A nurse is assessing a client who has been taking oral contraceptives for the past 6 months. Which of the following findings should the nurse immediately report to the provider?
Weight gain 2.3 kg (5 lb)
Frequent nausea
Breast tenderness
Persistent headache
The Correct Answer is D
A. Weight gain 2.3 kg (5 lb): Mild weight gain can occur with oral contraceptive use and is generally not dangerous. This finding does not require immediate reporting.
B. Frequent nausea: Nausea is a common side effect, especially during the first few months of therapy. While bothersome, it is usually not an urgent concern unless severe or persistent.
C. Breast tenderness: Breast tenderness is a common, mild side effect of oral contraceptives and does not typically indicate a serious problem requiring immediate intervention.
D. Persistent headache: A new, persistent, or severe headache can indicate vascular complications, such as hypertension or increased risk of thromboembolism, which are serious adverse effects of oral contraceptives. This finding requires immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "You have the right to refuse the procedure.": Clients have the legal and ethical right to refuse treatment at any time, including surgery. Acknowledging this respects the client’s autonomy and supports informed decision-making.
B. "We can manage your care following the procedure without complications.": This statement minimizes the client’s concerns and may be perceived as coercive. It does not address the client’s right to make an informed choice.
C. "Your doctor thinks this surgery is necessary.": Referencing the provider’s opinion without exploring the client’s concerns does not respect the client’s autonomy and may increase anxiety or pressure to comply.
D. "Let me review the procedure so you can understand what is going to happen.": While providing information is helpful, the client has already expressed refusal. This approach may be more appropriate if the client is undecided, but it does not acknowledge their right to decline.
Correct Answer is B
Explanation
A. Both fontanels are the same size: Fontanels differ in size and shape; the anterior is larger and diamond-shaped, while the posterior is smaller and triangular. Expecting them to be the same size is inaccurate.
B. The anterior fontanel is open: The anterior fontanel typically remains open until about 12–18 months of age. At 8 months, an open anterior fontanel is an expected finding and indicates normal skull development.
C. The posterior fontanel is open: The posterior fontanel usually closes by 6–8 weeks of age. An open posterior fontanel at 8 months may indicate delayed closure and should be evaluated further.
D. Both fontanels show molding: Molding refers to overlapping of cranial bones during birth. At 8 months, molding should no longer be present; its presence is not a normal finding at this age.
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