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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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Kyphosis: A rounding of the upper back, causing a hunchback appearance. While it can also be caused by other conditions, a mild kyphosis is a common finding in older adults due to weakening muscles and spinal compression.

B. Barrel chest: This refers to a chest that is fixed in an outward position, often caused by chronic obstructive pulmonary disease (COPD) or other lung conditions.

C. Lordosis: An exaggerated inward curve of the lower back, which is not a typical feature of normal aging.

D. Pectus excavatum: A sunken appearance of the chest wall, usually a congenital condition present from birth.

A. Increase fiber in diet and add daily prune juice. B. Perform a digital examination for fecal impaction. C. Assess type and frequency of physical activities. D. Check bowel sounds and abdominal tenderness.

Correct Answer is D

Explanation

A. Increase fibre in diet and add daily prune juice: Increasing dietary fibre and adding prune juice can help promote bowel movements and relieve constipation. However, this is a long-term solution and might not address any immediate underlying issues.

B. Perform a digital examination for faecal impaction: This invasive procedure can confirm or rule out faecal impaction, which is a potential cause of severe constipation, especially in older adults. However, it's not typically the first step without further assessment.

C. Assess type and frequency of physical activities: Physical activity affects bowel motility. Assessing activity levels can provide insight into one possible cause of constipation. However, this should come after assessing more direct symptoms.

D. Check bowel sounds and abdominal tenderness: This is a non-invasive initial assessment that can provide important information about the client's bowel activity and potential obstructions. It helps determine the next steps for diagnosis and treatment.

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Naxlex Comprehensive Predictor Exams

Which assessment finding of an older adult client should the nurse associate with normal aging?

Correct Answer is A

Explanation

Correct Answer is D

Explanation

To compare arterial circulation in a client's lower extremities, which assessment should the nurse complete?

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

A parent brings a preschool aged client to the clinic because of having diarrhea, vomiting, and high fevers for the past three days. The child begins to cry and cling to the parent when the nurse enters the examination room. Which action should the nurse implement to get the child to cooperate?

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

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

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