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 ["C","D","E","F"]

Explanation

The client is likely suffering from diabetes ketoacidosis with metabolic acidosis not respiratory alkalosis. They are also severely dehydrated which may lead to hypotension and acute renal injury. In DKA, clients may have hyperkalemia or hypokalemia who h may predispose to cardiac dysrhythmias.

Septic shock is unlikely as the chest exam indicates likely resolved pneumonia.

Cerebral edema is commonly seen in clients on hydration therapy in DKA due to rapid fluid replacement.

A. Move the client up and down in bed by holding onto the halo traction device. B. Ensure that there is space for one finger to fit between the vest and the client's skin. C. Apply medicated powder under the vest to reduce itching. D. Loosen or tighten the screws on the device as needed for the client's comfort.

Correct Answer is B

Explanation

B. Ensuring that there is space for one finger to fit between the vest and the client's skin helps prevent skin breakdown and pressure injuries. The halo vest should fit snugly but not too tight to allow for proper circulation and comfort.
A. Moving the client by holding onto the halo traction device can disrupt the device's stability and potentially cause harm to the client.
C. Applying medicated powder under the vest can introduce foreign substances to the skin and may increase the risk of skin irritation or infection.
D. This should only be performed under the guidance of a healthcare provider.

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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

Naxlex Comprehensive Predictor Exams

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Explanation

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