A 14-year-old girl presents to the school nurse with the fourth vaginal yeast infection she has had during the past 6 months. The nurse should assess the adolescent for which finding(s)? Select all that apply.

Thirst.

Increased appetite.

Heat intolerance.

Tachycardia.

Urinary frequency.

Answer and Explanation

Correct Answer : A,D,E

A. Thirst: Recurrent yeast infections in adolescents may indicate underlying hyperglycemia, as excessive glucose in the urine promotes fungal growth. Thirst is a classic symptom of diabetes mellitus and should be assessed.

B. Increased appetite: While diabetes can sometimes cause polyphagia, it is less specific than other signs such as thirst, urinary frequency, and tachycardia. It may not be present in every case and is not a primary screening indicator.

C. Heat intolerance: Heat intolerance is more commonly associated with hyperthyroidism, not recurrent yeast infections. Assessing for this symptom is not directly relevant to evaluating potential diabetes in this adolescent.

D. Tachycardia: Elevated heart rate can occur with dehydration caused by hyperglycemia and osmotic diuresis. Tachycardia may be an important clinical clue in assessing for undiagnosed diabetes.

E. Urinary frequency: Polyuria is a hallmark symptom of hyperglycemia and diabetes mellitus. Recurrent yeast infections may prompt assessment for urinary frequency as part of the screening for possible diabetes.

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Correct Answer is B

Explanation

A. Place a warm blanket on the client: Providing warmth may improve comfort temporarily but does not address the underlying cause of the client’s cool, moist hands, prolonged capillary refill, or low urine output, which suggest possible hypovolemia or shock.

B. Administer IV fluids per protocol: The client’s signs restlessness, cool clammy skin, prolonged capillary refill, and low urine output indicate hypoperfusion likely due to fluid deficit. Administering IV fluids promptly helps restore circulating volume and tissue perfusion.

C. Review the medication administration record: While medication review is important for overall safety, it does not address the immediate risk of hypovolemic shock or low urine output in this client.

D. Check the urinary catheter for an occlusion: Although checking for blockage is reasonable if a catheter is present, the client’s overall clinical presentation points to systemic hypovolemia rather than a localized urinary obstruction.

A. Administer intravenous antibiotic. B. Place in high Fowler's position. C. Determine last dose of analgesic. D. Prepare for emergency surgery.

Correct Answer is D

Explanation

A. Administer intravenous antibiotic: Antibiotics are often given as part of appendicitis management, but sudden pain relief may indicate appendix rupture. At this point, the priority is rapid surgical intervention, not antibiotics alone.

B. Place in high Fowler's position: Positioning may help with comfort but does not address the urgent complication of a possible perforated appendix. It is a supportive measure, not a definitive response to the change in symptoms.

C. Determine last dose of analgesic: While it is important to know when pain medication was last administered, relying on this alone could delay recognition of a surgical emergency. Sudden absence of pain in appendicitis is rarely due to analgesia but often due to perforation.

D. Prepare for emergency surgery: A sudden decrease in pain in appendicitis is concerning for rupture, as pressure is relieved when the appendix bursts. This is a life-threatening complication requiring immediate surgical evaluation and intervention.

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A 14-year-old girl presents to the school nurse with the fourth vaginal yeast infection she has had during the past 6 months. The nurse should assess the adolescent for which finding(s)? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a postoperative client who has a saline lock and minimal urine in the drainage bag, who appears anxious and restless. The nurse notices that the client's hands are cool and moist, with prolonged capillary refill. Which action should the nurse take?

Correct Answer is B

Explanation

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Correct Answer is D

Explanation

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