A nurse is reinforcing teaching with a client who is beginning menopause. Which of the following statements by the client indicates an understanding of the teaching?

“I may notice an increase in the firmness of my breasts.”

"My estrogen levels will elevate”

"I may experience more vaginal dryness."

"I may become cold more often."

Answer and Explanation

The Correct Answer is C

A. “I may notice an increase in the firmness of my breasts.”: During menopause, breasts typically become less firm and more fatty due to decreased estrogen levels. Loss of glandular tissue and changes in connective tissue elasticity cause breasts to feel softer, not firmer.

B. "My estrogen levels will elevate”: Estrogen levels decline significantly during menopause, not elevate. This hormonal decrease leads to many of the physical and emotional symptoms associated with menopause, including hot flashes, vaginal dryness, and bone density loss.

C. "I may experience more vaginal dryness.": Vaginal dryness is a common and expected symptom during menopause due to the reduction in estrogen. Lower estrogen levels cause thinning and decreased lubrication of the vaginal tissues, often resulting in discomfort during intercourse and increased risk of irritation or infection.

D. "I may become cold more often.": Clients undergoing menopause typically experience hot flashes and night sweats, not an increased tendency to feel cold. Hot flashes are sudden sensations of heat and are one of the most recognized and frequent symptoms of menopausal transition.

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Correct Answer is ["A","B","C"]

Explanation

Frequent headaches: Phenelzine, an MAOI, can cause hypertensive crisis, with one of the earliest signs being persistent or worsening headaches. Frequent headaches must be treated as a possible warning of dangerously elevated blood pressure and require immediate provider notification.
Elevated blood pressure (169/91 mm Hg): The significant rise in the client's blood pressure compared to baseline indicates new-onset hypertension. This is a serious adverse effect associated with MAOIs and signals the potential development of a hypertensive crisis, which must be urgently addressed.
Difficulty sleeping: Difficulty sleeping or insomnia is a common side effect of phenelzine and other antidepressants. Although not life-threatening, insomnia can impair recovery if untreated and should be documented and discussed with the provider to adjust management if needed.
Feeling much better: Improvement in mood and reduced fatigue are intended therapeutic outcomes of phenelzine treatment. These findings are positive signs and do not indicate an adverse reaction that needs intervention.
Heart rate 78/min and respiratory rate 18/min: Both values are within normal ranges and do not suggest immediate concerns related to cardiovascular or respiratory function. They should continue to be monitored but do not require urgent action.

A. Erythema B. Blood C. Edema D. Pruritus

Correct Answer is C

Explanation

A. Erythema: Erythema, or redness, is more commonly associated with phlebitis, an inflammation of the vein, rather than infiltration. While some redness may occur, it is not the primary or expected finding when infiltration is present.

B. Blood: The presence of blood at the insertion site may indicate a bleeding or hematoma issue but is not a typical sign of infiltration. Infiltration involves fluid, usually IV solution, leaking into surrounding tissue, not blood leaking out of the vein.

C. Edema: Edema at the insertion site is a hallmark sign of infiltration. When IV fluid escapes into the surrounding tissue instead of remaining in the vein, it causes localized swelling, coolness, and often discomfort or tightness around the insertion area.

D. Pruritus: Pruritus, or itching, is not a typical manifestation of infiltration. It may be seen with allergic reactions to IV medications or materials, but infiltration primarily presents with swelling, coolness, and sometimes blanching of the skin.

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A nurse is reinforcing teaching with a client who is beginning menopause. Which of the following statements by the client indicates an understanding of the teaching?

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Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C"]

Explanation

A nurse is collecting data from a client who is receiving IV therapy. The nurse suspects fluid infiltration. Which of the following findings should the nurse expect at the insertion site?

Correct Answer is C

Explanation

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