in PID, where infection signs and pelvic pain predominate.
• Presence of a Cullen sign: Cullen’s sign indicates intra-abdominal bleeding, often from ruptured ectopic pregnancy or pancreatitis, not PID.
• Irritation of the phrenic nerve: Phrenic nerve irritation, often causing shoulder tip pain, is associated with a ruptured spleen or ectopic pregnancy, and is not typical of PID.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Desquamation: Skin peeling or desquamation is an acute side effect of radiation therapy, typically appearing during or shortly after treatment, not years later.
B. Nausea: Nausea is also an acute effect that commonly occurs during radiation therapy, especially when the gastrointestinal tract or brain is involved. It is not considered a late effect years after treatment.
C. Mucosal ulceration: Ulceration of the mucous membranes is an early complication related to radiation affecting rapidly dividing cells. It resolves after treatment and is not a late manifestation.
D. Short stature: Radiation therapy in young children can damage growth plates and affect hormone production, leading to growth delays and short stature. This is a recognized late adverse effect seen years after treatment.
Correct Answer is B
Explanation
A. Rapid respirations: While tachypnea is common in bacterial pneumonia due to increased oxygen demand, it does not directly increase aspiration risk. It reflects respiratory distress rather than impaired protective airway reflexes.
B. Neurological deficit: Children with neurological impairment may have reduced gag and swallow reflexes, poor airway clearance, or altered consciousness. These deficits significantly increase the risk for aspiration, making this the most concerning finding.
C. Elevated temperature: Fever is a systemic response to infection but does not contribute to aspiration risk. It signals the body’s inflammatory process rather than an impairment in airway protection.
D. Inspiratory wheezing: Wheezing indicates narrowed airways due to inflammation or obstruction but does not directly predispose to aspiration. It is a respiratory complication, not a swallowing or airway protection issue.
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