A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the nurse make?
"These discomforts should decrease with time."
"Women your age experience thickening of the vaginal tissue."
"Your symptoms are likely due to decreasing estrogen levels."
"You should avoid intercourse to prevent injury to your vagina."
The Correct Answer is C
C. It acknowledges the client's symptoms and provides a likely explanation related to hormonal changes associated with aging. It opens the door for further discussion and potential interventions to address the underlying cause.
A. This response dismisses the client's symptoms without addressing the underlying cause or providing potential solutions.
B. The opposite tends to occur with age – vaginal tissue can become thinner and drier due to decreasing estrogen levels, leading to symptoms like vaginal dryness and itching.
D. While avoiding intercourse may be recommended in certain situations, such as if there is discomfort or pain, it does not address the underlying cause of the symptoms. Additionally, it may not be necessary if appropriate treatments are pursued to alleviate vaginal dryness and itching.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
D. Capillary refill time greater than 2 seconds suggests impaired peripheral circulation, which could indicate vascular compromise or inadequate perfusion to the extremity. In a client with an external fixator, compromised circulation could lead to serious complications such as compartment syndrome or tissue necrosis.
A. This finding may be within the expected range for drainage following surgery, particularly if the client has undergone orthopedic surgery involving the placement of an external fixator. However, the nurse should continue to monitor the drainage and assess for any signs of increased bleeding or hematoma formation.
B. While a low-grade fever alone may not require immediate intervention, the nurse should assess the client further for other signs and symptoms of infection, such as increased pain, redness, warmth, or drainage at the surgical site.
C. While the client's pain level of 7 may require intervention to manage discomfort, it does not necessarily indicate an immediate threat to the client's safety or well-being.
Correct Answer is C
Explanation
C. Stridor is a high-pitched, crowing sound that occurs during inspiration and indicates upper airway obstruction. Stridor following extubation is a concerning finding and requires immediate intervention to ensure adequate airway patency and prevent respiratory compromise. The nurse should notify the healthcare provider immediately and be prepared to provide interventions such as airway suctioning, supplemental oxygen, or reintubation if necessary.
A. While a sore throat is a common complaint after extubation due to irritation from the endotracheal tube, it does not typically require immediate intervention unless it is severe or accompanied by other concerning symptoms. The nurse should provide comfort measures and monitor for worsening symptoms.
B. An SPO2 of 92% is within normal rage and requires no immediate intervention.
D. While rhonchi may require intervention, they are not typically as immediately concerning as stridor, which indicates upper airway obstruction.
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