A 14-year-old girl presents to the school nurse with the fourth vaginal yeast infection she has had during the past 6 months. The nurse should assess the adolescent for which finding(s)? Select all that apply.

Thirst.

Increased appetite.

Heat intolerance.

Tachycardia.

Urinary frequency.

Answer and Explanation

Correct Answer : A,D,E

A. Thirst: Recurrent yeast infections in adolescents may indicate underlying hyperglycemia, as excessive glucose in the urine promotes fungal growth. Thirst is a classic symptom of diabetes mellitus and should be assessed.

B. Increased appetite: While diabetes can sometimes cause polyphagia, it is less specific than other signs such as thirst, urinary frequency, and tachycardia. It may not be present in every case and is not a primary screening indicator.

C. Heat intolerance: Heat intolerance is more commonly associated with hyperthyroidism, not recurrent yeast infections. Assessing for this symptom is not directly relevant to evaluating potential diabetes in this adolescent.

D. Tachycardia: Elevated heart rate can occur with dehydration caused by hyperglycemia and osmotic diuresis. Tachycardia may be an important clinical clue in assessing for undiagnosed diabetes.

E. Urinary frequency: Polyuria is a hallmark symptom of hyperglycemia and diabetes mellitus. Recurrent yeast infections may prompt assessment for urinary frequency as part of the screening for possible diabetes.

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Correct Answer is B

Explanation

A. Heart rate 130–136 beats/minute, blood pressure 190–200/90–100 mm Hg, Kussmaul respirations: Although hypertensive and tachycardic, Kussmaul respirations are typically associated with metabolic acidosis rather than ICP. These findings are concerning but not classic for increased ICP.

B. Heart rate 55–50 beats/minute, blood pressure 160/70–194/70 mm Hg, irregular respirations: This pattern reflects Cushing’s triad—bradycardia, hypertension with widening pulse pressure, and irregular respirations—which is a hallmark sign of increased ICP and requires immediate reporting.

C. Heart rate 110–100 beats/minute, blood pressure 130/70–110/70 mm Hg, shallow respirations: Vital signs are not indicative of ICP; shallow respirations may be due to other causes, and the blood pressure trend is decreasing rather than showing hypertension with widening pulse pressure.

D. Heart rate 70–100 beats/minute, blood pressure 120/60–90/60 mm Hg, rapid respirations: These findings suggest hypotension and tachypnea, which are more indicative of hypovolemia or other systemic issues rather than increased ICP.

A. Administer prescribed PRN sleep medications. B. Encourage use of prescribed analgesic perineal sprays. C. Encourage breastfeeding to promote uterine involution. D. Administer prescribed stool softener.

Correct Answer is D

Explanation

A. Administer prescribed PRN sleep medications: While adequate rest is important for postpartum recovery, it does not address the immediate risk to the client’s healing perineal tissue and comfort related to the fourth-degree laceration.

B. Encourage use of prescribed analgesic perineal sprays: Pain management is important for comfort and mobility, but it does not prevent complications such as wound disruption or trauma during defecation, which could impair healing.

C. Encourage breastfeeding to promote uterine involution: Breastfeeding supports uterine contraction and reduces postpartum bleeding, but it does not directly impact the care and protection of a severe perineal laceration.

D. Administer prescribed stool softener: Preventing straining during bowel movements is critical in promoting healing of a fourth-degree perineal laceration. Stool softeners reduce the risk of trauma to the repaired tissue, prevent pain, and minimize potential complications such as wound dehiscence.

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A 14-year-old girl presents to the school nurse with the fourth vaginal yeast infection she has had during the past 6 months. The nurse should assess the adolescent for which finding(s)? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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