A nurse conducts a physical exam of a client who reports feeling well.
Findings include:
General: No acute distress.
Cardiovascular: No murmur or rub.
Respiratory: Bilateral breath sounds clear.
Abdomen: Fundal height 38 cm.
Genitourinary: Purulent cervical discharge.
The Correct Answer is E
Choice A rationale
No acute distress indicates the client's physiological stability. It reflects an absence of acute systemic responses like tachycardia or labored breathing, suggesting normal homeostasis during examination.
Choice B rationale
No cardiovascular murmurs or rubs imply normal valve function and an absence of pericardial inflammation. This finding indicates no pathological blood flow changes or cardiac friction sounds.
Choice C rationale
Clear bilateral breath sounds suggest open airways and proper ventilation, excluding lower respiratory tract issues like pneumonia. Normal respiratory examination confirms adequate pulmonary function.
Choice D rationale
Fundal height at 38 cm corresponds to late-third trimester pregnancy. It reflects uterine enlargement due to fetal growth, indicating gestational progression but unrelated to cervical discharge.
Choice E rationale
Purulent cervical discharge suggests an ongoing infection, likely bacterial cervicitis. It reflects leukocyte accumulation due to pathogenic invasion, requiring clinical intervention to prevent complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Forcibly retracting the foreskin can cause pain, injury, or adhesions. The foreskin naturally separates over time, and forced retraction is not recommended.
Choice B rationale
Cotton swabs should not be used under the foreskin as they may cause irritation or damage. Cleaning with mild soap and water is sufficient.
Choice C rationale
Petroleum jelly is not necessary for uncircumcised penis care as the foreskin provides natural protection. Basic hygiene is adequate to prevent irritation or infection.
Choice D rationale
Daily washing with mild soap and water ensures proper hygiene and prevents infection. This method maintains cleanliness without causing harm to sensitive tissues.
Correct Answer is E
Explanation
Choice A rationale
No acute distress indicates the client's physiological stability. It reflects an absence of acute systemic responses like tachycardia or labored breathing, suggesting normal homeostasis during examination.
Choice B rationale
No cardiovascular murmurs or rubs imply normal valve function and an absence of pericardial inflammation. This finding indicates no pathological blood flow changes or cardiac friction sounds.
Choice C rationale
Clear bilateral breath sounds suggest open airways and proper ventilation, excluding lower respiratory tract issues like pneumonia. Normal respiratory examination confirms adequate pulmonary function.
Choice D rationale
Fundal height at 38 cm corresponds to late-third trimester pregnancy. It reflects uterine enlargement due to fetal growth, indicating gestational progression but unrelated to cervical discharge.
Choice E rationale
Purulent cervical discharge suggests an ongoing infection, likely bacterial cervicitis. It reflects leukocyte accumulation due to pathogenic invasion, requiring clinical intervention to prevent complications.
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