A 13-year-old female reports to the school nurse with concerns about her menstrual cycle. The client states that she has not yet started her period, and asks if this is normal
Which of the following should be included in the nurse's response? 1. The client should be referred to a gynecologist for a pelvic examination.
2. The client should have started her period by now.
3. It is not abnormal for the client to have not yet started her period.
4. The client should be tested for hormonal imbalances.
3. It is not abnormal for the client to have not yet started her period.
Rationale:
The average age of onset for menarche is 12.8 years. The absence of menarche at the age of 13 is not a reason for concern. It is premature for the client to be examined or have testing for a hormonal imbalance.
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A client with a history of cholelithiasis presents at the hospital with nausea and vomiting, abdominal pain, and jaundice. The nurse would assess the client for
a. common bile duct obstruction. b. infarct of the hepatic vein. c. perforation of the gallbladder. d. spasm of the biliary tree.
The nurse is caring for a client who has undergone a radical jaw and neck resection. The client tells the nurse that the area feels very swollen and painful. Which is the best intervention for the nurse to make this client more comfortable?
a. Frequently suction the client's mouth and airway. b. Apply warm moist compresses to the area. c. Elevate the head of the client's bed to semi-Fowler's. d. Administer ibuprofen (Motrin) 600 mg every 6 hours around the clock.
Bradypnea may accompany:
a. a subconscious response to observation. b. an excellent level of cardiovascular fitness. c. ascites. d. severe pain from a rib fracture.
The nurse rates a patient's biceps muscle strength as a 3. This finding would indicate which of the following?
1. Active ROM with gravity and moderate weakness 2. Complete active ROM with minimal weakness 3. Passive ROM 4. Complete ROM with no weakness