A 20-year-old nulliparous female college student sees the nurse because she has missed her last two menstrual periods. She reports she has not had sexual intercourse in one month. The nurse requests a pregnancy test, which is negative. Based on this client's history, which assessment is most important for the nurse to obtain?

Vaginal discharge, presence of genital warts, abdominal tenderness.

Urinary frequency, unsteady gait, dental enamel erosion.

Breast tenderness, tremors, high blood pressure.

Body weight, hirsutism, thyroid enlargement.

Answer and Explanation

The Correct Answer is D

A. Vaginal discharge, presence of genital warts, abdominal tenderness: While assessing for vaginal discharge and genital warts is important, they are not directly related to the menstrual irregularity described by the client. Abdominal tenderness may be relevant but is not the priority.

B. Urinary frequency, unsteady gait, dental enamel erosion: These symptoms are not specifically associated with missed periods. They may indicate other health issues, but they do not address the primary concern.

C. Breast tenderness, tremors, high blood pressure: Breast tenderness can be related to hormonal changes and menstrual irregularities. Tremors and high blood pressure are less likely to be directly connected to missed periods but should still be assessed.

D. Body weight, hirsutism, thyroid enlargement: Hirsutism (excessive hair growth) and thyroid enlargement (goiter) can be associated with hormonal imbalances, including conditions affecting the menstrual cycle. Assessing body weight is also relevant.

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Correct Answer is B

Explanation

A. Inspection of the abdomen for enlargement: Ascites causes abdominal distention. Inspection is a straightforward way to assess for fluid accumulation.

B. Palpation of an abdominal fluid wave: Palpating for a fluid wave (shifting of fluid within the abdomen) is a classic sign of ascites.

C. Bimanual palpation for liver enlargement: While liver enlargement can contribute to ascites, it is not the primary method for detecting early ascites.

D. Successive measurements of abdominal girth: Regular measurements of abdominal girth help track changes over time and detect early ascites.

A. Offer the child bubbles before the stethoscope is placed. B. Allow the child to use a stethoscope on a stuffed animal. C. Place a toy in the child's hands while listening to the breath sounds. D. Have the child blow a cotton ball and have the parent catch it.

Correct Answer is B

Explanation

A. Offer the child bubbles before the stethoscope is placed. Blowing bubbles can help distract the child and make them more relaxed, but it may not be as effective as involving the child directly in the process.

B. Allow the child to use a stethoscope on a stuffed animal. This is an effective approach as it involves the child in the process, making them more comfortable and cooperative. It helps demystify the stethoscope and can reduce fear or anxiety.

C. Place a toy in the child's hands while listening to the breath sounds. Holding a toy can be distracting and help keep the child still, but it does not directly involve the child in the assessment process as effectively as letting them use the stethoscope.

D. Have the child blow a cotton ball and have the parent catch it. Blowing a cotton ball can help with deep breathing, which is useful for lung auscultation. However, it may not ensure the child's cooperation throughout the entire assessment as effectively as option B.

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Naxlex Comprehensive Predictor Exams

Which method is best for the nurse to use in determining early development of ascites?

Correct Answer is B

Explanation

The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?

Correct Answer is B

Explanation

During a 2-year-old well-child visit, a toddler's parent tells the nurse that this son, who is the youngest of five, rarely talks spontaneously. Which intervention should the nurse implement?

In assessing a male client's level of consciousness, the nurse determines that the client does not open his eyes spontaneously. Which should the nurse do next?

When assessing a client's skin, which finding should the nurse report to the healthcare provider?

The nurse hears crackles when auscultating a client's lung sounds. Which is an accurate description of the sound of crackles?

When-obtaining an adolescent's health history, which intervention is most important of the nurse to implement?

In assessing a primigravida woman at 15 weeks gestation by dates, the nurse palpates the fundus at the umbilicus. Based on this assessment finding, it is most important for the nurse to obtain information about the occurrence of which condition?

The nurse plans to teach a client newly diagnosed with diabetes mellitus how to inject insulin. Upon entering the room with the injection supplies, the nurse finds the client in tears. How should the nurse respond?