To assess a female client for hirsutism, which action should the nurse take?

Observe the hair shafts on the client's scalp.

Apply and release light pressure to the skin.

Lightly palpate over the client's entire scalp.

Assess the appearance of the client's face.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Observe the hair shafts on the client's scalp: Observing scalp hair provides information about hair texture, thickness, or loss but does not help assess hirsutism. Hirsutism refers specifically to excessive hair growth in areas where women typically have minimal hair, not the scalp.

B. Apply and release light pressure to the skin: Applying pressure to the skin is used to assess for skin turgor, edema, or blanching but is unrelated to evaluating abnormal hair growth patterns like hirsutism.

C. Lightly palpate over the client's entire scalp: Scalp palpation assesses for tenderness, lesions, or scalp integrity. It does not evaluate for the presence of androgenic hair patterns on the face or body that characterize hirsutism.

D. Assess the appearance of the client's face: Hirsutism most commonly appears as coarse, dark hair on the upper lip, chin, cheeks, and sometimes the chest or back in women. Visual assessment of the client's face is critical for identifying the presence and severity of this condition.

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Free Nursing Study Resources

Correct Answer is A

Explanation

Rationale:
A. Flex and hold as opposing force is applied: This technique evaluates the strength of prime-mover muscle groups by having the client actively flex against resistance. It allows the nurse to assess muscle function, endurance, and the ability to maintain strength against an external force.

B. Perform sets of passive range of motion: Passive range of motion exercises assess joint flexibility and mobility but do not evaluate the client's active muscle strength since the movements are performed by the examiner rather than the client.

C. Hold arms straight forward with eyes closed: This action is part of a neurological assessment, specifically testing for proprioception and balance (Romberg test), not a direct evaluation of muscle group strength.

D. Stand on each foot without assistance: Standing on one foot assesses balance and coordination more than muscle strength. It involves neuromuscular control but does not directly isolate or test specific prime-mover muscle groups under resistance.

A. An overactive bladder B. A cloudy discharge. C. A weak urinary stream. D. Black tarry stools.

Correct Answer is C

Explanation

Rationale:
A. An overactive bladder: Overactive bladder typically presents with urgency, frequency, and sometimes incontinence, but it does not usually cause suprapubic tenderness or the sensation of incomplete bladder emptying. These symptoms are more consistent with urinary retention or bladder outlet obstruction.

B. A cloudy discharge: Cloudy urinary discharge is more indicative of a urinary tract infection (UTI) rather than urinary retention. While infections can cause some bladder discomfort, the client’s description points more specifically to mechanical urinary issues rather than infection.

C. A weak urinary stream: A weak urinary stream is commonly associated with bladder outlet obstruction, often due to benign prostatic hyperplasia (BPH) in older males. The combination of suprapubic tenderness and the feeling of incomplete emptying aligns with urinary retention caused by obstruction, making this the expected additional finding.

D. Black tarry stools: Black tarry stools are usually a sign of gastrointestinal bleeding, particularly from the upper GI tract. They are unrelated to urinary symptoms and would not explain suprapubic tenderness or voiding difficulties described by the client.

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To assess a female client for hirsutism, which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client's skeletal muscle movements and strength. Which action should the nurse instruct the client to perform to evaluate prime-mover muscle groups?

Correct Answer is A

Explanation

Correct Answer is C

Explanation

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