- (Topic 2)
The nurse would be concerned if a client exhibited which of the following symptoms during her postpartum stay?

1. A. Pulse rate of 50–70 bpm by her third postpartum day
2. B. Diuresis by her second or third postpartum day
3. C. Vaginal discharge or rubra, serosa, then rubra
4. D. Diaphoresis by her third postpartum day

Correct Answer: C
(A) Bradycardia is an expected assessment during the postpartum period. (B) Diuresis can occur during labor and the postpartum period and is an expected physiological adaptation.
(C) A return of rubra after the serosa period may indicate a postpartal complication. (D) Diaphoresis, especially at night, is an expected physiological change and does not indicate an infectious process. Bradycardia, diuresis, and diaphoresis are normal postpartum physiological responses to adjust the cardiac output and blood volume to the nonpregnant state.

- (Topic 2)
In assisting preconceptual clients, the nurse should teach that the corpus luteum secretes progesterone, which thickens the endometrial lining in which of the phases of the menstrual cycle?

1. A. Menstrual phase
2. B. Proliferative phase
3. C. Secretory phase
4. D. Ischemic phase

Correct Answer: C
(A) Menses occurs during the menstrual phase, during which levels of both estrogen and progesterone are decreased. (B) The ovarian hormone responsible for the proliferative phase, during which the uterine endometrium enlarges, is estrogen. (C) The ovarian hormone responsible for the secretory phase is progesterone, which is secreted by the corpus luteum and causes marked swelling in the uterine endometrium. (D) The corpus luteum begins to degenerate in the ischemic phase, causing a fall in both estrogen and progesterone.

- (Topic 5)
A 40-year-old client has lived for 8 years with an abusive spouse. She married her husband in her senior year of high school after becoming pregnant. Shortly after the baby was born, he began to physically abuse her. She has attempted to leave him several times, but she has always returned. She is unable to support herself financially, and her husband threatens to kill her if she leaves him. This time, her husband has beaten her so badly she cannot stop the bleeding from the gash above her eye. She admits her husband caused her injury. In assessing a person after experiencing spousal abuse, which need has the highest priority?

1. A. Assess the level of anxiety, coping responses, and support systems.
2. B. Assess the history of physical abuse.
3. C. Assess suicide potential.
4. D. Assess drug and alcohol use.

Correct Answer: C
(A) Assessing the level of anxiety, coping responses, and support systems is very important, but not of highest priority at this time. (B) A history of physical abuse is an important part of assessment. The nurses must also always ask if there is abuse of the children. (C) Although all of these answers are very important in assessment, the highest priority is assessment of suicide potential, because this could cause the greatest harm to the client. Feeling there is no other way out, abused spouses may consider suicide. (D) The spouse may be self-medicating herself with alcohol or drugs to escape an awful
situation. The abuser may also be abusing drugs or alcohol. If this is so, the nurse should encourage the spouse to seek counseling and not to return to the home.

- (Topic 3)
A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of:

1. A. Impaired communication
2. B. Sensory-perceptual alterations
3. C. Altered thought processes
4. D. Impaired social interaction

Correct Answer: B
(A) Impaired communication refers to decreased ability or inability to use or understand language in an interaction. (B) In sensory-perceptual alterations an individual has distorted, impaired, or exaggerated responses to incoming stimuli (i.e., a hallucination, which is a false sensory perception that is not associated with real external stimuli). (C) An altered thought processes problem statement is used when an individual experiences a disruption in cognitive operations and activities (i.e., delusions, loose associations, ideas of reference). (D) In impaired social interaction, the individual participates too little or too much in social interactions.

- (Topic 5)
A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must:

1. A. Assess the site for leakage of blood or fluids
2. B. Auscultate the site for a bruit
3. C. Assess the site for bruising or hematoma
4. D. Inspect the site for color, warmth, and sensation

Correct Answer: B
(A) This is an internal device. Assessment of the site should include assessing for swelling, pain, warmth, and discoloration. This measure does not assess patency. (B) The presence of a bruit indicates good blood flow through the device. (C) The nurse should inspect the site for bruising or hematoma; however, this measure does not assure patency of the device. (D) The nurse should inspect the vascular access site frequently for signs of infection. However, this does not assure patency.