A nurse at the family planning clinic triages several clients over the phone. Which of the following clients should the nurse instruct to come to the clinic?
A client who uses a diaphragm for contraception and has lost 30 lb in the past 6 months dieting
A client who had an intrauterine device (IUD) inserted yesterday and has cramping and bleeding
A client who has started taking oral contraceptives and is experiencing bright red vaginal breakthrough bleeding
A client who has sharp pain in her shoulder following a laparoscopic tubal ligation yesterday
The Correct Answer is D
A. Weight loss while using a diaphragm is not typically an urgent concern and may be related to dieting; the client should be advised to follow up with her primary care provider for further
evaluation.
B. Cramping and bleeding are common side effects following an IUD insertion and typically do not require immediate attention unless severe or accompanied by other concerning symptoms;
the client should be advised to monitor her symptoms and follow up if they worsen.
C. Breakthrough bleeding is a common side effect of starting oral contraceptives and may resolve on its own after a few cycles; the client should be advised to continue taking her pills as prescribed and to follow up if the bleeding persists or worsens.
D. Shoulder pain following a laparoscopic procedure may indicate a potential complication such as referred pain from gas used during the procedure or more serious issues such as internal bleeding or organ injury; the client should be instructed to come to the clinic for further
evaluation and management.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Diminished bowel sounds are not typically indicative of fluid overload. They may suggest decreased gastrointestinal motility, but this finding alone does not specifically indicate fluid overload.
B. Bradycardia is not typically associated with fluid overload. Instead, tachycardia may occur as the body attempts to compensate for decreased cardiac output.
C. Hypotension may occur with fluid overload in severe cases, but it is not a consistent or specific finding. Other signs, such as bounding pulses, are more indicative of fluid overload.
D. Bounding pulses, or strong and forceful arterial pulses, can be a sign of fluid overload due to increased blood volume. This finding may be observed in clients receiving excessive enteral feedings or intravenous fluids.
Correct Answer is C
Explanation
A. Holding the newborn in an en face position: This action promotes bonding between the mother and the newborn and is a positive interaction.
B. Asking the father to change the newborn's diaper: Involving the father in caregiving tasks fosters family involvement and bonding.
C. Viewing the newborn's actions to be uncooperative: This suggests a negative perception of the newborn's behavior, which could indicate potential issues with bonding or misunderstanding
infant cues, requiring the nurse's intervention.
D. Requesting the nurse take the newborn to the nursery so she can rest: While rest is important for the mother, separating the newborn from the mother could disrupt bonding and breastfeeding, so this action should be discussed further with the client to explore other options.
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