The nurse has reviewed the Graphic Record and Diagnostic Results at 1030.
Complete the following sentence by using the lists of options.
The nurse should first address the client's
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
This question focuses on prioritization of care in a client presenting with signs and symptoms highly suggestive of an ectopic pregnancy. The client has a positive pregnancy test, delayed menses, right lower quadrant abdominal tenderness, and vaginal spotting, along with a history of pelvic inflammatory disease, which increases risk for ectopic implantation. A rising heart rate alongside abdominal pain and bleeding raises concern for possible internal hemorrhage and early hypovolemia. In obstetric emergencies, priority is given to identifying hemodynamic instability first, followed by addressing ongoing sources of bleeding.
Rationale for correct choices:
• Heart rate: An increasing heart rate from 90/min to 104/min is an early compensatory response to possible internal blood loss, which is highly concerning in suspected ectopic pregnancy. Tachycardia may indicate the beginning of hypovolemia even before significant changes appear in blood pressure or hemoglobin. In this context, the priority is to assess for potential rupture and hemorrhage. Monitoring and addressing circulatory instability is essential to prevent rapid deterioration.
• Vaginal spotting: Vaginal spotting in early pregnancy, especially in combination with abdominal pain and a positive hCG, is a key indicator of possible ectopic pregnancy or threatened pregnancy loss. The presence of dark red spotting suggests older blood and possible ongoing bleeding. This finding requires immediate evaluation because it may reflect bleeding from an abnormal implantation site. Managing and monitoring bleeding is critical after stabilizing circulation.
Rationale for incorrect choices:
• Bowel sounds: Hyperactive bowel sounds are not a priority concern in this scenario and may be related to anxiety, hormonal changes, or nonspecific gastrointestinal activity. They do not directly indicate hemodynamic instability or pregnancy complications. While abdominal assessment is important, bowel sounds are not the most urgent finding compared to signs of bleeding or circulatory compromise. Therefore, they are not prioritized in this situation.
• Lung sounds: The client’s lung sounds are only described as slight inspiratory wheezes, likely related to the history of asthma. There are no signs of respiratory distress, hypoxia, or acute pulmonary compromise. Respiratory status is stable compared to the potential for hemorrhagic shock in suspected ectopic pregnancy. Thus, lung findings are not the immediate priority.
• Anxiety: Anxiety is an expected emotional response given the uncertainty of pregnancy complications and does not pose an immediate physiological threat. While important for supportive care, it does not take priority over signs of possible internal bleeding or hemodynamic instability. Addressing anxiety is part of holistic care but is secondary to stabilizing circulation and monitoring bleeding.
• Hemoglobin level: Although hemoglobin is slightly low, it has not yet shown a critical drop and may not reflect acute blood loss at this stage. Hemoglobin changes often lag behind actual bleeding, especially in early hemorrhage. Therefore, relying on hemoglobin alone could delay recognition of worsening instability. Continuous monitoring is important, but heart rate and active bleeding provide more immediate clinical cues.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Teaching a client to use a cane focuses on improving balance, stability, and safety during ambulation, especially when unilateral weakness is present. A cane should be used on the stronger side of the body to provide optimal support for the weaker lower extremity. Proper sequencing of cane and leg movement helps redistribute weight and reduce fall risk. Correct technique is essential for clients recovering from neurologic conditions such as stroke.
Rationale:
A. Positioning the cane 30.5 cm (12 in) to the side of the body is incorrect because the cane should be held close to the body for stability. Holding it too far away increases the risk of imbalance and reduces effective weight-bearing support. Proper placement is directly adjacent to the stronger leg.
B. Placing the cane on the right side is correct because the cane should be used on the unaffected or stronger side when the client has left-sided weakness. This allows the right side to support body weight while the left, weaker side advances safely. This technique improves balance and reduces fall risk in clients with conditions such as Stroke.
C. Advancing the cane 40.64 cm (16 in) with each step is incorrect because the cane should be moved only a short distance forward, typically about 15–25 cm (6–10 in). Moving it too far ahead reduces stability and increases the risk of loss of balance. Controlled, small movements are essential for safe ambulation.
D. Moving the right foot forward first is incorrect because the sequence should involve moving the cane and the weaker (left) leg first, followed by the stronger leg. Advancing the strong leg first disrupts balance and does not provide proper support for the affected side. Correct sequencing ensures safety and coordination during walking.
Correct Answer is A
Explanation
Client education is most effective when the learner is physically and psychologically able to concentrate, process information, and engage in teaching. Pain, anxiety, fatigue, and acute physiological distress can significantly impair attention span and memory retention. Nurses must first assess for factors that may interfere with learning readiness before initiating an education session. Addressing barriers ensures that teaching is meaningful and improves long-term adherence to care instructions.
Rationale:
A. A pain level of 8/10 is a significant barrier to learning because severe pain decreases concentration, cognitive processing, and willingness to participate in education. In a client experiencing high-intensity pain related to conditions such as Acute pain, the body’s stress response further limits attention and memory formation. Pain should be managed before initiating teaching to ensure effective learning.
B. Mild to moderate edema (2+ pitting) does not directly interfere with the client’s ability to learn. While it may indicate an underlying medical condition, it does not significantly impair cognitive function or attention. Therefore, it is not considered a primary barrier to learning readiness.
C. Anticipation about upcoming discharge may actually enhance readiness to learn because the client is motivated to understand self-care instructions. Motivation and positive expectation often improve engagement and information retention. This is generally considered a facilitator rather than a barrier.
D. Participating in physical therapy 2 hours ago may cause some fatigue, but it does not necessarily prevent learning. If the client is rested and alert, teaching can still be effective. Fatigue would only become a barrier if it significantly impairs attention or alertness.
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