Nokea
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.
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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 parent of an adolescent female is asking the nurse for guidelines of when the daughter should have her first Papanicolaou test (Pap test) and then the subsequent frequency. The nurse is most correct to state which?
- A. The first Pap test should be at age 16 years and then annually thereafter.
- B. The first Pap test should be no later than 18 years of age and then every other year afterward.
- C. The first Pap test should be between 25 and 29 years and then every 3 years afterward.
- D. The first Pap test should be within the first year of menstruation and annually afterward.
Correct Answer: C
Rationale: The American Cancer Society (ACS) recommends no testing/screenings for women aged 21 to 24 years. Women between the ages of 25 and 29 years have the recommendation for HPV testing to be every 5 years (preferred), the HPV/Pap co-test every 5 years (acceptable), or the Pap test every 3 years (acceptable).
What information would the nurse give the client when the client inquires what makes breast milk production?
- A. Estrogen
- B. Progesterone
- C. Prolactin
- D. Testosterone
Correct Answer: C
Rationale: Prolactin promotes the production of breast milk. Estrogen secreted by the ovaries at the onset of puberty causes the development of the mammary system. Progesterone, secreted by the placenta, stimulates the development of alveoli, which secrete the milk. Testosterone does not impact milk production.
The nurse is outlining the female internal reproductive structures on a diagram. Where on the diagram would the nurse highlight the typical site of ovum fertilization?
- A. The nurse would highlight the uterus.
- B. The nurse would highlight the cervix.
- C. The nurse would highlight the fallopian tube.
- D. The nurse would highlight the ovaries.
Correct Answer: C
Rationale: The nurse would highlight the fallopian tubes as the site of ovum fertilization. Once fertilized, the fertilized egg moves to the uterus for implantation. The cervix is the lower, narrowed neck portion leading to the center of the uterus. The ovaries release the ovum, which is swept into the fallopian tubes.