The nurse examines a client who is concerned about the amount of menstrual flow she is having. Which finding indicates an abnormality related to the client's current menstruation?

An odorless, red menstrual blood flow.

Cramping associated with the amount of flow.

Blood clots sized at 0.5 cm (0.2 in) with menstrual flow.

Blood saturation of one pad an hour.

Answer and Explanation

The Correct Answer is D

A. An odorless, red menstrual blood flow: This is considered a normal characteristic of menstruation. Menstrual blood may have a slight metallic scent due to the mixing with vaginal secretions, but an odorless red flow is not a concern and does not suggest abnormality.

B. Cramping associated with the amount of flow: Mild to moderate cramping (dysmenorrhea) is a common and expected part of menstruation related to the release of prostaglandins that cause uterine contractions especially during heavier flow days. While it can be uncomfortable, it is not typically considered abnormal unless severe or disabling.

C. Blood clots sized at 0.5 cm (0.2 in) with menstrual flow: Small blood clots can occur during menstruation, especially during heavier flow, and clots under 1 inch (2.5 cm) in diameter are generally not worrisome. This size is within normal limits and not an indication of a menstrual disorder.

D. Blood saturation of one pad an hour: This finding suggests menorrhagia, or abnormally heavy menstrual bleeding. Saturating a pad or tampon every hour for several consecutive hours is clinically significant and warrants further investigation, as it can lead to anemia and may signal an underlying gynecological issue such as fibroids or a bleeding disorder.

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Correct Answer is A

Explanation

A. Hearing loss: A tuning fork is commonly used in the Rinne and Weber tests to assess the type and extent of hearing loss. These tests help differentiate between conductive and sensorineural hearing deficits by comparing air and bone conduction.

B. Neurological pathology: While some neurological assessments may include evaluation of hearing or balance, a tuning fork is not a primary tool for identifying central nervous system pathology. Neurological exams rely more on reflexes, motor function, and sensory testing.

C. Otitis media: Otitis media is diagnosed based on otoscopic findings such as tympanic membrane bulging, fluid presence, or redness. A tuning fork cannot visualize internal structures or confirm middle ear infections.

D. Tinnitus: Tinnitus is the perception of ringing or buzzing in the ears, often self-reported by the patient. A tuning fork does not directly diagnose tinnitus but may be used to evaluate associated hearing changes if present.

A. Ecchymosis. B. Hematoma. C. Petechiae. D. Vesicle.

Correct Answer is C

Explanation

A. Ecchymosis: Ecchymosis refers to larger areas of bruising or discoloration due to bleeding under the skin, typically caused by trauma. It appears as purple or bluish patches but does not present as tiny pinpoint spots.

B. Hematoma: A hematoma is a localized collection of blood under the skin or tissue that results in swelling and discoloration. It is typically raised and larger than petechiae, often caused by blunt force trauma.

C. Petechiae: Petechiae are small, pinpoint, round red or purple spots caused by minor bleeding under the skin. They are flat, do not blanch with pressure, and are often associated with pressure or trauma. In the context of intimate partner violence, petechiae can be a sign of strangulation or other abuse-related injuries.

D. Vesicle: A vesicle is a small, fluid-filled blister on the skin, commonly associated with infections like herpes or chickenpox. They appear as a raised lesion containing clear fluid. It is not red or pinpoint in appearance and would not match the described findings in this scenario.

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The nurse examines a client who is concerned about the amount of menstrual flow she is having. Which finding indicates an abnormality related to the client's current menstruation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When conducting a physical examination, the nurse uses a tuning fork to assess for which condition?

Correct Answer is A

Explanation

The nurse is performing a head-to-toe physical examination on a known victim of intimate partner violence. The visual exam reveals several round, flat, pinpoint, red spots. How should the nurse document this finding?

Correct Answer is C

Explanation

Which subjective assessment data supports the nurse's conclusion that a client is experiencing orthopnea?

While taking a history on an older adult male client, his wife reports that he is having increasing periods of short-term memory loss and he occasionally gets confused. How should the nurse proceed with an assessment of the client's sensory system?

The nurse assesses that a client has nailbed clubbing. Which additional information is consistent with this finding?

When preparing a female client for an abdominal examination, the nurse should provide her with which instruction?

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?

The nurse observes generalized weakness and diminished deep tendon reflexes on the right side of an older adult client who has a history of a cerebrovascular accident. Which deep tendon reflex response should the nurse document to support the client's clinical assessment?