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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Correct Answer is D

Explanation

Rationale:
A. Ask the interpreter to tell the client to write down questions: Asking the client to write down questions places an unnecessary burden on communication and may not be feasible if the client struggles with written English or literacy. It does not foster an open and supportive dialogue during the interview.

B. Give the interpreter a form that lists the interview questions: Providing the interpreter with a form could help with preparation but does not substitute for real-time interpretation and direct engagement. It risks turning the encounter into a transactional experience rather than building therapeutic rapport with the client.

C. Use an interpreter throughout client's hospitalization: While it is important to use an interpreter when needed, the question asks about what the nurse should implement during the interview itself. Additionally, not all interactions may require an interpreter if communication becomes clearer over time, so blanket use is not always appropriate.

D. Maintain eye contact with the client when questions are asked: Maintaining eye contact reinforces that the nurse is communicating directly with the client, not the interpreter. It promotes trust, respect, and engagement, helping the client feel heard and respected even when a language barrier exists.

A. Acute pain, change in visual acuity, and foreign body sensation. B. Frequent burning, irritation and tearing of the eyes. C. Bilateral itchy, red eyes with watery discharge. D. Diminished ability to focus on close work and excessive illumination required.

Correct Answer is A

Explanation

Rationale:
A. Acute pain, change in visual acuity, and foreign body sensation: These symptoms are concerning and require immediate ophthalmologic evaluation. Subconjunctival hemorrhages are usually benign and painless, so the presence of pain, vision changes, and foreign body sensation suggests a more serious underlying ocular injury or pathology.

B. Frequent burning, irritation and tearing of the eyes: These symptoms are commonly associated with dry eye syndrome or minor irritations. While uncomfortable, they do not typically indicate an urgent need for specialist referral unless severe or persistent.

C. Bilateral itchy, red eyes with watery discharge: This presentation is most consistent with allergic conjunctivitis. Although it may warrant treatment, it is not typically emergent and does not usually require urgent evaluation by an ophthalmologist.

D. Diminished ability to focus on close work and excessive illumination required: These are classic signs of presbyopia, an age-related decline in near vision. Presbyopia is a gradual process and not an emergency that requires immediate referral for urgent evaluation.

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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 performing a health interview for a client who does not speak fluent English and has obtained an interpreter. Which action should the nurse implement?

Correct Answer is D

Explanation

A client sustained a subconjunctival hemorrhage. The presence of which set of symptoms indicate that the client needs to be seen for further evaluation by an ophthalmologist?

Correct Answer is A

Explanation

A client reports episodes of syncope. Which assessment finding should the nurse anticipate?

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