A nurse on a postpartum unit is caring for a client.

Exhibits

Complete the following sentence by using the lists of options.

The client is most likely experiencing
dropdown
as evidenced by the client's
dropdown
.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Rationale for Correct Choices

Endometritis: This uterine infection is common after cesarean delivery, especially with prolonged rupture of membranes. The client’s uterine tenderness, elevated fundus, boggy consistency, and foul-smelling lochia are hallmark signs of endometritis, making it the most likely diagnosis.
Uterus and lochia: The presence of a tender uterus that is elevated above the umbilicus and only firms with massage, combined with dark, malodorous lochia, strongly suggests infection of the uterine lining. These findings point specifically to endometritis rather than general postpartum changes.

Rationale for Incorrect Choices

Mastitis: Although the client reports heavy, warm breasts with nipple discomfort, there is no breast erythema, localized swelling, or high-grade fever typical of mastitis. These symptoms are likely due to engorgement related to lactation rather than infection.
Pneumonia: The client’s respiratory assessment shows clear lungs with only slight basal changes common postoperatively. There are no signs of cough, sputum production, hypoxia, or respiratory distress, which makes pneumonia an unlikely cause of her symptoms.
Fever: A temperature of 38.2°C is above normal, but mild postpartum fever can have various causes, including engorgement, dehydration, or early infection. Fever alone is not specific enough to confirm a diagnosis without targeted findings.
WBC count: Although an elevated WBC of 33,000/mm³ raises concern, postpartum leukocytosis can be physiologic or related to many infections. It is not diagnostic of endometritis without more specific correlating signs like uterine tenderness and abnormal lochia.

Nursing Test Bank

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Correct Answer is A

Explanation

Rationale:

A. Smoked salmon: Smoked and aged foods are high in tyramine, which can interact dangerously with phenelzine, a monoamine oxidase inhibitor (MAOI). This interaction can trigger a hypertensive crisis, making smoked salmon a food to avoid during therapy.

B. Cottage cheese: Cottage cheese contains low levels of tyramine compared to aged cheeses and is generally considered safe for clients taking MAOIs like phenelzine. It does not pose a significant risk for hypertensive crisis.

C. Grapefruit: Grapefruit can interact with many medications by affecting liver enzymes, but it does not have a known interaction with phenelzine. The concern with phenelzine is primarily with tyramine-rich foods, not citrus fruits.

D. Spinach: Spinach is not high in tyramine and does not interact with MAOIs. It is a leafy green that is safe and healthy for clients to consume while on phenelzine.

A. Monitor the client for hypoglycemia. B. Perform range-of-motion exercises once per shift C. Place the client in high-Fowler's position. D. Implement seizure precautions.

Correct Answer is D

Explanation

Rationale:

A. Monitor the client for hypoglycemia: Hypoglycemia is not a common complication of bacterial meningitis. More relevant concerns include increased intracranial pressure, fever, and potential neurological damage, rather than altered glucose metabolism.

B. Perform range-of-motion exercises once per shift: While maintaining mobility is important, this is not a priority during the acute phase of bacterial meningitis. The client may be photophobic, confused, or in too much discomfort for routine exercises early in treatment.

C. Place the client in high-Fowler's position: High-Fowler’s can increase discomfort and may worsen meningeal irritation. A more appropriate position is 30 degrees with head midline to promote venous drainage and reduce intracranial pressure.

D. Implement seizure precautions: Seizures are a potential complication of bacterial meningitis due to inflammation, increased intracranial pressure, and irritation of the cerebral cortex. Seizure precautions are a critical safety measure in the acute phase of care.

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A nurse on a postpartum unit is caring for a client. Exhibits Complete the following sentence by using the lists of options. The client is most likely experiencing dropdown as evidenced by the client's dropdown.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to a client who has a depressive disorder and a new prescription for phenelzine. Which of the following foods should the nurse instruct the client to avoid?

Correct Answer is A

Explanation

A nurse is caring for a newly admitted client who has bacterial meningitis. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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A nurse is caring for a client who has major depressive disorder. Which of the following findings should indicate to the nurse that the client's condition is improving?

A nurse is caring for a client who has increased intracranial pressure following a traumatic brain injury. Which of the following actions should the nurse take? (Select all that apply.)

A nurse in an outpatient clinic is assessing a client who is pregnant for unsafe behaviors during pregnancy. Which of the following findings indicates a need for further evaluation?

A nurse in a clinic is caring for an adolescent client who is at 24 weeks of gestation and showing signs of preeclampsia. Which of the following findings should the nurse expect?

A nurse on a postpartum unit is caring for a client.

Exhibits

Complete the following sentence by using the lists of options.

The client is most likely experiencing
dropdown
as evidenced by the client's
dropdown
.