Question

A home health nurse is assessing a client who is 2 weeks postpartum. The nurse should identify that which of the following client reports is an Indication of postpartum depression and should be investigated further.

Answer 1

Correct Answers:

Feelings of intense guilt

Rationale :

🌸 Postpartum depression (PPD) is a serious mental health condition that can occur within the first few weeks to months after delivery, marked by emotional distress that goes beyond the normal “baby blues.”

🌸 Feelings of intense guilt, especially when persistent or disproportionate, are a red flag for PPD and should be investigated immediately. This emotional symptom often coexists with low mood, fatigue, sleep disturbances, and disinterest in the baby.

🌸 Early identification is essential to ensure timely mental health support and safety of both mother and infant, as untreated PPD can impair bonding and increase risk for self-harm or neglect.

🌸 Unlike physical discomforts such as hot flashes or mild pain, emotional symptoms like intense guilt signify psychological imbalance, not normal postpartum recovery.

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Answer 2

Correct Answers:

"This medication might cause drowsiness."

Rationale :

🔷 Methylphenidate (e.g., Ritalin) is a central nervous system stimulant used to treat ADHD by improving attention and impulse control.

🔷 A known adverse effect is appetite suppression, which can lead to weight loss and slowed growth in children. Therefore, growth rate must be monitored regularly during therapy.

🔷 The medication is usually administered in the morning, as giving it at bedtime can cause insomnia due to its stimulating effects.

🔷 Drowsiness is uncommon; instead, it may cause insomnia, restlessness, or irritability in some children.

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Answer 3

Correct Answers:

"This infection can be spread even when lesions are not present."

Rationale :

🔺 Genital herpes is caused by herpes simplex virus (HSV), most often HSV-2, and it remains latent in nerve ganglia with periodic reactivations.

🔺 Viral shedding can occur even when lesions are absent, making asymptomatic transmission possible. This underscores the need for consistent condom use and informing partners.

🔺 Acyclovir helps reduce outbreak severity and viral shedding, but it does not cure herpes—it is a lifelong viral infection.

🔺 Clients should also avoid oil-based lubricants with latex condoms, as they can cause condom breakdown and increase the risk of transmission.

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Answer 4

Correct Answers:

Take a stool softener.

Rationale :

🔶 Chemotherapy frequently causes gastrointestinal side effects, including constipation, due to reduced activity, medication effects (e.g., antiemetics, opioids), and decreased fluid intake.

🔶 Stool softeners help prevent straining, reduce the risk of rectal bleeding or hemorrhoids, and promote comfort and regularity during treatment.

🔶 Aspirin should be avoided because chemotherapy can reduce platelet counts, increasing the risk of bleeding—making NSAIDs unsafe.

🔶 High-fiber diets, not low-fiber, are typically encouraged unless neutropenic precautions apply, and heat should not be applied to bruised areas, as it may worsen bleeding or mask signs of infection.

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Answer 5

Correct Answers:

Client report of back pain of 7 on a 0 to 10 scale

Rationale :

✴️ In a client who is 1 hour postoperative following Roux-en-Y gastric bypass, severe back or shoulder pain can be a red flag for a serious complication, such as an anastomotic leak.

✴️ An anastomotic leak occurs when the connection between the stomach and intestines leaks gastric contents into the peritoneal cavity, leading to peritonitis or sepsis.

✴️ This type of pain, especially if sharp or unrelenting, requires immediate evaluation, imaging, and possible return to surgery.

✴️ While the other findings warrant monitoring, sudden or severe back pain post-abdominal surgery takes priority due to the potential for life-threatening complications.

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Answer 6

Correct Answers:

"Plan to start taking this medication 1 week before you stop smoking."

Rationale :

🌿 Varenicline (Chantix) is a partial nicotine receptor agonist used for smoking cessation. It works by reducing cravings and withdrawal symptoms while also blocking the rewarding effects of nicotine.

🌿 The client should begin taking varenicline 1 week before their planned quit date, allowing the drug to build up to effective levels in the body by the time nicotine is stopped.

🌿 It can cause side effects like nausea, vivid dreams, or mood changes, but drowsiness is not a primary concern, and there is no grapefruit interaction with varenicline.

🌿 The medication course typically lasts 12 weeks and may be extended based on clinical judgment—not limited to 30 days.

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Answer 7

Correct Answers:

Decreased albumin

Rationale :

🌟 Crohn’s disease is a chronic inflammatory condition of the gastrointestinal tract that impairs nutrient absorption and increases protein loss through inflamed mucosa.

🌟 This leads to hypoalbuminemia, or decreased serum albumin, due to malnutrition, chronic inflammation, and protein-losing enteropathy.

🌟 Albumin is a key plasma protein responsible for maintaining oncotic pressure, and low levels can contribute to edema, delayed healing, and increased infection risk.

🌟 Clients with active Crohn’s typically show increased ESR (inflammation marker) and decreased hematocrit from chronic blood loss or anemia—not elevated protein levels.

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Answer 8

Correct Answers:

Stands with assistance

Rationale :

🟦 Infants with Down syndrome often experience developmental delays, but by 7 months, many are still able to reach gross motor milestones, such as standing with assistance, especially with support and early intervention.

🟦 Although milestones may occur later than in typically developing infants, partial weight-bearing and supported standing are achievable for many at this age.

🟦 Using utensils and speaking multiple words are more advanced milestones expected around 12–18 months in typical development and even later in Down syndrome.

🟦 Crawling also generally occurs after 8–10 months, especially in children with hypotonia, which is common in Down syndrome.

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Answer 9

Correct Answers:

Weight gain

Rationale :

🟩 Acute glomerulonephritis leads to inflammation of the glomeruli, impairing the kidneys’ ability to filter properly and resulting in sodium and water retention.

🟩 This causes edema and weight gain, which are hallmark signs of fluid overload.

🟩 Clients often present with periorbital or generalized edema, decreased urine output, and dark, tea- or cola-colored urine due to hematuria—not straw-colored urine.

🟩 Additionally, clients tend to be hypertensive due to fluid retention, and serum sodium may appear normal or even elevated due to dilution, but hyponatremia is not a key finding.

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Answer 10

Correct Answers:

Determine if the client is experiencing suicidal ideation.

Rationale :

❗ In any situational crisis, the nurse's first priority is client safety, and that includes assessing for suicidal ideation or risk of self-harm.

❗ Clients in crisis may feel overwhelmed, hopeless, or emotionally unstable, making them more vulnerable to impulsive or harmful behaviors.

❗ Once safety is ensured, the nurse can proceed with assessing support systems, perceptions, and teaching coping mechanisms.

❗ This approach aligns with the Maslow’s hierarchy of needs, where safety and survival must be addressed before psychological or educational interventions.

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QLexNursing

1 :
A home health nurse is assessing a client who is 2 weeks postpartum. The nurse should identify that which of the following client reports is an Indication of postpartum depression and should be investigated further.

2 :
A nurse is providing education to the guardian of a child who has ADHD and a prescription for methylphenidate. Which of the following statements should the nurse make?

3 :
A nurse is providing education for a client who has a genital herpes infection. Which of the following statements should the nurse include in the teaching

4 :
A nurse is providing discharge teaching for a client who has non-Hodgkin's lymphoma and will be receiving outpatient chemotherapy. Which of the following instructions should the nurse include?

5 :
A nurse is assessing a client who is 1 hr postoperative following roux-en Y gastric bypass surgery. Which of the following findings is the priority for the nurse to report to the provider?

6 :
A nurse is providing teaching about varenicline to a client who is in a smoking cessation program. Which of the following statements should the nurse make?

7 :
A nurse is reviewing the laboratory results of an older adult client who has inflammatory bowel disease and Crohn's disease. Which of the following laboratory results should the nurse expect?

8 :
A nurse is assessing a 7-month-old infant who has Down syndrome. Which of the following developmental milestones should the nurse expect?

9 :
A nurse is assessing a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?

10 :
A nurse is caring for a client who is experiencing a situational crisis. Which of the following actions should the nurse take first?

QLexNursing

1 : A home health nurse is assessing a client who is 2 weeks postpartum. The nurse should identify that which of the following client reports is an Indication of postpartum depression and should be investigated further.

2 : A nurse is providing education to the guardian of a child who has ADHD and a prescription for methylphenidate. Which of the following statements should the nurse make?

3 : A nurse is providing education for a client who has a genital herpes infection. Which of the following statements should the nurse include in the teaching

4 : A nurse is providing discharge teaching for a client who has non-Hodgkin's lymphoma and will be receiving outpatient chemotherapy. Which of the following instructions should the nurse include?

5 : A nurse is assessing a client who is 1 hr postoperative following roux-en Y gastric bypass surgery. Which of the following findings is the priority for the nurse to report to the provider?

6 : A nurse is providing teaching about varenicline to a client who is in a smoking cessation program. Which of the following statements should the nurse make?

7 : A nurse is reviewing the laboratory results of an older adult client who has inflammatory bowel disease and Crohn's disease. Which of the following laboratory results should the nurse expect?

8 : A nurse is assessing a 7-month-old infant who has Down syndrome. Which of the following developmental milestones should the nurse expect?

9 : A nurse is assessing a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?

10 : A nurse is caring for a client who is experiencing a situational crisis. Which of the following actions should the nurse take first?

1 :
A home health nurse is assessing a client who is 2 weeks postpartum. The nurse should identify that which of the following client reports is an Indication of postpartum depression and should be investigated further.

2 :
A nurse is providing education to the guardian of a child who has ADHD and a prescription for methylphenidate. Which of the following statements should the nurse make?

3 :
A nurse is providing education for a client who has a genital herpes infection. Which of the following statements should the nurse include in the teaching

4 :
A nurse is providing discharge teaching for a client who has non-Hodgkin's lymphoma and will be receiving outpatient chemotherapy. Which of the following instructions should the nurse include?

5 :
A nurse is assessing a client who is 1 hr postoperative following roux-en Y gastric bypass surgery. Which of the following findings is the priority for the nurse to report to the provider?

6 :
A nurse is providing teaching about varenicline to a client who is in a smoking cessation program. Which of the following statements should the nurse make?

7 :
A nurse is reviewing the laboratory results of an older adult client who has inflammatory bowel disease and Crohn's disease. Which of the following laboratory results should the nurse expect?

8 :
A nurse is assessing a 7-month-old infant who has Down syndrome. Which of the following developmental milestones should the nurse expect?

9 :
A nurse is assessing a client who has acute glomerulonephritis. Which of the following findings should the nurse expect?

10 :
A nurse is caring for a client who is experiencing a situational crisis. Which of the following actions should the nurse take first?