NCLEX NCLEX-PN - National Council Licensure Examination(NCLEX-PN)

When taking estrogen, there is an increased risk of diabetes or hyperglycemia due to lowered glucose tolerance. It is true that monthly menses might return when taking combination hormones. The progestin is responsible for this. There is also a risk of gallbladder disease. It is also true that there is an increased risk of breast, cervical, and ovarian cancer with long-term hormone replacement therapy.Health Promotion and Maintenance

The use of restraints as an emergency measure is taken primarily as a last resort to protect a client from harm. Typically, the nurse acts under a physician’s order, but in an emergency, the nurse may restrain a client out of necessity for one hour prior to the client being seen by a physician or an advanced practice mental health provider.Safety and Infection Control

Because semen analysis is the least invasive of the tests listed and because in 35% of the cases the infertility is related to a male factor, semen analysis should be one of the first diagnostic tests performed. Hysterosalpingography fills the uterus and fallopian tubes with a radiopaque substance that can be seen with an X ray. It demonstrates tubal patency or any distortion of the uterine cavity. Endometrial biopsy provides information about the effects of progesterone after ovulation and the endometrial receptivity. Transvaginal ultrasound is mostly used in the treatment of infertility. For diagnosis it allows the endocrinologist to evaluate the developing follicle, assess oocyte maturity, and diagnose luteal phase defects. All the tests listed in Choices 1, 3, and 4 are more invasive, require greater expertise to evaluate and treat, and are more costly. If the semen analysis is normal, the couple can expect to progress through these tests as well.Health Promotion and Maintenance

Uterine bleeding on combination hormone replacement therapy, after 12 months of menses cessation, indicates an increased risk of carcinoma and should be reported to the physician immediately. Breast tenderness, weight gain, and fluid retention are all routine side effects ofhormone replacement therapy. They should be noted in the record and reported to the physician, but they are not urgent.Health Promotion and Maintenance

This statement reassures the client that there is a solution for relief of his anxiety. The other responses minimize the client’s feelings.Reduction of Risk Potential

The client with urinary tract calculi needs to avoid cheese, which has high calcium content. The other foods do not.Physiological Adaptation

A side effect of postpartum epidural morphine is the onset of itching within 3 hours of injection and lasting up to 10 hours. Nausea and vomiting might occur 4–7 hours after injection. Urinary retention is a side effect of postpartum epidural morphine but is not assessed as such within the first 3 hours. Somnolence is a rare side effect.Health Promotion and Maintenance

Assemble all equipment first; place the client in a side-lying position so that fluid can easily flow out or pool in the side of the mouth for suctioning (to prevent aspiration); and then place a towel under the client’s chin and a curved basin against the chin. Gloves should be worn.Basic Care and Comfort

Normal serum potassium levels fall in a range of 3.5–5.5mEq/L. The other choices listed fall below or above this range.Reduction of Risk Potential

Padding distributes pressure so that bony prominences do not receive the brunt of pressure when a client pulls against the restraints. Pressure, especially over bony prominences, causes tissue damage due to ischemia.Safetyand Infection Control

The ingestion of nonfood substances (alcohol) can lead to a clinical iron deficiency and might actually be the first sign of a problem. The client might substitute alcohol for a nutrition program that fosters a positive health habit.Physiological Adaptation

These are the accepted parameters for mild PIH. Mild preclampsia includes an increase in systolic blood pressure higher than 30 mmHg or an increase in diastolic blood pressure higher than 15 mmHg, noted on two readings taken 6 hours apart (or 140/90).Physiological Adaptation

The problem statement is Negative Self Concept. A successful resolution of the problem is when the client can report a positive self-concept. When the nurse determines how the client perceives himself, effort should be directed to reinforce self-worth and promote a positive self-concept,including helping a client to identify areas of strength. Assisting the client to evaluate himself and make behavior changes is a nursing intervention.Psychosocial Integrity

The blood pressure should be checked first for a client who has just vomited 300 cc of bright red blood, to determine whether the client is hypotensive. The other actions can be taken later.Reduction of Risk Potential