Nursing Elites

1. During a health assessment interview, the client tells the nurse that she has some vaginal drainage. The client is concerned that it may indicate a sexually transmitted infection (STI). Which statement should the nurse make to the client?

• A. 'When was your last gynecological checkup?'
• B. 'Have you been engaging in unprotected sexual intercourse?'
• C. Don't worry about the discharge. Some vaginal discharge is normal.'
• D. 'I need some more information about the discharge. What color is it?'

Correct answer: D

Rationale: If the client reports having vaginal drainage and concerns about a possible STI, it is essential for the nurse to gather more information about the discharge. Asking about the color of the discharge helps in determining its characteristics, which can be crucial in identifying potential causes. The color, consistency, odor, and associated symptoms can provide valuable insights into the underlying issue. Statements A and B are relevant questions but not as immediate or specific to addressing the client's concern about the discharge. Statement C dismisses the client's worries and does not encourage further assessment, which is not appropriate in this context.

2. While assessing for costovertebral angle tenderness, a nurse percusses the area, and the client complains of sharp pain. The nurse interprets this finding as most indicative of which disorder?

• A. Liver enlargement
• B. Ovarian infection
• C. Spleen enlargement
• D. Kidney inflammation

Correct answer: D

Rationale: When assessing for costovertebral angle tenderness, sharp pain on percussion of the area indicates inflammation of the kidney or paranephric area. The correct technique involves placing one hand over the 12th rib, at the costovertebral angle, and thumping that hand with the ulnar edge of the other fist. The client normally feels a thud and should not experience pain. Ovarian infection, liver enlargement, or spleen enlargement are not associated with the costovertebral angle tenderness. Therefore, the correct answer is kidney inflammation.

3. A healthcare professional reviewing a client's record notes documentation that the client has melena. How does the healthcare professional detect the presence of melena?

• A. By checking the client's urine for blood
• B. By checking the client's stool for blood
• C. By checking the client's urine for a decrease in output
• D. By checking the client's bowel movements for diarrhea

Correct answer: B

Rationale: Melena' is the term used to describe abnormal black tarry stool that has a distinctive odor and contains digested blood. It usually results from bleeding in the upper gastrointestinal tract and is often a sign of peptic ulcer disease or small bowel disease. The presence of melena is detected by checking the client's stool for blood. Blood in the client's urine, decreased urine output, and diarrhea are not associated with the assessment for melena.

4. When a client wishes to improve her appearance by removing excess skin from her face and neck, the nurse should provide teaching regarding which of the following procedures?

• A. dermabrasion
• B. rhinoplasty
• C. blepharoplasty
• D. rhytidectomy

Correct answer: D

Rationale: The correct answer is 'rhytidectomy.' Rhytidectomy, commonly known as a face-lift, is the procedure for removing excess skin from the face and neck. Dermabrasion involves spraying a chemical to freeze the skin lightly, followed by abrasion with sandpaper or a revolving wire brush, used for removing scars, severe acne, and tattoo pigment. Rhinoplasty is for improving the nose's appearance by reshaping the nasal skeleton and overlying skin. Blepharoplasty removes loose and protruding fat from the upper and lower eyelids. Therefore, when a client wants to address excess skin in the face and neck, rhytidectomy is the appropriate procedure.

5. During a genital examination of a male client, a nurse notices wrinkled skin on the penis and scrotum. What should the nurse do based on this finding?

• A. Documents the normal finding
• B. Checks for penile discharge, as this indicates infection
• C. Palpates for a mass in the scrotum, as wrinkling suggests the presence of one
• D. Obtains additional subjective data from the client, focusing on the scrotal abnormality

Correct answer: A

Rationale: The penile skin typically appears wrinkled and hairless, without lesions, during a normal examination. Also, the scrotal skin naturally has a wrinkled appearance known as rugae. It is common for the left half of the scrotum to be positioned lower than the right, indicating normal asymmetry. Given these normal variations, the nurse should document the finding of wrinkled skin on the penis and scrotum. Checking for penile discharge or palpating for a mass in the scrotum is not indicated based on the presence of wrinkled skin, as this is a normal finding. Obtaining additional subjective data focusing on a scrotal abnormality is unnecessary since the wrinkled appearance is typical.

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