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.

Answer and Explanation

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.

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Correct Answer is C

Explanation

A. Clamping the catheter before irrigation is not recommended as it could cause urine retention and increase the risk of infection.
B. An infusion pump is not typically used for catheter irrigation as manual control is preferred for monitoring flow and pressure.
C. Using a sterile syringe to gently irrigate the catheter with 20 mL of normal saline is the correct approach. This method helps to clear fibrin clots and sediment without applying excessive pressure, which could damage the bladder or catheter.
D. Power flushing with 60 mL could apply excessive pressure, potentially causing trauma to the bladder or urethra.

A. Advise the client to see his healthcare provider for immediate evaluation. B. Encourage the client to keep checking the mole with a magnifying mirror. C. Ask the client if he often spends time outside in the sun without a shirt. D. Offer to teach a family member how to monitor the skin around the mole.

Correct Answer is A

Explanation

A. Changes in a mole's color, size, or shape could indicate melanoma, a serious type of skin cancer. Immediate evaluation by a healthcare provider is critical for early diagnosis and treatment.
B. While monitoring the mole is important, immediate professional evaluation is the priority to rule out malignancy.
C. Assessing sun exposure is relevant for skin cancer risk, but it is not the immediate priority in this scenario.
D. Teaching a family member to monitor the mole is not sufficient when there is a significant change that requires professional evaluation.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?

Correct Answer is C

Explanation

A client asks the nurse to look at a mole located on the back. The client tells the nurse that the mole has changed from brown to black and enlarged in size. Which is the priority nursing action?

Correct Answer is A

Explanation

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