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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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.
Correct Answer is A
Explanation
A. Decreased height: Osteoporosis often leads to vertebral fractures, especially in the upper (thoracic) spine. These fractures can cause pain, height loss, and a stooped or hunched posture (kyphosis).
B. Loss of appetite: While osteoporosis itself does not directly cause loss of appetite, it’s essential to assess overall health and nutritional status. However, this symptom is not directly related to kyphosis.
C. Weight gain: Weight gain is not typically associated with osteoporosis or kyphosis. It is less relevant in this context.
D. Painful swallowing: Painful swallowing is not directly related to osteoporosis or kyphosis. It is less relevant in this context.
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