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?
Persistent headache.
Weight gain 2.3 kg (5 lb).
Frequent nausea.
Breast tenderness.
The Correct Answer is A
Choice A reason: Persistent headache on oral contraceptives may indicate serious complications like stroke or hypertension, requiring immediate reporting to prevent life-threatening events. This is critical for timely intervention, ensuring client safety, and guiding potential medication adjustments in women using hormonal contraception for 6 months.
Choice B reason: Weight gain of 2.3 kg is common with oral contraceptives and not urgent, unlike persistent headache, which signals serious risks. Assuming weight gain requires reporting risks overlooking critical neurological symptoms, critical to avoid in ensuring safe monitoring of contraceptive side effects.
Choice C reason: Frequent nausea is a common contraceptive side effect, typically managed with counseling, not urgent like headache. Assuming nausea is priority risks delaying serious symptom evaluation, critical to prevent in ensuring timely reporting of potentially life-threatening complications in contraceptive users.
Choice D reason: Breast tenderness is a common, non-urgent side effect of oral contraceptives, unlike persistent headache, which may indicate stroke risk. Assuming tenderness is urgent risks missing critical symptoms, critical to avoid in ensuring proper monitoring and safety in clients on hormonal contraception.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Bed rest for 24 hours post-surgery increases stasis, risking thrombosis; range-of-motion exercises promote circulation. Assuming bed rest is correct risks complications, critical to avoid in ensuring active circulation and preventing venous thromboembolism in postoperative clients during recovery.
Choice B reason: Placing a pillow under knees promotes venous pooling, increasing clot risk; range-of-motion exercises are safer. Assuming pillow use is correct risks impaired circulation, critical to prevent in ensuring effective postoperative care and reducing thrombosis risk in surgical clients.
Choice C reason: Incentive spirometry prevents respiratory complications, not directly promoting circulation; range-of-motion exercises are key. Assuming spirometry aids circulation risks overlooking mobility needs, critical to avoid in ensuring proper venous return and clot prevention in postoperative clients during recovery.
Choice D reason: Range-of-motion exercises promote circulation post-surgery, preventing venous stasis and thrombosis, critical for recovery. This instruction ensures active blood flow, essential for reducing clot risk, supporting healing, and enhancing postoperative outcomes in clients across various surgical procedures.
Correct Answer is D
Explanation
Choice A reason: Discussing communication methods addresses client behaviors but not the caregiver’s stress from constant care. A daycare program offers respite. Focusing on communication risks neglecting caregiver well-being, potentially worsening burnout, critical to avoid in supporting caregivers of Alzheimer’s clients with high care demands.
Choice B reason: Suggesting antipsychotics for the client addresses behavior but not caregiver stress, and is inappropriate without medical evaluation. Daycare provides relief. Assuming medication is the solution risks unnecessary drug use, potentially causing side effects, critical to avoid in supporting caregiver health and client safety.
Choice C reason: Allowing the client time alone is unsafe for Alzheimer’s patients due to wandering risks and does not relieve caregiver stress. Daycare is effective. Assuming alone time helps risks client safety and caregiver burden, critical to prevent in ensuring comprehensive care for Alzheimer’s clients and caregivers.
Choice D reason: Assisting with a daycare program provides respite, reducing caregiver stress and preventing burnout while ensuring client safety. This intervention supports caregiver well-being, critical for sustained care quality, promoting mental health, and enabling effective management of Alzheimer’s disease in home settings with high care demands.
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