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 A
Explanation
A. Kawasaki disease involves inflammation of the blood vessels and can lead to serious cardiac complications, including coronary artery aneurysms. Monitoring cardiac status is essential to detect and manage these risks.
B. While managing fever is a part of treating Kawasaki disease, acetaminophen is typically used as needed rather than on a strict schedule unless fever is persistent.
C. During the acute phase of Kawasaki disease, children often feel very irritable and unwell; large group activities may be overwhelming and inappropriate.
D. Kawasaki disease is not caused by a bacterial infection, and antibiotics are not part of the treatment. Instead, treatment usually involves high-dose aspirin and intravenous immunoglobulin.
Correct Answer is B
Explanation
A: Heparin administration requires careful monitoring of clotting times, so discharging this client early may not be safe or appropriate.
B: A vertebroplasty is a procedure that injects cement into a fractured vertebra to help relieve pain and stabilize the spine. The recovery time for this procedure is usually short and the complications are rare.
C: This client has a respiratory rate suggestive of respiratory distress and may require immediate medical attention, hence early discharge is not an option.
D: The client with cancer and a sealed implant for radiation therapy may require ongoing monitoring and supportive care, so early discharge may not be advisable.
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