A female client who has been taking oral contraceptives for the past year comes into the clinic for an annual exam. Which finding is most important for the practical nurse (PN) to report to the healthcare provider?
Breast tenderness.
Left calf pain.
Change in menstrual flow.
Weight gain of 5 pounds (2.3 kg).
The Correct Answer is B
A. Breast tenderness is a common side effect of oral contraceptives and is generally not a cause for immediate concern unless accompanied by other symptoms.
B. Left calf pain is a significant finding that could indicate deep vein thrombosis (DVT), a serious condition requiring prompt evaluation and potential treatment to prevent complications such as pulmonary embolism.
C. A change in menstrual flow can occur with oral contraceptives but is usually less critical than other symptoms. It should be monitored but does not indicate an immediate problem.
D. A weight gain of 5 pounds is a relatively minor side effect and not as urgent as symptoms suggestive of a serious condition like DVT.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Measure urinary output.
Measuring urinary output is important for monitoring fluid balance but is not the most critical intervention for assessing left-sided heart failure specifically.
B. Auscultate all lung fields.
Auscultating lung fields is crucial for assessing signs of pulmonary edema, a key symptom of left-sided heart failure. It provides direct information about the severity of the condition and guides further management.
C. Check mental acuity.
Checking mental acuity can be useful but is not the most critical intervention for managing left-sided heart failure. It is less directly related to evaluating the severity of heart failure compared to lung auscultation.
D. Inspect for sacral edema.
Inspecting for sacral edema is more relevant for right-sided heart failure. For left-sided heart failure, the priority is evaluating pulmonary symptoms, not peripheral edema.
Correct Answer is A
Explanation
A. Reporting any foot injury or sore that does not readily heal is the most crucial instruction for minimizing long-term complications in diabetes management. Poor circulation and neuropathy in diabetic patients can lead to serious complications from minor foot injuries, so prompt medical evaluation is essential for preventing severe outcomes.
B. Drying feet thoroughly between toes is important for preventing fungal infections, but it is a standard part of foot care rather than a primary measure for preventing long-term complications like ulcers or infections.
C. Ensuring that shoe size fits to minimize rubbing and blisters is important for foot health, but it is not as critical as promptly addressing any injuries or sores that may arise.
D. Monitoring fingerstick glucose daily for tight control is necessary for diabetes management but does not directly address foot care issues. It is important for overall disease management but not specifically for immediate foot care concerns.
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