Nokea
The nurse is preparing a 51-year-old client for a vaginal examination. The nurse should place the client in which position?
- A. Prone
- B. Lateral Sims’
- C. Lithotomy
- D. High Fowler’s
Correct Answer: C
Rationale: The correct answer is C: Lithotomy position. This position allows for optimal visualization of the vaginal area and easier access for the examination. The client lies on their back with knees flexed and feet in stirrups, providing proper exposure. Prone (A) is face down and not suitable for a vaginal exam. Lateral Sims' (B) is on the side and not ideal for this exam. High Fowler's (D) is sitting upright, which is not appropriate for a vaginal examination.
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A woman has been diagnosed with galactorrhea. Which signs and symptoms should the nurse expect to see? Select all that apply.
- A. Milky white discharge from one or both nipples
- B. Absence of menstrual periods
- C. Temperature intolerance
- D. Less interest in sex
Correct Answer: D
Rationale: The correct answer is D: Less interest in sex. Galactorrhea is the spontaneous flow of milk from the breast unassociated with childbirth or nursing. It is commonly caused by elevated levels of prolactin, which can suppress the production of sex hormones like estrogen and testosterone, leading to symptoms like decreased libido and less interest in sex. The other choices, A, B, and C, are incorrect because milky white discharge from nipples (A) is a symptom of galactorrhea, absence of menstrual periods (B) is more indicative of conditions like amenorrhea, and temperature intolerance (C) is not typically associated with galactorrhea.
The pregnant woman who becomes infected with chickenpox should be taught to report promptly:
- A. Cough or dyspnea
- B. Severe skin itching
- C. Joint pain
- D. Increased urination
Correct Answer: A
Rationale: The correct answer is A: Cough or dyspnea. Chickenpox can lead to pneumonia in pregnant women, causing cough or dyspnea. Prompt reporting is crucial for timely intervention. B: Severe itching is common in chickenpox but not a critical symptom. C: Joint pain is not a typical complication of chickenpox. D: Increased urination is not directly related to chickenpox complications during pregnancy. It's important for the pregnant woman to be aware of respiratory symptoms as they can indicate a serious complication that requires immediate medical attention.
The test used to screen for gestational diabetes is the:
- A. Glycosylated hemoglobin test.
- B. Glucose challenge test.
- C. Oral glucose tolerance test.
- D. Postprandial glucose test.
Correct Answer: B
Rationale: The correct answer is B: Glucose challenge test. This test is used to screen for gestational diabetes as it involves drinking a glucose solution and measuring blood sugar levels afterward. This test is specifically designed to assess how well the body processes sugar during pregnancy. The other choices are incorrect because:
A: Glycosylated hemoglobin test measures average blood sugar levels over the past 2-3 months and is not specific for gestational diabetes.
C: Oral glucose tolerance test is used to diagnose gestational diabetes, not to screen for it.
D: Postprandial glucose test measures blood sugar levels after a meal and is not the recommended screening test for gestational diabetes.
A client comes to an outpatient clinic for evaluation. What in the client's blood sample reveals that administration of the hepatitis B vaccine has been effective?
- A. Hepatitis B surface antigen (HBsAg)
- B. anti-HBs
- C. anti-HBc IgM
- D. anti-HBc
Correct Answer: B
Rationale: The correct answer is B: anti-HBs. This antibody indicates successful immunity after hepatitis B vaccination. It is produced in response to the vaccine and signifies protection against the virus. Choice A, HBsAg, is present in acute infection. Choices C and D, anti-HBc IgM and anti-HBc, indicate acute or chronic infection, not vaccine response.
The client calls the nurse and states she has not had a menstrual cycle in 3 months. What does the nurse know is the most common cause of secondary amenorrhea?
- A. Weight loss
- B. Pregnancy
- C. Cancer
- D. Menopause
Correct Answer: B
Rationale: The correct answer is B: Pregnancy. In the case of secondary amenorrhea, where a woman stops menstruating after previously having regular cycles, pregnancy is the most common cause. Pregnancy leads to a halt in the menstrual cycle due to hormonal changes to support the developing fetus. Other choices are incorrect: A) Weight loss can affect menstruation but is not the most common cause of secondary amenorrhea. C) Cancer can also disrupt the menstrual cycle, but it is not the primary cause in this scenario. D) Menopause typically occurs in women in their late 40s to early 50s, and would not be the most common cause of secondary amenorrhea in a younger woman.