Free NCLEX-RN Exam Braindumps (page: 216)

Page 216 of 431

The client tells the nurse, "I have pain in my left shoulder."
This is considered:

  1. Evaluation process
  2. Objective information
  3. Subjective information
  4. Complaining

Answer(s): C

Explanation:

(A) Evaluation process follows a nursing intervention. (B) Objective information can be measured. (C) Subjective information is provided by a person. (D) Client is reporting a symptom that needs to be assessed.



The client tells the nurse, "I have pain in my left shoulder."
This is considered:

  1. Evaluation process
  2. Objective information
  3. Subjective information
  4. Complaining

Answer(s): C

Explanation:

(A) Evaluation process follows a nursing intervention. (B) Objective information can be measured. (C) Subjective information is provided by a person. (D) Client is reporting a symptom that needs to be assessed.



When a client arrives on the labor and delivery unit, she informs the nurse that she has been having contractions for the last 5 hours. Now the pain is constant and not cyclical as it was earlier. The nurse considers the possibility of uterine rupture. Which of the following symptoms would be consistent with a uterine rupture?

  1. A large gush of clear fluid from the vagina
  2. Systolic hypertension
  3. Abdominal rigidity
  4. Increased fetal movements

Answer(s): C

Explanation:

(A) This symptom would indicate a rupture of the membranes, which would be expected during labor. There would be no cause for alarm if the fluid were clear. (B) With uterine rupture and the risk of maternal shock secondary to blood loss, the most likely sign would be hypotension indicating hypovolemic shock. (C) In the event of a uterine rupture, an abdominal examination would likely reveal rigidity or tenderness. (D) The most likely finding would be a decrease in fetal movement related to fetal distress due to impaired uteroplacental blood flow. Maintaining the client on her left side would help to maximize uterine blood flow.



When a client arrives on the labor and delivery unit, she informs the nurse that she has been having contractions for the last 5 hours. Now the pain is constant and not cyclical as it was earlier. The nurse considers the possibility of uterine rupture. Which of the following symptoms would be consistent with a uterine rupture?

  1. A large gush of clear fluid from the vagina
  2. Systolic hypertension
  3. Abdominal rigidity
  4. Increased fetal movements

Answer(s): C

Explanation:

(A) This symptom would indicate a rupture of the membranes, which would be expected during labor. There would be no cause for alarm if the fluid were clear. (B) With uterine rupture and the risk of maternal shock secondary to blood loss, the most likely sign would be hypotension indicating hypovolemic shock. (C) In the event of a uterine rupture, an abdominal examination would likely reveal rigidity or tenderness. (D) The most likely finding would be a decrease in fetal movement related to fetal distress due to impaired uteroplacental blood flow. Maintaining the client on her left side would help to maximize uterine blood flow.



Page 216 of 431



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