A nurse is collecting data from a client who has been taking medroxyprogesterone for 6 months. Which of the following statements by the client should the nurse identify as the priority to report?
I have occasional vaginal spotting."
I have developed brown patches on my face."
I have breast tenderness."
I have intermittent calf pain."
The Correct Answer is D
A) I have occasional vaginal spotting: Vaginal spotting can occur as a side effect of medroxyprogesterone, especially in the first few months of use. While this should be monitored, it is not an immediate concern that requires urgent reporting unless the spotting becomes heavy or persistent, which could indicate other issues.
B) I have developed brown patches on my face: The development of brown patches on the face (known as melasma) is a known side effect of hormonal contraceptives, including medroxyprogesterone. Although this is an undesirable cosmetic effect, it is not an urgent medical concern that requires immediate attention.
C) I have breast tenderness: Breast tenderness is a common side effect of medroxyprogesterone and other hormonal medications. It is usually mild and resolves over time. While the client should continue to monitor the tenderness, it does not present an immediate risk or require urgent intervention.
D) I have intermittent calf pain: Intermittent calf pain could be a sign of a more serious complication, such as a deep vein thrombosis (DVT), especially since medroxyprogesterone can increase the risk of blood clots. This symptom should be reported immediately to the healthcare provider, as a DVT could potentially lead to a pulmonary embolism if left untreated, which is a life-threatening condition. Therefore, this is the priority finding to report.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Drain the tub water before the client gets out: Draining the water before the client gets out of the tub is the safest option. This helps prevent the risk of slipping or falling, as the water level will lower once the client begins to stand. Additionally, it ensures that the client can safely exit the tub without the danger of being unbalanced or disoriented by the water.
B) Check on the client every 10 min during the bath: While monitoring the client during the bath is important, checking every 10 minutes may not be frequent enough to ensure their safety, especially for clients who have mobility or cognitive issues. Ideally, the nurse should stay with or observe the client more closely or provide assistance if needed. Continuous supervision is preferred, particularly if the client is at risk for falls or other complications.
C) Add bath oil to the water after the client gets into the tub: Bath oils can create a slippery surface, which could increase the risk of falls or accidents. It's generally better to avoid adding oils to the bath water, as they can make the tub and the client’s skin slick, posing safety hazards. If oil is necessary for skin care, it should be applied to the skin after the bath, not in the water.
D) Allow the client to remain in the bath for 30 min: While the client may enjoy a bath, staying in the tub for too long can lead to skin irritation, dehydration, or overheating, especially for older adults or clients with medical conditions. The client should not stay in the water for prolonged periods. A typical recommendation would be to allow the bath to last about 10-20 minutes, depending on the client’s condition and safety.
Correct Answer is A
Explanation
A) Bran muffin:
Bran is high in fiber, which is beneficial for managing constipation. Fiber helps to promote bowel movements by adding bulk to stool and improving gut motility. A bran muffin is an excellent choice for a client with constipation because it is rich in insoluble fiber, which is particularly effective in relieving constipation.
B) Tomato juice:
While tomato juice can provide some vitamins and nutrients, it is low in fiber, which is essential for managing constipation. For constipation relief, it is better to choose foods high in fiber, such as whole grains, fruits, and vegetables.
C) Puffed rice cereal:
Puffed rice cereal is low in fiber, making it an unsuitable choice for someone with constipation. Although it may provide some calories, it does not offer the beneficial fiber that can help relieve constipation.
D) Cottage cheese:
Cottage cheese is low in fiber and high in protein, but it does not contribute to bowel regularity. For constipation management, it is crucial to choose foods that are high in fiber, like fruits, vegetables, and whole grains, rather than low-fiber foods like cottage cheese.
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