A nurse is caring for a client who is 4 days postpartum following a cesarean birth
For each potential assessment finding, click to specify if the assessment finding is consistent with mastitis or endometritis. Each finding may support more than 1 disease process
Painful, tender breast
Temperature
Chills
Foul-smelling lochia
The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A,B"},"C":{"answers":"A,B"},"D":{"answers":"B"}}
Mastitis: A, B, C
Endometritis: B, C, D
Rationale:
A. This finding is consistent with mastitis. Mastitis is characterized by inflammation of the breast tissue, often presenting with pain, tenderness, warmth, and redness in the affected breast.
B. This finding can be indicative of both mastitis and endometritis. A fever, as indicated by an elevated temperature (38.8°C or 101.9°F), is a common symptom of both mastitis and endometritis. It suggests an inflammatory response or infection in the body.
C. This finding is also consistent with both mastitis and endometritis. Chills often accompany fever and can be a sign of systemic infection or inflammation.
D. This finding is more indicative of endometritis. Endometritis involves infection or inflammation of the uterine lining, which can result in foul-smelling lochia. Foul- smelling lochia may indicate the presence of infection within the uterus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. A towel on the floor outside of the shower could be a tripping hazard.
B. This prevents slipping and falls, which is crucial for someone recovering from knee surgery.
C. Slippers with non-slip soles would be a safer choice to prevent falls.
D. While handrails are helpful for mobility and safety, this recommendation does not address the immediate postoperative care needs of the client following knee surgery.
Correct Answer is C
Explanation
A. While rest and a quiet environment can be beneficial, encouraging the client to address the hallucinations directly is more appropriate.
B. Avoiding eye contact may be perceived as dismissive or unhelpful.
C. Engaging the client in open communication about their hallucinations can help build trust and rapport, as well as provide valuable information for treatment planning.
D. Validating hallucinations as real can reinforce delusional thinking and may not be therapeutically beneficial.
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