The nurse in the women's health clinic has four patients who are waiting to be seen. Which patient should the nurse see first?

A 42-yr-old patient with secondary amenorrhea who says that her last menstrual cycle was 3 months ago

A 19-yr-old patient with menorrhagia who has been using superabsorbent tampons and has fever with weakness

A 22-yr-old patient with persistent red-brown vaginal drainage 3 days after having balloon thermotherapy

A 35-yr-old patient with heavy spotting after having a progestin-containing IUD (Mirena) inserted a month ago

Answer and Explanation

The Correct Answer is B

Choice A rationale: The 42-yr-old patient with secondary amenorrhea may have menopause, pregnancy, or a hormonal disorder. This is less urgent compared to the 19- year old patient.

Choice B rationale: This patient may have toxic shock syndrome, which is a life- threatening complication of tampon use that can cause organ failure and shock. The nurse should assess the patient's vital signs, remove the tampon, and initiate fluid resuscitation and antibiotic therapy.

Choice C rationale: This patient may have an infection or a complication of the balloon thermotherapy, which is a procedure to destroy the endometrial lining of the uterus and is not an emergency compared to the 19 year old.

Choice D rationale: This patient may have a displacement or perforation of the IUD, which is a contraceptive device that releases progestin into the uterus. However, this is not urgent compared to the 19 year old.

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Correct Answer is D

Explanation

Choice A rationale: A breast lump that increases in size before the menstrual period might be related to hormonal changes and is not necessarily indicative of a concerning issue.

Choice B rationale: Bilateral breast nodules that are tender with palpation might be related to benign conditions or hormonal changes.

Choice C rationale: A small, mobile, rubbery breast lump could suggest a benign condition like a fibroadenoma, which might not be as concerning.

Choice D rationale: A breast nodule that is 1 cm in size, nontender, and fixed could potentially raise concerns about malignancy and requires further evaluation.

A. A/V fistula assessment B. Blood pressure C. Pulse D. Anuria E. Oxygen saturation F. Temperature G. Neurological assessment

Correct Answer is ["B","C","D","E"]

Explanation

Choice A rationale: A/V fistula assessment is not concerning because a positive bruit and thrill indicate adequate blood flow through the fistula. A dry dressing with scant amount of blood is expected after hemodialysis.

Choice B rationale: The client's low blood pressure could indicate hypotension, which can be critical, especially after hemodialysis. It may contribute to the client's reported dizziness and fatigue.

Choice C rationale: The client’s pulse is irregular which may indicate cardiac arrhythmia. Choice D rationale: Anuria, the absence of urine output, is a significant concern. It could indicate kidney dysfunction or inadequate clearance of waste products, which may have implications following hemodialysis.

Choice E rationale: Oxygen saturation at 92% is relatively low. While the client is alert and oriented, a low oxygen saturation level may indicate potential respiratory compromise or inadequate oxygenation.

Choice F rationale: Temperature is not concerning because it is within normal range.

Choice G rationale: Neurological assessment is not concerning because the client is alert and oriented. The dizziness is likely related to the hypotension and will resolve once the blood pressure is stabilized.

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The nurse in the women's health clinic has four patients who are waiting to be seen. Which patient should the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment finding in a 36-yr-old patient is most indicative of a need for further evaluation?

Correct Answer is D

Explanation

The nurse is caring for a 67-year-old client in the medical-surgical unit following hemodialysis. The nurse reviews the nursing note, vital signs, assessment, and medical history Which clinical data is most concerning to the nurse? Select all that apply

Correct Answer is ["B","C","D","E"]

Explanation

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