A nurse is caring for a client who has an ectopic pregnancy. Which of the following findings should the nurse expect?
Bradycardia
Abdominal pain
Hypertension
Hydramnios
The Correct Answer is B
Rationale:
A. Bradycardia: Ectopic pregnancy does not typically cause bradycardia. If cardiovascular changes occur, tachycardia is more common due to pain, blood loss, or hypovolemic shock in the event of rupture.
B. Abdominal pain: Abdominal or pelvic pain is a hallmark sign of ectopic pregnancy. Pain may be localized to one side, often corresponding to the site of implantation, and can become severe if tubal rupture occurs.
C. Hypertension: Hypertension is not associated with ectopic pregnancy. Blood pressure may decrease if significant internal bleeding occurs, potentially leading to hypotensive shock.
D. Hydramnios: Hydramnios (excess amniotic fluid) occurs in certain intrauterine complications but is not a feature of ectopic pregnancy, as the gestation occurs outside the uterine cavity.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Obtaining the initial assessment of assigned clients: The initial assessment requires nursing judgment and clinical decision-making, which are within the scope of practice of a registered nurse only. It involves data interpretation and establishing a baseline for care, tasks that cannot be delegated to assistive personnel.
B. Educating a client and family members on home care: Client and family teaching requires specialized nursing knowledge to ensure understanding and accuracy. This task involves evaluating learning needs and reinforcing critical information, responsibilities that cannot be legally delegated to assistive personnel.
C. Changing a nonsterile dressing: Assistive personnel can safely perform nonsterile procedures such as changing a clean dressing under the supervision of a nurse. This task involves routine care that does not require nursing judgment, making it appropriate for delegation.
D. Interpreting a client's diagnostic laboratory results: Interpretation of laboratory data involves analysis, clinical reasoning, and the ability to make informed nursing decisions. These actions fall strictly within the nurse’s professional scope of practice and cannot be delegated to assistive personnel.
Correct Answer is D
Explanation
Rationale:
A. "I understand that my scars will eventually fade.": This statement reflects acceptance and understanding of the healing process rather than distress about appearance. It indicates the client is cognitively processing changes without expressing body image disturbance.
B. "I am ready to join a breast cancer support group.": Willingness to participate in a support group demonstrates coping and adjustment. The client is seeking social and emotional support, which is a healthy response to surgery rather than a sign of altered body image.
C. "I want to have reconstructive surgery as soon as I can.": Desire for reconstructive surgery is a proactive coping strategy and a way to regain body image control. It reflects planning for recovery rather than expressing negative feelings about current body changes.
D. "I prefer to leave the lights off when I am changing my clothes.": Avoiding exposure of the body and seeking darkness when changing clothes indicates discomfort and distress with physical appearance. This behavior reflects an altered body image and difficulty accepting the changes after surgery.
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