A 20-year-old nulliparous female college student sees the nurse because she has missed her last two menstrual periods. She reports she has not had sexual intercourse in one month. The nurse requests a pregnancy test, which is negative. Based on this client's history, which assessment is most important for the nurse to obtain?

Vaginal discharge, presence of genital warts, abdominal tenderness.

Urinary frequency, unsteady gait, dental enamel erosion.

Breast tenderness, tremors, high blood pressure.

Body weight, hirsutism, thyroid enlargement.

Answer and Explanation

The Correct Answer is D

A. Vaginal discharge, presence of genital warts, abdominal tenderness: While assessing for vaginal discharge and genital warts is important, they are not directly related to the menstrual irregularity described by the client. Abdominal tenderness may be relevant but is not the priority.

B. Urinary frequency, unsteady gait, dental enamel erosion: These symptoms are not specifically associated with missed periods. They may indicate other health issues, but they do not address the primary concern.

C. Breast tenderness, tremors, high blood pressure: Breast tenderness can be related to hormonal changes and menstrual irregularities. Tremors and high blood pressure are less likely to be directly connected to missed periods but should still be assessed.

D. Body weight, hirsutism, thyroid enlargement: Hirsutism (excessive hair growth) and thyroid enlargement (goiter) can be associated with hormonal imbalances, including conditions affecting the menstrual cycle. Assessing body weight is also relevant.

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Correct Answer is C

Explanation

A. Notify the healthcare provider. Notifying the healthcare provider might be necessary if the kyphosis is a new finding or is associated with pain, neurological symptoms, or other complications. However, kyphosis is often a chronic condition associated with osteoporosis.

B. Observe muscle fasciculations. Muscle fasciculations are not directly related to kyphosis and osteoporosis. This option does not address the primary concern of the assessment finding.

C. Document the assessment finding. Documenting the presence of kyphosis is essential for the medical record and ongoing management of the client's osteoporosis. It ensures that the condition is noted and can be monitored over time.

D. Palpate the area for an effusion. Effusions are related to fluid accumulation in joints or tissues, which is not directly related to kyphosis. This is not an appropriate action in response to observing kyphosis.

A. Determine degree of skin elasticity. B. Measure muscle size and strength. C. Inspect appearance of the spine. D. Note 24-hour fluid intake and output.

Correct Answer is B

Explanation

A. Determine degree of skin elasticity: While decreased skin elasticity can be a sign of aging, it doesn't directly assess muscle tone or strength.

B. Measure muscle strength: This is the most appropriate next step to confirm the nurse's initial suspicion of weak muscles. Techniques like manual muscle testing can assess muscle strength.

C. Inspect appearance of the spine: Spinal issues can affect movement and coordination, but they wouldn't necessarily explain soft and boggy muscles in one arm.

D. Note 24-hour fluid intake and output: This might be relevant for overall health assessment but doesn't directly assess muscle tone or strength.

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Naxlex Comprehensive Predictor Exams

During an admission assessment, the nurse observes the presence of kyphosis on an older adult female client with a history of osteoporosis. Which action should the nurse take in response to this finding?

Correct Answer is C

Explanation

In assessing an older adult client, the nurse notes that the client's right arm muscles feel soft and boggy. To gather additional data related to this finding, which assessment should the nurse complete next?

Correct Answer is B

Explanation

The nurse completes palpation of the thoracic region on an adolescent client. Which finding is considered normal for this adolescent client?

In assessing a primigravida woman at 15 weeks gestation by dates, the nurse palpates the fundus at the umbilicus. Based on this assessment finding, it is most important for the nurse to obtain information about the occurrence of which condition?

The nurse is conducting a functional assessment on an older adult client who is reporting decreased activity due to reduced energy and strength. Which action should the nurse perform during the functional assessment?

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

A client has a prescription for vital sign measurement every four hours. The nurse observes that the client's blood pressure has increased from 140/60 mm Hg at noon to 180/90 mm Hg four hours later. Which action should the nurse implement?

The nurse is admitting an older adult client with possible malnutrition. Which parameters are most indicative of the client's nutritional status?

While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

Which finding, obtained during a skin assessment of a student, should the school nurse report to the healthcare provider?