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."

Answer and Explanation

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.

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Correct Answer is B

Explanation

B. Triiodothyronine (T3) is one of the thyroid hormones, and in Graves' disease, there is excessive production of thyroid hormones, including T3. Therefore, T3 levels are often elevated in individuals with Graves' disease due to the hyperthyroid state.
A. Phosphorus levels are typically not significantly affected by Graves' disease.
C. In Graves' disease, there is typically suppression of TSH secretion due to the negative feedback from elevated levels of thyroid hormones. Therefore, TSH levels are typically decreased (low) in individuals with Graves' disease.
D. Calcium levels are typically not directly affected by Graves' disease.

A. Apply mitten restraints to prevent the client from disconnecting their tube feeding. B. Apply a vest restraint daily at bedtime to prevent nighttime wandering. C. Apply an abduction pillow between the client's knees while they are in bed to prevent hip dislocation. D. Apply soft heel protectors bilaterally while client is in bed.

Correct Answer is B

Explanation

Restraints should be avoided whenever possible. Addressing the underlying cause of wandering (such as anxiety, discomfort, or confusion) is essential.
A. In cases where restraints are deemed necessary to prevent harm to the client, such as preventing them from dislodging their tube feeding, it may be appropriate.
C. The use of an abduction pillow is a common preventive measure to maintain proper hip alignment and prevent hip dislocation, especially after hip surgery.
D. Soft heel protectors are used to prevent pressure ulcers and protect the heels from injury while the client is in bed.

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A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the nurse make?

Nursing Test Bank

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