A parent brings a preteen daughter to the clinic for her first female examination. During the health assessment, the nurse should implement which technique to determine if the client has reached the age of menarche?

Assess for presence of a supernumerary breast nipple.

Palpate for evidence of temporary gynecomastia.

Calculate approximate age menstruation should occur.

Use the Tanner staging to determine sexual maturity.

Answer and Explanation

The Correct Answer is D

A. The presence of a supernumerary breast nipple is not related to the onset of menarche and is not a common assessment in determining sexual maturity.
B. Temporary gynecomastia is more commonly observed in adolescent boys rather than preteen girls.
C. While age can provide a rough estimate, it is not as accurate as a physical assessment of sexual maturity.
D. The Tanner staging is a reliable method used to assess sexual maturity in adolescents. It includes evaluating the development of breasts, pubic hair, and other secondary sexual characteristics, which can help determine if the client has likely reached menarche.

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Correct Answer is C

Explanation

A. Erythromycin does not require the client to avoid sunlight, unlike some other antibiotics.
B. The timing of medication intake does not affect the interaction between erythromycin and oral contraceptives.
C. Erythromycin can reduce the effectiveness of oral contraceptives. It is essential to use an additional contraceptive method to prevent unintended pregnancy.
D. Stopping the oral contraceptive is not necessary but using an additional form of contraception is important.

A. Palpate the client's muscle tone. B. Instruct the client to close his eyes. C. Apply resistance to the client's arms. D. Give the client an object to hold.

Correct Answer is C

Explanation

A. Palpating muscle tone is important but should be done in conjunction with resistance testing to assess strength.

B. Asking the client to close his eyes is not necessary for assessing muscle strength.

C. Applying resistance while the client extends and flexes his arms helps evaluate the muscle strength and function accurately.

D. Providing an object to hold is not relevant for assessing muscle strength in this context.

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A parent brings a preteen daughter to the clinic for her first female examination. During the health assessment, the nurse should implement which technique to determine if the client has reached the age of menarche?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is taking an oral contraceptive receives a new prescription for erythromycin. Which instruction should the nurse provide to the client?

Correct Answer is C

Explanation

To assess a male client's muscle strength, the nurse first asks the client to extend his arms. Before asking the client to flex his arms, what should the nurse do?

Correct Answer is C

Explanation

The nurse is caring for a client who is taking the mood stabilizer divalproex sodium. Which laboratory value is most important for the nurse to monitor?

After receiving large doses of chlorpromazine for two weeks, a client begins to develop spasms of the neck and back. Which action should the nurse take?

When entering a client's room to assess vital signs, the nurse finds the client crying. After allowing the client to express feelings, which intervention should the nurse implement?

The nurse is planning discharge teaching for a client with type 2 diabetes mellitus who has a new prescription for insulin glargine. Which action should the nurse plan to Include in the discharge teaching?

To detect common untoward effects of phenytoin, the nurse should assess a client with a seizure disorder for which sign or symptom?

In preparing to perform colostomy care, the nurse observes that a client's colostomy stoma has become a dark red to bluish color. Which action should the nurse implement?