Lewis Test Bank Final Exam With 100% Correct Resolutions

Lewis Test Bank Final Exam With 100% Correct Resolutions The nurse in the women's health clinic has four patients who are waiting to be seen. Which patient should the nurse see FIRST? - CORRECT ANSWER-a. 22-year-old with persistent red-brown vaginal drainage 3 days after having balloon thermotherapy b. 42-year-old with secondary amenorrhea who says that her last menstrual cycle was 3 months ago c. 35-year-old with heavy spotting after having a progestin-containing IUD (Mirena) inserted a month ago D. 19-year-old with menorrhagia who has been using superabsorbent tampons and has fever with weakness Rational: The patients history and clinical manifestations suggest possible toxic shock syndrome, which will require rapid intervention. The symptoms for the other patients are consistent with their diagnoses and do not indicate life-threatening complications. A healthy 28-year-old who has been vaccinated against human papillomavirus (HPV) has a normal Pap test. Which information will the nurse include in patient teaching when calling the patient with the results of the Pap test? - CORRECT ANSWER-Pap testing is recommended every 3 years for women your age. To prevent pregnancy in a patient who has been sexually assaulted, the nurse in the emergency department will plan to teach the patient about the use of - CORRECT ANSWER-levonorgestrel (Plan-B One-Step). Rational: Plan B One-Step reduces the risk of pregnancy when taken within 72 hours of intercourse. The other methods are used for therapeutic abortion, but not for pregnancy prevention after unprotected intercourse. A 22-year-old tells the nurse that she has not had a menstrual period for the last 2 months. Which action is MOST important for the nurse to take? - CORRECT ANSWERA. Obtain a urine specimen for a pregnancy test. b. Ask about any recent stressful lifestyle changes. c. Measure the patients current height and weight. d. Question the patient about prescribed medications. Rational: Pregnancy should always be considered a possible cause of amenorrhea in women of childbearing age. The other actions are also appropriate, but it is important to check for pregnancy in this patient because pregnancy will require rapid implementation of actions to promote normal fetal development such as changes in lifestyle, folic acid intake, etc. Which information will the nurse include when teaching a patient who has developed a small vesicovaginal fistula 2 weeks into the postpartum period? - CORRECT ANSWERa. Take stool softeners to prevent fecal contamination of the vagina. b. Limit oral fluid intake to minimize the quantity of urinary drainage. C. Change the perineal pad frequently to prevent perineal skin breakdown. d. Call the health care provider immediately if urine drains from the vagina. Rational: Because urine will leak from the bladder, the patient should plan to use perineal pads and change them frequently. A high fluid intake is recommended to decrease the risk for urinary tract infections. Drainage of urine from the vagina is expected with vesicovaginal fistulas. Fecal contamination is not a concern with vesicovaginal fistulas. The nurse has just received change-of-shift report about the following four patients. Which patient should be assessed FIRST? - CORRECT ANSWER-a. A patient with a cervical radium implant in place who is crying in her room b. A patient who is complaining of 5/10 pain after an abdominal hysterectomy C. A patient with a possible ectopic pregnancy who is complaining of shoulder pain d. A patient in the fifteenth week of gestation who has uterine cramping and spotting Rational: The patient with the ectopic pregnancy has symptoms consistent with rupture and needs immediate assessment for signs of hemorrhage and possible transfer to surgery. The other patients should also be assessed as quickly as possible but do not have symptoms of life-threatening complications A 27-year-old patient tells the nurse that she would like a prescription for oral contraceptives to control her premenstrual dysphoric disorder (PMD-D) symptoms. Which patient information is MOST important to communicate to the health care provider? - CORRECT ANSWER-a. Bilateral breast tenderness b. Frequent abdominal bloating C. History of migraine headaches d. Previous spontaneous abortion Rational: Oral contraceptives are contraindicated in patients with a history of migraine headaches. The other patient information would not prevent the patient from receiving oral contraceptives. The nurse notes that a patient who has a large cystocele, admitted 10 hours ago, has not yet voided. Which action should the nurse take FIRST? - CORRECT ANSWER-a. Insert a straight catheter per the PRN order. b. Encourage the patient to increase oral fluids. c. Notify the health care provider of the inability to void. D. Use an ultrasound scanner to check for urinary retention. Rational: Because urinary retention is common with a large cystocele, the nurses first action should be to use an ultrasound bladder scanner to check for the presence of urine in the bladder. The other actions may be appropriate, depending on the findings with the bladder scanner. A 58-year-old patient who has undergone a radical vulvectomy for vulvar carcinoma returns to the medical-surgical unit after the surgery. The PRIORITY nursing diagnosis for the patient at this time is - CORRECT ANSWER-A. risk for infection related to contact of the wound with urine and stool. b. self-care deficit: bathing/hygiene related to pain and difficulty moving. c. imbalanced nutrition: less than body requirements related to low-residue diet. d. risk for ineffective sexual pattern related to disfiguration caused by the surgery. Rational: Complex and meticulous wound care is needed to prevent infection and delayed wound healing. The other nursing diagnoses may also be appropriate for the patient but are not the highest priority immediately after surgery. A 32-year-old woman brought to the emergency department reports being sexually assaulted. The patient is confused about where she is and she has a large laceration above the right eye. Which action should the nurse take FIRST? - CORRECT ANSWER-A. Assess the patients neurologic status. b. Assist the patient to remove her clothing. c. Contact the sexual assault nurse examiner (SANE). d. Ask the patient to describe what occurred during the assault. Rational: The first priority is to treat urgent medical problems associated with the sexual assault. The patients head injury may be associated with a head trauma such as a skull fracture or subdural hematoma. Therefore her neurologic status should be assessed first. The other nursing actions are also appropriate, but they are not as high in priority as assessment and treatment for acute physiologic injury. Which assessment finding in a woman who recently started taking hormone therapy (HT) is MOST important for the nurse to report to the health care provider? - CORRECT ANSWER-a. Breast tenderness B. Left calf swelling c. Weight gain of 3 lb d. Intermittent spotting Rational: Unilateral calf swelling may indicate deep vein thrombosis caused by the changes in coagulation associated with HT and would indicate that the HT should be discontinued. Breast tenderness, weight gain, and intermittent spotting are common side effects of HT and do not indicate a need for a change in therapy. An 18-year-old requests a prescription for birth control pills to control severe abdominal cramping and headaches during her menstrual periods. Which should the nurse take FIRST? - CORRECT ANSWER-a. Determine whether the patient is sexually active. b. Teach about the side effects of oral contraceptives. C. Take a personal and family health history from the patient.