The nurse is caring for a client in the emergency department (ED) after an assault by the spouse. The client has a history of similar emergency visits. Which action best assists the client?

Provide guidance to identify triggering behaviors.

Develop a plan for initiating a rapid exit.

Advise couple's counseling as the next step.

Complete a Patient Health Questionnaire-9 (PHQ9).

Answer and Explanation

The Correct Answer is B

A. Provide guidance to identify triggering behaviors: While identifying triggering behaviors can be helpful for future prevention, the immediate priority is ensuring the client’s safety. This is effectively achieved through a rapid exit plan, especially in cases of repeated assaults.

B. Develop a plan for initiating a rapid exit: The highest priority is ensuring the client's safety. A rapid exit plan, which involves knowing how to leave the abusive situation quickly and safely, is essential for protecting the client from immediate harm and planning for their long-term safety.

C. Advise couple's counseling as the next step: While counseling may be useful later, it is not appropriate to suggest it immediately after an assault. The client’s safety is the priority, and counseling should not be recommended until the client is in a safe environment.

D. Complete a Patient Health Questionnaire-9 (PHQ9): The PHQ9 is useful for assessing depression, but the immediate priority is addressing the client's safety and planning for protection, which should come before assessing for mental health concerns.

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Correct Answer is ["A","B","G","H"]

Explanation

A. The temperature taken at home is 99.0° F (37.2° C): A normal temperature of 99.0°F indicates that the fever associated with mastitis has resolved from he initial 38.4° C, suggesting that the infection has been treated successfully.

B. The infant is breastfeeding every 2 to 3 hours for 20 minutes in a variety of positions:
Regular breastfeeding every 2-3 hours for 20 minutes helps ensure proper drainage of the breast, which is essential for preventing mastitis recurrence. Using various positions encourages effective drainage of milk from all areas of the breast.

C. After a feeding, the nipple is creased: A creased nipple suggests a potential problem with latching, which may cause pain or nipple damage. It is not indicative of mastitis resolution or proper breastfeeding management.

D. The infant continues to want to nurse all the time: Increased demand for nursing could indicate a growth spurt or an ineffective milk transfer, which doesn’t directly confirm that mastitis has been resolved. It shows breastfeeding might need to be reassessed.

E. Pain during feeding lasts for 10 of the 20 minutes of the feed: Persistent pain during feeding may indicate an improper latch, nipple trauma, or other issues, and is not a sign that mastitis has resolved. This requires evaluation of breastfeeding technique.

F. Pumping continues on the right side instead of breastfeeding on that side: Pumping rather than breastfeeding may suggest that the patient is avoiding breastfeeding from the affected breast due to pain or discomfort. It does not confirm that mastitis has been fully resolved.

G. The red area on her right breast has resolved: The red area in the breast, a key symptom of mastitis, resolving suggests that the infection has improved and that the inflammation is subsiding. This is a clear indicator that the mastitis has resolved.

H. The feelings of fatigue continue, but there are no chills, achiness, or dizziness: Fatigue can persist in the postpartum period, but the absence of chills, achiness, or dizziness indicates that the mastitis infection has resolved and the systemic symptoms are no longer present.

A. Iron. B. Vitamin D. C. Folic acid. D. Calcium.

Correct Answer is C

Explanation

A. Iron: While iron is important during pregnancy to prevent anemia, it does not specifically help in the prevention of anencephaly. Its main function is oxygen transport and red blood cell production.
B. Vitamin D: Vitamin D is essential for bone health by playing a role in calcium absorption, but it does not have a direct role in preventing neural tube defects such as anencephaly. It is still an important nutrient during pregnancy.
C. Folic acid: Folic acid is the key supplement recommended before and during early pregnancy to prevent neural tube defects like anencephaly. It helps in the proper development of the neural tube in the fetus.
D. Calcium: Calcium is important for fetal bone development, but it does not prevent neural tube defects like anencephaly. It is more critical later in pregnancy for the developing skeletal system.

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The nurse is caring for a client in the emergency department (ED) after an assault by the spouse. The client has a history of similar emergency visits. Which action best assists the client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Which description(s) by the client should help confirm that the mastitis has been resolved and breastfeeding/breast health is well maintained? Select all that apply.

Correct Answer is ["A","B","G","H"]

Explanation

The nurse is providing preconception counseling. Which supplement should the nurse recommend to help prevent the occurrence of anencephaly?

Correct Answer is C

Explanation

A client tells the nurse that she thinks she is pregnant. Which sign or symptom provides the best indication that the client is pregnant?

When reading the obstetrical history of a client who is currently at 36 weeks gestation, the nurse notes that she has had one full term infant, one premature infant born at 32 weeks gestation that survived, and one miscarriage. Which is this client's gravidity?

Exhibits The nurse has reviewed the client's chart. Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided. The nurse recognizes that this client is dropdowndue todropdown.

The nurse is caring for a client with the sexually transmitted infection (STI) human papillomavirus (HPV). The client reports having sex with someone who had many partners. Which response should the nurse provide?

Prior to performing a postpartum assessment, the client tells the nurse, "I have pain in my stitches." The nurse knows that the client had a midline episiotomy. Which action should the nurse take first?

How should the nurse plan to position a client who has just undergone a radical mastectomy?

Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.