Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the nurse make?
A. "These discomforts should decrease with time."
This response dismisses the client's symptoms without addressing the underlying cause or providing potential solutions.
B. "Women your age experience thickening of the vaginal tissue."
The opposite tends to occur with age – vaginal tissue can become thinner and drier due to decreasing estrogen levels, leading to symptoms like vaginal dryness and itching.
C. "Your symptoms are likely due to decreasing estrogen levels."
It acknowledges the client's symptoms and provides a likely explanation related to hormonal changes associated with aging. It opens the door for further discussion and potential interventions to address the underlying cause.
D. "You should avoid intercourse to prevent injury to your vagina."
While avoiding intercourse may be recommended in certain situations, such as if there is discomfort or pain, it does not address the underlying cause of the symptoms. Additionally, it may not be necessary if appropriate treatments are pursued to alleviate vaginal dryness and itching.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Rn Adult Medical Surgical 2023 Proctored Exam. Take the full exam now
Full Explanation
C. It acknowledges the client's symptoms and provides a likely explanation related to hormonal changes associated with aging. It opens the door for further discussion and potential interventions to address the underlying cause.
A. This response dismisses the client's symptoms without addressing the underlying cause or providing potential solutions.
B. The opposite tends to occur with age – vaginal tissue can become thinner and drier due to decreasing estrogen levels, leading to symptoms like vaginal dryness and itching.
D. While avoiding intercourse may be recommended in certain situations, such as if there is discomfort or pain, it does not address the underlying cause of the symptoms. Additionally, it may not be necessary if appropriate treatments are pursued to alleviate vaginal dryness and itching.
Similar Questions
A nurse is performing a fall risk assessment on a client. Which of the following findings indicates the client has an increased fall risk?
A. The client asks for help before ambulating.
This indicates that the client is aware of their limitations and is proactive in seeking assistance, which may actually decrease their fall risk. It demonstrates awareness and caution.
B. The client has a history of urinary incontinence.
Urinary incontinence can increase fall risk due to the need for frequent trips to the bathroom, which may increase the chances of tripping or falling, especially if the client rushes to the bathroom.
C. The client lives with their caregiver.
While having a caregiver present can provide support and assistance, it doesn't necessarily indicate an increased fall risk. In fact, having a caregiver present may decrease the risk of falls by providing supervision and assistance as needed.
D. The client has bronchitis.
Bronchitis itself does not directly contribute to an increased fall risk.
Full Explanation
B. Urinary incontinence can increase fall risk due to the need for frequent trips to the bathroom, which may increase the chances of tripping or falling, especially if the client rushes to the bathroom.
A. This indicates that the client is aware of their limitations and is proactive in seeking assistance, which may actually decrease their fall risk. It demonstrates awareness and caution.
C. While having a caregiver present can provide support and assistance, it doesn't necessarily indicate an increased fall risk. In fact, having a caregiver present may decrease the risk of falls by providing supervision and assistance as needed.
D. Bronchitis itself does not directly contribute to an increased fall risk.
A nurse is caring for a client following an insertion of a chest tube drainage system for a pneumothorax. Which of the following manifestations should the nurse expect the client to demonstrate?
A. Gentle bubbling in the water seal chamber
Bubbling indicates that the system is functioning properly and that air is being evacuated from the pleural space.
B. Drainage and warmth at tube insertion site
Drainage and warmth at the tube insertion site could indicate inflammation or infection, which are potential complications following insertion of a chest tube.
C. Crackling sensation felt around tube insertion site
Crackling sensation felt around tube insertion site could indicate subcutaneous emphysema, which occurs when air leaks into the tissues surrounding the chest tube insertion site. It's a potential complication of chest tube insertion and should be monitored closely
D. Drainage output less than 70 mL/hr
The specific amount can vary.
Full Explanation
A. Bubbling indicates that the system is functioning properly and that air is being evacuated from the pleural space.
B. Drainage and warmth at the tube insertion site could indicate inflammation or infection, which are potential complications following insertion of a chest tube.
C. Crackling sensation felt around tube insertion site could indicate subcutaneous emphysema, which occurs when air leaks into the tissues surrounding the chest tube insertion site. It's a potential complication of chest tube insertion and should be monitored closely
D. The specific amount can vary.
A nurse is caring for a client after total hip replacement surgery. Which of the following actions should the nurse take?
A. Use an elevated toilet seat.
Use an elevated toilet seat: Using an elevated toilet seat can help prevent excessive bending of the hip joint, reducing strain and potential dislocation risk after total hip replacement surgery.
B. Log roll the client onto the operative side.
Log rolling onto the operative side is contraindicated after total hip replacement surgery. This movement could place excessive stress on the newly replaced hip joint, increasing the risk of dislocation and complications.
C. Keep client's affected heel on the bed.
Keeping the affected heel on the bed helps maintain proper alignment and precautions after total hip replacement surgery. It supports the hip joint and reduces the risk of dislocation by preventing excessive rotation or movement.
D. Perform internal and external rotation exercises of hip.
While some hip exercises are beneficial, internal and external rotation exercises are typically avoided immediately after total hip replacement surgery to prevent strain on the new joint.
Full Explanation
A. Use an elevated toilet seat: Using an elevated toilet seat can help prevent excessive bending of the hip joint, reducing strain and potential dislocation risk after total hip replacement surgery.
B. Log rolling onto the operative side is contraindicated after total hip replacement surgery. This movement could place excessive stress on the newly replaced hip joint, increasing the risk of dislocation and complications.
C. Keeping the affected heel on the bed helps maintain proper alignment and precautions after total hip replacement surgery. It supports the hip joint and reduces the risk of dislocation by preventing excessive rotation or movement.
D. While some hip exercises are beneficial, internal and external rotation exercises are typically avoided immediately after total hip replacement surgery to prevent strain on the new joint.