Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a middle adult female client who reports that her menstrual periods have become irregular and she has been having hot flashes.
The nurse should expect the client to have which of the following manifestations associated with early menopause?.
A. Urinary retention.
Urinary retention is not typically associated with menopause.
B. Dryness with intercourse.
Dryness with intercourse is a common symptom of menopause due to decreased estrogen levels.
C. Elevation in body temperature above 37.8° C (100° F).
An elevation in body temperature above 37.8° C (100° F) is not typically associated with menopause.
D. Decreased blood pressure.
Decreased blood pressure is not typically associated with menopause.
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Full Explanation
Choice A rationale:
Urinary retention is not typically associated with menopause.
Choice B rationale:
Dryness with intercourse is a common symptom of menopause due to decreased estrogen levels.
Choice C rationale:
An elevation in body temperature above 37.8° C (100° F) is not typically associated with menopause.
Choice D rationale:
Decreased blood pressure is not typically associated with menopause.
Similar Questions
A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations?
A. Apneustic respirations.
Apneustic respirations are characterized by prolonged inspiratory phase with shortened expiratory phase, not alternating periods of hyperventilation and apnea.
B. Stridor.
Stridor is a high-pitched, wheezing sound caused by disrupted airflow, not a pattern of breathing.
C. Kussmaul respirations.
Kussmaul respirations are deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis, not alternating periods of hyperventilation and apnea.
D. Cheyne-Stokes respirations.
Cheyne-Stokes respirations are characterized by alternating periods of hyperventilation and apnea.
Full Explanation
Choice A rationale:
Apneustic respirations are characterized by prolonged inspiratory phase with shortened expiratory phase, not alternating periods of hyperventilation and apnea.
Choice B rationale:
Stridor is a high-pitched, wheezing sound caused by disrupted airflow, not a pattern of breathing.
Choice C rationale:
Kussmaul respirations are deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis, not alternating periods of hyperventilation and apnea.
Choice D rationale:
Cheyne-Stokes respirations are characterized by alternating periods of hyperventilation and apnea.
A nurse is developing a teaching plan for a client who has a new diagnosis of type 2 diabetes mellitus.
Which of the following actions should the nurse plan to take first?
A. Give the client access to a video about diabetes.
Giving the client access to a video about diabetes is a good teaching tool, but it should come after assessing the client’s knowledge.
B. Determine what the client knows about managing diabetes.
The first step in patient education is to assess the client’s learning needs. This includes determining what the client already knows about managing diabetes.
C. Establish short-term, realistic goals for the client.
Establishing short-term, realistic goals for the client is important, but it should be done after assessing the client’s knowledge.
D. Evaluate the effectiveness of the client's admission teaching plan.
Evaluating the effectiveness of the client’s admission teaching plan is a later step, after assessing the client’s knowledge and teaching them about their condition.
Full Explanation
Choice A rationale:
Giving the client access to a video about diabetes is a good teaching tool, but it should come after assessing the client’s knowledge.
Choice B rationale:
The first step in patient education is to assess the client’s learning needs. This includes determining what the client already knows about managing diabetes.
Choice C rationale:
Establishing short-term, realistic goals for the client is important, but it should be done after assessing the client’s knowledge.
Choice D rationale:
Evaluating the effectiveness of the client’s admission teaching plan is a later step, after assessing the client’s knowledge and teaching them about their condition.
A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?
A. Turn the client's head to the side.
Turning the client’s head to the side is important to prevent aspiration, but it should be done after documenting the time the seizure began.
B. Document the time the seizure began.
The first action when a client begins having a tonic-clonic seizure is to document the time the seizure began. This helps in determining the duration of the seizure, which is critical information for the healthcare team.
C. Loosen the clothing around the client's waist.
Loosening the clothing around the client’s waist is important for the client’s comfort and safety during a seizure, but it should be done after documenting the time the seizure began.
D. Check the client's motor strength.
Checking the client’s motor strength is not the first action to take when a client begins having a tonic-clonic seizure.
Full Explanation
Choice A rationale:
Turning the client’s head to the side is important to prevent aspiration, but it should be done after documenting the time the seizure began.
Choice B rationale:
The first action when a client begins having a tonic-clonic seizure is to document the time the seizure began. This helps in determining the duration of the seizure, which is critical information for the healthcare team.
Choice C rationale:
Loosening the clothing around the client’s waist is important for the client’s comfort and safety during a seizure, but it should be done after documenting the time the seizure began.
Choice D rationale:
Checking the client’s motor strength is not the first action to take when a client begins having a tonic-clonic seizure.