A nurse is in the process of taking a patient’s oral temperature.
The patient informs the nurse that they have just consumed some ice chips. What should the nurse do next?

Choice A rationale

Lower quadrant pain is a common symptom of many conditions, including ectopic pregnancy. However, it does not specifically indicate the presence of blood in the peritoneum.

Choice B rationale

Cullen’s sign, which is the appearance of bruising in the skin around the umbilicus, is a sign of blood in the peritoneum. It can occur in conditions such as a ruptured ectopic pregnancy.

Choice C rationale

Goodell’s sign is a softening of the cervix that typically occurs early in pregnancy. It does not indicate the presence of blood in the peritoneum.

Choice D rationale

Chadwick’s sign is a bluish discoloration of the cervix, vagina, and labia that occurs in early pregnancy. It does not indicate the presence of blood in the peritoneum.

Choice A rationale: CNS manifestations such as headaches are not a therapeutic effect of nafarelin. These are side effects of the medication. Nafarelin, a gonadotropin-releasing hormone (GnRH) agonist, works by reducing the production of estrogen in the body. This can lead to a variety of side effects, including headaches. While these side effects can be bothersome, they do not indicate that the medication is effectively treating the endometriosis.

Choice B rationale: The reduction in pain level during sexual intercourse, or dyspareunia, is a therapeutic effect of nafarelin. Endometriosis can cause painful sexual intercourse, and one of the goals of treatment with nafarelin is to reduce this pain. The client’s report of decreased dyspareunia suggests that the nafarelin is effectively treating the endometriosis.

Choice C rationale: Changes in the nasal mucosa, such as irritation, are not a therapeutic effect of nafarelin. These are side effects of the medication. Nafarelin is administered intranasally, which can lead to irritation of the nasal mucosa. While this side effect can be bothersome, it does not indicate that the medication is effectively treating the endometriosis.

Choice D rationale: Changes in breast size are not a therapeutic effect of nafarelin. These are side effects of the medication. Nafarelin can cause a variety of side effects, including changes in breast size. While this side effect can be bothersome, it does not indicate that the medication is effectively treating the endometriosis.

Choice E rationale: The absence of menstruation, or amenorrhea, is a therapeutic effect of nafarelin. Nafarelin works by reducing the production of estrogen in the body, which can lead to a temporary halt in menstruation. This is a therapeutic effect as it can help to reduce the pain and other symptoms associated with endometriosis.

Choice F rationale: Dermatological manifestations such as increased acne are not a therapeutic effect of nafarelin. These are side effects of the medication. Nafarelin can cause a variety of side effects, including increased acne. While this side effect can be bothersome, it does not indicate that the medication is effectively treating the endometriosis.