The nurse is talking with a 14-year-old female client who has just had her first sexual experience with a boy. At this time, the nurse should assess the client's knowledge of: (SELECT ALL THAT APPLY)

sexually transmitted infections.

the need for contraception.

facts vs. myths about sex.

hormonally-induced decrease in vaginal lubrication.

erectile dysfunction.

Answer and Explanation

Correct Answer : A,B,C

A. Sexually transmitted infections (STIs): Assessing the client's knowledge of STIs is crucial following the initiation of sexual activity to ensure understanding of risks and preventive measures. It enables the nurse to provide education on STI transmission, symptoms, prevention methods (such as condom use), and the importance of regular STI screening.

B. The need for contraception: Assessing the client's understanding of contraception is essential to prevent unintended pregnancies. The nurse can explore the client's knowledge of contraceptive methods, their effectiveness, correct usage, and availability. Providing education on contraceptive options empowers the client to make informed decisions about protecting their sexual health.

C. Facts vs. myths about sex: Assessing the client's understanding of facts and myths surrounding sex helps identify any misconceptions or gaps in knowledge. This allows the nurse to provide accurate information about sexual anatomy, physiology, reproductive health, and healthy sexual practices. Addressing myths promotes sexual health literacy and reduces the risk of misinformation influencing behavior.

D. Hormonally-induced decrease in vaginal lubrication: Assessing hormonal changes affecting vaginal lubrication is less relevant in this context, as it primarily applies to physiological changes in older individuals or those experiencing hormonal fluctuations due to menopause or medical conditions. It is not typically a concern immediately following a first sexual experience in adolescence.

E. Erectile dysfunction: Assessing knowledge of erectile dysfunction is more pertinent in males and is typically not a primary concern immediately following a first sexual experience for a female client. While it is valuable to address sexual health comprehensively, focusing on topics directly relevant to the client's situation is paramount for effective assessment and education.

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Correct Answer is C

Explanation

A. Polyuria: Polyuria refers to abnormally large volume of urine output, typically exceeding 2.5 to 3 liters per day in adults. It is often associated with conditions such as diabetes mellitus, diabetes insipidus, or certain medications that increase urine production. Urinating 250 mL over 24 hours does not meet the criteria for polyuria.

B. Retention: Urinary retention refers to the inability to completely empty the bladder, leading to accumulation of urine. It is characterized by difficulty initiating urination or incomplete bladder emptying. Urinating 250 mL over 24 hours does not indicate urinary retention.

C. Oliguria: Oliguria is defined as diminished urine output, typically less than 400 mL per day in adults. It is a common sign of kidney dysfunction or acute kidney injury. Urinating 250 mL over 24 hours falls within the range of oliguria, indicating decreased urine production compared to normal.

D. Anuria: Anuria is the absence of urine production or excretion, typically defined as urine output less than 100 mL per day. It is often indicative of severe kidney dysfunction, renal failure, or obstruction of the urinary tract. While the client's urine output of 250 mL over 24 hours is low, it does not meet the criteria for anuria.

A. Daily weights, vital signs and fluid intake and output B. Monitoring temperature, fluid intake and output and administering IV fluids C. Auscultation of lung sounds. Monitoring urine color and placing an indwelling urinary catheter in the client D. Daily weights, diuretics and waist measurement

Correct Answer is A

Explanation

A. Daily weights, vital signs, and fluid intake and output: These are essential nursing assessments and interventions that can be implemented without a physician's order to monitor the client's fluid volume deficit and hypovolemia. Daily weights help assess changes in fluid status, vital signs provide information on the client's hemodynamic stability, and monitoring fluid intake and output helps track fluid balance.

B. Monitoring temperature, fluid intake and output, and administering IV fluids: While monitoring temperature and fluid intake and output are important aspects of nursing care, administering IV fluids typically requires a physician's order, especially in the context of hypovolemia. The nurse should collaborate with the healthcare team to determine the need for IV fluid therapy.

C. Auscultation of lung sounds, monitoring urine color, and placing an indwelling urinary catheter in the client: Auscultation of lung sounds and monitoring urine color are relevant assessments for fluid volume status, but placing an indwelling urinary catheter typically requires a physician's order unless there is a specific nursing protocol in place allowing nurses to insert catheters under certain circumstances.

D. Daily weights, diuretics, and waist measurement: While daily weights are appropriate for assessing fluid status, administering diuretics should be based on a physician's order and assessment findings. Waist measurement is not typically used to assess fluid volume deficit and hypovolemia.

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The nurse is talking with a 14-year-old female client who has just had her first sexual experience with a boy. At this time, the nurse should assess the client's knowledge of: (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client who has kidney disease. The client has urinated 250 mL over the past 24 hours. The nurse describes this urine output as:

Correct Answer is C

Explanation

The nurse is caring for a client with a fluid volume deficit and hypovolemia. What actions can the nurse take without a physician's order?

Correct Answer is A

Explanation

When caring for a patient in pain, the most important principle that the nurse must recognize is that:

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