Nokea
The expert nurse is assisting a novice nurse insert a Foley catheter. The novice nurse has tried unsuccessfully to insert the catheter, and the expert nurse is providing verbal guidance while spreading which area to reveal the urethral opening?
- A. Labia majora and minora
- B. Meatus
- C. Clitoris
- D. Fourchette
Correct Answer: A
Rationale: The labia majora and minora are a portion of the external genitalia and when parted reveals the urethral opening. The meatus refers to an opening or passage. The clitoris is sensitive erectile tissue considered the site of sexual pleasure. The fourchette is the area beneath the vaginal opening at the base of the labia majora.
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The nurse is preparing the female client for a pelvic examination. Into which position will the nurse assist the client?
- A. Lithotomy position
- B. Supine position
- C. Trendelenburg position
- D. Lateral recumbent
Correct Answer: A
Rationale: For a pelvic examination, the nurse is most correct to assist the client to the lithotomy position. In this position, the client lies on the back with the legs bent and spread. Many times, the feet are in lithotomy stirrups. The supine position is flat on the back. The Trendelenburg position provides the feet higher than the head at a 15?° to 30?° angle. The lateral recumbent position is a side-lying position.
The nurse is completing community education when asked by a client without health insurance why a mammogram is needed if the women are completing breast self-examinations at home. The nurse is most correct to respond stating which of the following?
- A. Mammograms are just better.
- B. Mammograms can detect cysts or tumors too small to palpate.
- C. Mammograms provide a baseline that shows changes in breast tissue.
- D. Mammograms provide a reassurance that the breast is free of cancer.
Correct Answer: B
Rationale: During community instruction, it is most important to relay facts in a clear, factual, and nonjudgmental way. Stating the need for mammograms to detect small cysts or tumors is clear and factual. Stating that mammograms are 'better' is vague and provides no better understanding. Although a mammogram does provide a baseline and reassurance of breast health, the most clear and factual reason why the mammogram is completed is its ability to detect cancerous tumors at an early stage.
The nurse is caring for a client who states having an irregular menstrual period. Which diagnostic test provides information of the body's ability to ovulate?
- A. Thyroid level
- B. Serum luteinizing hormone
- C. Serum follicle-stimulating hormone
- D. Estrogen level
Correct Answer: C
Rationale: The anterior pituitary hormone known as follicle-stimulating hormone (FSH) initiates ovulation monthly. Monitoring the FSH level provides information about the timing of ovulation. Thyroid level, estrogen level, and serum luteinizing hormone do not give information about the ability to ovulate.
A client presents with symptoms of menstrual difficulties and infertility. Which hormone is essential in the maintenance of the endometrium?
- A. Estrogen
- B. Progesterone
- C. Testosterone
- D. Prolactin
Correct Answer: B
Rationale: Without a high level of progesterone, the endometrium (uterine lining) degenerates and sheds. Estrogen is a hormone that is essential for menstruation and prepares the uterus for pregnancy. Women produce testosterone, which maintains muscle mass, bone strength, and sex drive. Prolactin is produced by the pituitary gland and stimulates lactation.
The nurse is preparing a client for a pelvic examination. Which nursing question is essential for the nurse to ask?
- A. Are you sexually active?
- B. Do you have any sexually transmitted diseases?
- C. Would you like to have assistance to get in position for the exam?
- D. Would you like to void at this time?
Correct Answer: D
Rationale: Prior to a pelvic examination, the nurse offers the client the use of the restroom to void. It is most important for the client to empty the bladder so that the physician can feel pelvic structures more clearly and for the comfort of the client. Asking client history questions is completed at the beginning of the appointment. It is important to offer assistance to those who may need help in assuming the lithotomy position.