A woman is in her seventh month of pregnancy.
She has been reporting nasal congestion and occasional epistaxis. The nurse suspects that:
This is a normal respiratory change in pregnancy caused by elevated levels of estrogen.
This is an abnormal cardiovascular change, and the nosebleeds are an ominous sign.
The woman is a victim of domestic violence and is being hit in the face by her partner.
The woman has been using cocaine intranasally.
The Correct Answer is A
This is a normal respiratory change in pregnancy caused by elevated levels of estrogen. Estrogen increases blood flow and causes the nasal mucosa to swell, leading to congestion and nosebleeds. This condition is called pregnancy rhinitis and affects up to 20% of pregnant women.
Choice B is wrong because this is not an abnormal cardiovascular change, and the nosebleeds are not an ominous sign. They are usually harmless and do not affect the pregnancy outcome.
Choice C is wrong because there is no evidence that the woman is a victim of domestic violence.
This is a serious accusation that should not be made without proper assessment and screening.
Choice D is wrong because there is no indication that the woman has been using cocaine intranasally. Cocaine use can cause nasal damage and bleeding, but it can also have other signs and symptoms such as agitation, euphoria, dilated pupils, increased heart rate and blood pressure, and risk of miscarriage or preterm labor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A brilliant, uniform red reflex in both eyes is a sign of a healthy retina and optic nerve. The red reflex is the reflection of light from the retina that varies in color depending on the patient’s skin tone. It can be seen by holding the ophthalmoscope directly in front of your eye and asking the patient to focus on a point in the distance.
Choice B is wrong because an abnormal finding would be an absent or asymmetric red reflex, which could indicate cataracts, retinal detachment, or other eye diseases.
Choice C is wrong because a possible visual defect would not affect the red reflex, but rather the visual acuity or field of vision of the patient.
A vision screening would involve testing the patient’s ability to read letters or numbers at different distances.
Choice D is wrong because small hemorrhages would not cause a brilliant, uniform red reflex, but rather dark spots or blotches on the retina that can be seen with the ophthalmoscope.
Hemorrhages can be caused by diabetes, hypertension, or trauma.
Correct Answer is D
Explanation
Diabetes insipidus is a disorder of the posterior pituitary gland that causes a deficiency of antidiuretic hormone (ADH). This leads to excessive urination (polyuria) and excessive thirst (polydipsia) as the body tries to balance the fluid loss. These symptoms may be so severe that the child does little other than drink and urinate.
Choice A is wrong because oliguria means decreased urine production and is not associated with diabetes insipidus.
Choice B is wrong because glycosuria means glucose in the urine and is associated with diabetes mellitus, not diabetes insipidus.
Choice C is wrong because nausea and vomiting are associated with inappropriate ADH secretion (SIADH), which causes fluid retention and hyponatremia, not diabetes insipidus.
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