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 A

No explanation

A. Assess for the use of illicit drugs. B. Obtain a smoking history first. C. Evaluate vital signs and laboratory findings. D. Ask the parents to leave the room.

Correct Answer is D

Explanation

A. Assess for the use of illicit drugs. While assessing illicit drug use is important, it may not be the most crucial intervention during the initial health history-taking process.

B. Obtain a smoking history first. While obtaining a smoking history is important, it may not take precedence over other aspects of the health history, especially if there are more pressing concerns.

C. Evaluate vital signs and laboratory findings. While vital signs and laboratory findings are important components of the assessment, they are typically obtained after the health history has been completed.

D. Ask the parents to leave the room. Ensuring privacy and confidentiality is crucial during adolescent health assessments to encourage open communication and address sensitive issues. Asking the parents to leave the room allows the adolescent to speak freely about their health concerns without fear of judgment or disclosure to their parents.

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Naxlex Comprehensive Predictor Exams

While assessing a client who is obese, the nurse is unable to locate the gallbladder when palpating below the liver margin at the lateral border of the rectus abdominal muscle. Which is the most likely explanation for failure to locate the gallbladder by palpation?

Correct Answer is A

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

Correct Answer is D

Explanation

While assisting a client to ambulate who has left hemiplegia due to a stroke, the nurse notices that the client is having difficulty walking in a straight line. Based on this assessment finding, it is most important to include which intervention in this client's plan of care?

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

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Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness?

The charge nurse observes a practical nurse (PN) measuring the waist circumference of a client who has expressed a concern about health problems related to obesity. Which action should the nurse implement?

In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

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