Which assessment findings might raise the nurse's suspicion of endometriosis in the client they are evaluating?

Unexplained weight gain

Pain during menstrual period

Pain during intercourse

Infertility

Answer and Explanation

Correct Answer : B,C,D

A. Unexplained weight gain
This is incorrect because weight gain is not a characteristic symptom of endometriosis. Endometriosis primarily affects the reproductive organs and is associated with pain and infertility rather than metabolic or weight-related changes.

B. Pain during menstrual period
This is correct because dysmenorrhea (painful menstruation) is a hallmark symptom of endometriosis due to the presence of ectopic endometrial tissue responding to hormonal changes.

C. Pain during intercourse
This is correct because dyspareunia (pain during intercourse) is a common symptom of endometriosis due to the inflammatory and fibrotic changes caused by ectopic endometrial tissue.

D. Infertility
This is correct because endometriosis can lead to infertility due to scarring, adhesions, and inflammation affecting the fallopian tubes and ovaries. Many clients with endometriosis seek medical attention due to difficulty conceiving.

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Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"C"}}

Explanation

Preeclampsia:

Blood pressure of 150/96 mmHg: A BP of ≥140/90 mmHg on two occasions at least 4 hours apart after 20 weeks of gestation in a previously normotensive client is diagnostic of preeclampsia.

Preeclampsia with Severe Features:

Blood pressure of 162/112 mmHg: Severe hypertension is ≥160/110 mmHg on two occasions at least 4 hours apart. This is a criterion for severe preeclampsia, requiring immediate intervention to prevent complications like eclampsia or stroke.

Elevated liver enzymes (ALT/AST > 2x the upper limit of normal) are indicative of severe preeclampsia due to hepatic involvement. This can progress to HELLP syndrome, increasing the risk of liver rupture and disseminated intravascular coagulation (DIC).

Neither:

Negative for protein on a urine dipstick: Preeclampsia is typically diagnosed with proteinuria (≥300 mg in 24 hours or protein/creatinine ratio ≥0.3). A negative urine dipstick means proteinuria is absent, making preeclampsia unlikely. However, preeclampsia can also be diagnosed without proteinuria if other systemic features (e.g., thrombocytopenia, renal dysfunction) are present.

Seizures in a client with preeclampsia indicate eclampsia, which is a medical emergency requiring magnesium sulfate to prevent further seizures. If the client had no preeclampsia, the seizures could be due to another cause (e.g., epilepsy, metabolic disturbance).

A. During the next attempt to get pregnant B. Immediately after delivery C. During the third trimester of pregnancy D. During the first trimester of pregnancy

Correct Answer is B

Explanation

A. During the next attempt to get pregnant
This is incorrect because waiting until the next pregnancy increases the risk of congenital rubella syndrome in future pregnancies. The vaccine should be given immediately postpartum to provide immunity.

B. Immediately after delivery
This is correct because the rubella vaccine (MMR) is a live vaccine and is contraindicated during pregnancy due to teratogenic effects. It should be given postpartum before hospital discharge to prevent future rubella infections.

C. During the third trimester of pregnancy
This is incorrect because live vaccines are contraindicated in pregnancy due to the risk of fetal infection.

D. During the first trimester of pregnancy
This is incorrect because administering a live vaccine early in pregnancy is dangerous and could cause fetal harm or congenital anomalies.

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Which assessment findings might raise the nurse's suspicion of endometriosis in the client they are evaluating?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

G1P1, 37 weeks' gestation patient with a scheduled nonstress test (NST) As the nurse, you can identify whether the following findings are indicative of preeclampsia, preeclampsia with severe features, or neither. Select at least one answer in each row.

Correct Answer is {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"C"}}

Explanation

A nurse is caring for a client in the first trimester of pregnancy and discovers that the client lacks immunity to rubella based on her blood work. When is the recommended time for administering rubella immunization?

Correct Answer is B

Explanation

G1P1, 37 weeks' gestation patient with a scheduled nonstress test (NST) Complete the following sentence using the drop-down options. The nurse's greatest concern is the client's risk of developing __i_____ and related to __ii____ and ___iii____.

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