A young female client is discussing the various methods of contraception with the nurse. Which factor is most important for the nurse to consider in counseling the client?
The cost of the contraceptive method.
The client's sexual history.
Client reports a history of migraine headaches.
✓
Client has an irregular menstrual cycle.
Correct Answer
Client reports a history of migraine headaches.
Migraine headaches are a concern with contraceptive medications that contain progestins because they may exacerbate the headaches.
Question 2
A client in labor is receiving an oxytocin infusion. Which signs and symptoms are a priority for the nurse to assess further?
Sudden onset of confusion and muscle cramps
✓
Urine output of 100 mL/hour
Client-reported headache of 4 out of 10 on the pain scale
Maternal heart rate of 102 beats/minute and blood pressure of 146/90 mm Hg
Correct Answer
Sudden onset of confusion and muscle cramps
Oxytocin's effect on the kidneys can cause water intoxication and dilutional hyponatremia, which are considered significant side effects. Signs and symptoms of hyponatremia are related to the central nervous system (CNS) and musculoskeletal system.
Question 3
A 68-year-old male client comes to the emergency department with chest pain. Before administering the ordered sublingual nitroglycerin, which question is most important for the nurse to ask the client?
"Do you have a history of cardiac problems?"
"How long have you had the chest pain?"
"Do you take any medications for erectile dysfunction?"
✓
"When did you last eat or drink anything?"
Correct Answer
"Do you take any medications for erectile dysfunction?"
Nitroglycerin is contraindicated when a client is using drugs for ED. The combination can cause significant hypotension and possible cardiac arrest.
Question 4
An 11-year-old client is undergoing hormone therapy with testosterone for hypogonadism. Which assessment is most important for the nurse to monitor?
Serum hemoglobin and hematocrit monthly
Results of radiographic images of the long bones every 6 months
✓
Serum electrolytes weekly
Blood pressure and electrocardiogram weekly
Correct Answer
Results of radiographic images of the long bones every 6 months
Prepubescent clients on testosterone therapy may develop early closure of epiphyseal growth plates and stunted growth. Testosterone therapy may need to be decreased or stopped.
Question 5
The nurse is caring for a client in labor who will be receiving an MgSO4 infusion for eclampsia. Which provider's order is most important to implement?
Oxygen saturation monitoring
Nothing by mouth (NPO)
Hourly urine output
Continuous cardiac monitoring
✓
Correct Answer
Continuous cardiac monitoring
MgSO4 can cause serious life-threatening cardiac rhythm changes and circulatory collapse. Therefore, continuous cardiac monitoring is the most important order to implement.
Question 6
A male high school student who plays on the football team has been referred to the school nurse. He reports feeling anxious and irritable, and his stomach bothers him most of the time. He tells the nurse, "I never had acne problems, but now it's terrible. And my hair is falling out." What question by the nurse would be most appropriate?
"How many hours of sleep are you getting each night?"
"Are you eating a lot of greasy or spicy foods?"
"Do you have a family history of depression or anxiety?"
"Are you taking anything to help you build up your muscle strength?"
✓
Correct Answer
"Are you taking anything to help you build up your muscle strength?"
Given the context of a high school football player with these signs and symptoms, the nurse should recognize that the student may be misusing steroids. This question can help the nurse further assess the situation.
Question 7
A postmenopausal female is at high risk for developing osteoporosis. Her provider has prescribed alendronate. Which statement by the client indicates a need for further teaching by the nurse?
"Walking 30 minutes a day can help prevent my bones from becoming weak."
"I can go ahead and have a tooth that is bothering me pulled."
✓
"I need to sit or stand for 30 minutes after taking the medication."
"I should drink a full glass of water with the medication."
Correct Answer
"I can go ahead and have a tooth that is bothering me pulled."
Invasive dental procedures should not be planned during bisphosphonate therapy because of the high risk of developing bisphosphonate-induced osteonecrosis of the jaws (BIONJ).
Question 8
A 45-year-old client with prostate cancer is undergoing treatment with bicalutamide. Which problem is a priority for the nurse to address?
Risk for injury: impaired liver function
✓
Chronic pain
Disturbed body image
Risk for imbalanced nutrition
Correct Answer
Risk for injury: impaired liver function
Impaired liver function is a serious side effect of antiandrogen medications. Clients on bicalutamide have developed liver failure and died. Liver function must be monitored closely.
Question 9
A postmenopausal client is taking a bisphosphonate medication. Which diagnostic testing for this client does the nurse expect to be a priority?
Electrocardiogram and stress testing
Bone density
✓
Upper endoscopy
Venous ultrasound
Correct Answer
Bone density
Bone density testing should be scheduled routinely to determine the effectiveness of the drug therapy.
Question 10
A client with a chronic illness is taking an anabolic steroid. Which condition indicates the drug is having a therapeutic effect?
Increased hemoglobin
✓
Worsening acne
Hirsutism
Alopecia
Correct Answer
Increased hemoglobin
In this case, the anabolic steroid would be used to improve health status, indicated by increased hemoglobin.