Exhibits

A nurse is caring for a client in the emergency department (ED). Which of the following actions should the nurse take? Select all that apply.

Inform the dient that they cannot refuse medical examination

Report laboratory findings to law enforcement.

Prepare to administer prophylaxis for STIs.

Assess for thoughts of self-harm

Recommend emergency contraception to the client.

Answer and Explanation

Correct Answer : C,D,E

A. Inform the client that they cannot refuse medical examination: All patients, including those who have been sexually assaulted, have the legal right to refuse any part of the examination. Informed consent is essential.
B. Report laboratory findings to law enforcement: Unless there is a mandatory reporting law in effect for that specific jurisdiction, results and disclosures require the client's consent before being shared with law enforcement.
C. Prepare to administer prophylaxis for STIs: Clients who have experienced sexual assault are at risk for sexually transmitted infections. Early administration of prophylactic antibiotics is a standard, time-sensitive intervention.
D. Assess for thoughts of self-harm: Sexual assault survivors are at increased risk for depression, suicidal ideation, and PTSD. A mental health assessment should be conducted immediately to ensure safety.
E. Recommend emergency contraception to the client: If pregnancy is a potential concern, emergency contraception should be offered within a limited time window after the assault, regardless of the client’s current hCG level.

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

Explanation

Rationale for Correct Options:

Preeclampsia is a hypertensive disorder of pregnancy that typically occurs after 20 weeks of gestation. This client has elevated blood pressure (156/96 mm Hg), proteinuria (25 mg/dL), hyperreflexia, headache, right upper quadrant pain, and facial edema—all hallmark signs of preeclampsia.
Urinalysis shows elevated protein, which is a diagnostic criterion for preeclampsia. Proteinuria is a result of kidney involvement due to endothelial damage from hypertension indicating kidney involvement due to the systemic vascular changes in preeclampsia.

Rationale for Incorrect Options:

Chorioamnionitis typically presents with maternal fever, uterine tenderness, foul-smelling amniotic fluid, and fetal tachycardia. This client is afebrile and has no signs of intrauterine infection.
Preterm labor is indicated by cervical changes and regular uterine contractions, neither of which are present. The fetal monitor shows no contractions, and there are no reports of vaginal drainage or pressure.
Serum WBC count is mildly elevated at 12,500/mm³, which can be normal in pregnancy and does not indicate infection or inflammation in this context.
Fundal assessment: The fundal height of 29 cm at 30 weeks is within the normal range (+/- 2 cm), so it does not evidence a particular risk.

A. Hyperthyroidism B. Hypocalcemia C. Thrombophlebitis D. Diverticulosis

Correct Answer is C

Explanation

A. Hyperthyroidism: Although thyroid function should be monitored, hyperthyroidism itself is not a contraindication for combination oral contraceptives. However, uncontrolled hyperthyroidism may require careful evaluation before starting any hormonal therapy.
B. Hypocalcemia: Low calcium levels do not directly affect the safety of combination oral contraceptives, so this condition is not a contraindication. Oral contraceptives do not typically influence calcium metabolism in a way that would cause harm in hypocalcemic patients.
C. Thrombophlebitis: This condition indicates a history of blood clots or venous inflammation, which significantly increases the risk of thromboembolism with combination oral contraceptives due to their estrogen content. Therefore, thrombophlebitis is a contraindication.
D. Diverticulosis: This condition affects the colon and is not related to the risks associated with combination oral contraceptives. It does not contraindicate their use.

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Exhibits A nurse is caring for a client in the emergency department (ED). Which of the following actions should the nurse take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse continues to care for the client who is at 30 weeks of gestation. Exhibits Complete the following sentence by using the lists of options. The client is at highest risk for developing dropdownas evidenced by the client'sdropdown.

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

Explanation

A nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client's history is a contraindication to the use of combination oral contraceptives?

Correct Answer is C

Explanation

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Exhibits A nurse is caring for a client in the emergency department (ED). Which of the following actions should the nurse take? Select all that apply.

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Exhibits

A nurse is caring for a client in the emergency department (ED). Which of the following actions should the nurse take? Select all that apply.