A parent brings a preteen daughter to the clinic for her first female examination. During the health assessment, the nurse should implement which technique to determine if the client has reached the age of menarche?
Assess for presence of a supernumerary breast nipple.
Palpate for evidence of temporary gynecomastia.
Calculate approximate age menstruation should occur.
Use the Tanner staging to determine sexual maturity.
The Correct Answer is D
A. The presence of a supernumerary breast nipple is not related to the onset of menarche and is not a common assessment in determining sexual maturity.
B. Temporary gynecomastia is more commonly observed in adolescent boys rather than preteen girls.
C. While age can provide a rough estimate, it is not as accurate as a physical assessment of sexual maturity.
D. The Tanner staging is a reliable method used to assess sexual maturity in adolescents. It includes evaluating the development of breasts, pubic hair, and other secondary sexual characteristics, which can help determine if the client has likely reached menarche.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Renal creatinine clearance is important in assessing kidney function but is not directly related to divalproex sodium therapy.
B. While CBC monitoring is essential, especially for detecting thrombocytopenia, liver function tests are more critical in this context.
C. A chemistry panel is valuable but does not specifically monitor for the primary risks associated with divalproex sodium.
D. Divalproex sodium (valproate) can cause hepatotoxicity, so monitoring liver function tests (LFTs) is crucial. Regular LFTs help detect early signs of liver damage, which can be a serious adverse effect of this medication.
Correct Answer is C
Explanation
A. Examining feet daily is important for preventing foot complications, such as ulcers, in diabetics but is not directly related to preventing retinopathy and nephropathy.
B. Wearing compression stockings is not specifically recommended for preventing retinopathy or nephropathy in diabetes.
C. Maintaining stable blood glucose levels is crucial for preventing or slowing the progression of diabetic complications such as retinopathy and nephropathy. Good glycemic control minimizes the damage to blood vessels in the eyes and kidneys.
D. While regular eye exams are important for detecting retinopathy early, maintaining stable blood glucose levels is key to preventing the development of complications in the first place.
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