A nurse is collecting data from a client who is taking an oral contraceptive. Which of the following findings is a contraindication for the use of oral contraceptives?

Headaches with aura

History of mononucleosis 1 year ago.

Irregular menstrual cycles

Gastroesophageal reflux disease.

Answer and Explanation

The Correct Answer is A

A. Headaches with aura is correct. Headaches with aura, a warning sign that can precede a migraine, are a contraindication for the use of oral contraceptives. This is because oral contraceptives increase the risk of stroke, especially in women who experience migraines with aura.

B. History of mononucleosis 1 year ago is incorrect. There is no specific contraindication for oral contraceptives related to a history of mononucleosis. This condition does not affect the effectiveness or safety of oral contraceptive use.

C. Irregular menstrual cycles is incorrect. Irregular menstrual cycles are not a contraindication for oral contraceptive use. In fact, oral contraceptives may help regulate menstrual cycles.

D. Gastroesophageal reflux disease (GERD. is incorrect. While GERD may cause discomfort, it is not a contraindication for oral contraceptives. Women with GERD can typically use oral contraceptives safely.

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Correct Answer is B

Explanation

A. The client's potassium level is 2.7 mEq/L is incorrect. A potassium level of 2.7 mEq/L is low and indicates hypokalemia, which is a life-threatening condition that can occur in anorexia nervosa, particularly if the client is engaging in behaviors like purging. This level should be addressed immediately, not considered a positive outcome.

B. The client resumes menstruation is correct. The resumption of menstruation is a positive outcome of treatment for anorexia nervosa. It indicates that the client's nutritional status has improved and that the body is starting to regain normal function after addressing issues like malnutrition and hormonal imbalances.

C. The client's pulse rate is 44/min is incorrect. A pulse rate of 44/min is bradycardia, which is a common sign of anorexia nervosa due to malnutrition and the body's attempt to conserve energy. While it may improve with treatment, this finding would not be considered a positive outcome.

D. The client develops lanugo is incorrect. Lanugo (fine, soft hair) typically develops in severe anorexia nervosa due to malnutrition and is a sign of starvation. The appearance of lanugo is not a positive outcome but rather a compensatory mechanism to retain heat, indicating that the client is still in a malnourished state.

A. Tell the APs to stop the conversation. B. Document the event in the client's progress notes. C. Inform the client of the APs' actions. D. Submit an incident report to the risk manager.

Correct Answer is A

Explanation

A. Telling the APs to stop the conversation is correct. Discussing client information in a public area violates HIPAA (Health Insurance Portability and Accountability Act) privacy regulations. The nurse should immediately intervene and remind the APs about maintaining client confidentiality.

B. Documenting the event in the client's progress notes is incorrect. Client progress notes should contain only information relevant to client care. Documenting an overheard conversation about a privacy violation does not belong in the medical record.

C. Informing the client of the APs' actions is incorrect. While privacy is essential, informing the client may cause unnecessary distress. The nurse should focus on correcting the behavior of the APs rather than alarming the client.

D. Submitting an incident report to the risk manager is incorrect. While some breaches of confidentiality require reporting, the first step is to address the issue directly with the APs. If the behavior continues or is severe, reporting to a supervisor may be necessary.

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A nurse is collecting data from a client who is taking an oral contraceptive. Which of the following findings is a contraindication for the use of oral contraceptives?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has anorexia nervosa. Which of the following findings should the nurse identify as a positive outcome of treatment?

Correct Answer is B

Explanation

A nurse overhears two assistive personnel (AP) in the nurses' station discussing a client who was recently admitted. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is reinforcing teaching with a client's family about home oxygen use via nasal cannula. Which of the following statements by a family member indicates an understanding of the teaching?

A nurse is reinforcing teaching about disease management with a client who has GERD. Which of the following statements should the nurse make?

A nurse is reinforcing teaching with a newly licensed nurse about caring for a client who has a history of dysphagia. Which of the following instructions should the nurse include in the teaching?

A nurse is reinforcing teaching with a parent of a preschooler about immunizations. Which of the following statements by the parent indicates an understanding of the teaching?

A nurse is caring for a client who is confused and is trying to pull out their IV catheter. After attempting other measures to prevent the client from self-harm, the nurse places wrist restraints on the client. Which of the following actions should the nurse take?

A home health nurse is reinforcing teaching about home safety with an older adult client who lives alone. Which of the following client statements indicates an understanding of the teaching?

A nurse is reviewing the medical record of a client who is at 37 weeks of gestation and has HELLP syndrome. Which of the following laboratory findings should the nurse expect?

A nurse is caring for a client who has a prescription for acetaminophen 300 mg with codeine 30 mg, 1 tablet every 3 to 4 hr. PRN for pain. The nurse inadvertently administers 2 tablets to the client. In which of the following locations should the nurse document this client care incident?