NUR 131: Exam 3 Questions || Top Grade Assured.
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
B. Decreased blood pressure
C. Dryness with intercourse
D. Elevation in body temperature above (100F) correct answers C. Dryness with intercourse
Rationale: Menopause, the cessation of a woman's menstrual periods, occurs when the ovaries
stop making estrogen. Because of the changes in the vagina, some women can have dryness,
discomfort, or pain during sexual intercourse.
A nurse is caring for a client who is 1 day postoperative following a left radical mastectomy.
Which of the following behaviors should alert the nurse to the possibility that the client is having
difficulty adjusting to the loss of her breast?
A. Refusing to look at the dressing or surgical incision
B. Asking for pain medication every 3hr
C. Asking questions about the information on her postoperative care pamphlet
D. Performing arm exercises once or twice a day correct answers A. Refusing to look at the
dressing or surgical incision
Rationale: Clients who refuse to look at the surgical incision or surgical dressing are having
difficulty adjusting to the loss of a body part or with body disfigurement. This indicates the client
is not yet ready to acknowledge the results of the surgery.
,A nurse is teaching for a client who is to begin taking tamoxifen to treat breast cancer. The nurse
should instruct the client to expect which of the following findings as an adverse effect of the
medication?
A. Tinnitus
B. Constipation
C. Urinary retention
D. Hot flashes correct answers D. Hot flashes
Rationale: The nurse should instruct the client to expect hot flashes as an adverse effect of
tamoxifen, because it is an antiestrogen medication that blocks estrogen receptors.
A nurse is providing teaching to a client about the manifestations of uterine prolapse. Which of
the following statements by the client should indicate to the nurse a need for further teaching?
A. The symptoms can get worse with penile penetration during intercourse.
B. A sensation of pressure in the pelvis can occur
C. Low back pain can occur frequently
D. Feces can be present in the vagina correct answers D. Feces can be present in the vagina
Rationale: The presence of feces in the vagina is a manifestation of a genital fistula. This
statement indicates a need for further teaching.
A nurse is presenting educational materials for a group of middle-aged clients about menopausal
hormone therapy following total hysterectomy. Which of the following information should the
nurse include in the information?
A. Take at different times of the day
B. Take an extra dose if missed a day
,C. Prevents from having cerebral hemorrhage
D. Prevents osteoporotic fractures correct answers D. Prevents osteoporotic fractures
Rationale: Menopausal hormone therapy may decrease and protect the client from osteoporotic
fracture due to the preservation of bone mineral density.
During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood
that soon stops. On assessment, a nurse finds the uterus to be firm, midline, and at the level of
the umbilicus. Which of the following findings should the nurse interpret this data as being?
A. Evidence of a possible vaginal hematoma
B. An indication of a cervical or perineal laceration
C. A normal postural discharge of lochia
D. Abnormally excessive lochia rubra flow correct answers C. A normal postural discharge of
lochia
A nurse is completing postpartum discharge teaching to a client who had no immunity to rubella
and was given a measles, mumps, and rubella (MMR) vaccine. Which of the following
statements by the client indicates understanding of the teaching?
A. "I will need to use contraception for 1-3 months before considering getting pregnant again."
B. "I need a second vaccination during my postpartum visit."
C. "I was given the vaccine because my baby is O-positive blood type."
D. "I will be tested in 3 months to see if I have developed immunity." correct answers A. "I will
need to use contraception for 1-3 months before considering getting pregnant again."
A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the
perineal pad for lochia. She notes the pad to be saturated approximately 12 cm with lochia that is
bright red and contains small clots. Which of the following findings should the nurse document?
A. Moderate lochia rubra
, B. Large lochia rubra
C. Light lochia rubra
D. Scant lochia serosa correct answers B. Large lochia rubra
A nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed
with mastitis. Which of the following instructions would be included on the list? Select all that
apply
A. Wear a supportive bra
B. Rest during the acute phase
C. Maintain a fluid intake of at least 3000 ml
D. Continue to breast-feed if the breasts are not too sore.
E. Take the prescribed antibiotics until the soreness subsides.
F. Avoid decompression of the breasts by breast-feeding or breast pump. correct answers A, B, C,
D
A nurse is teaching a postpartum client about breast-feeding. Which of the following instructions
should the nurse include?
A. The diet should include additional fluids
B. Prenatal vitamins should be discontinued
C. Soap should be used to cleanse the breasts.
D. Birth control measures are unnecessary while breast-feeding. correct answers A. The diet
should include additional fluids
A client who is breast-feeding her newborn infant is experiencing nipple soreness. To relieve the
soreness, the nurse suggests that the client:
A. Encourage rotating breast-feeding positions with each feeding
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
B. Decreased blood pressure
C. Dryness with intercourse
D. Elevation in body temperature above (100F) correct answers C. Dryness with intercourse
Rationale: Menopause, the cessation of a woman's menstrual periods, occurs when the ovaries
stop making estrogen. Because of the changes in the vagina, some women can have dryness,
discomfort, or pain during sexual intercourse.
A nurse is caring for a client who is 1 day postoperative following a left radical mastectomy.
Which of the following behaviors should alert the nurse to the possibility that the client is having
difficulty adjusting to the loss of her breast?
A. Refusing to look at the dressing or surgical incision
B. Asking for pain medication every 3hr
C. Asking questions about the information on her postoperative care pamphlet
D. Performing arm exercises once or twice a day correct answers A. Refusing to look at the
dressing or surgical incision
Rationale: Clients who refuse to look at the surgical incision or surgical dressing are having
difficulty adjusting to the loss of a body part or with body disfigurement. This indicates the client
is not yet ready to acknowledge the results of the surgery.
,A nurse is teaching for a client who is to begin taking tamoxifen to treat breast cancer. The nurse
should instruct the client to expect which of the following findings as an adverse effect of the
medication?
A. Tinnitus
B. Constipation
C. Urinary retention
D. Hot flashes correct answers D. Hot flashes
Rationale: The nurse should instruct the client to expect hot flashes as an adverse effect of
tamoxifen, because it is an antiestrogen medication that blocks estrogen receptors.
A nurse is providing teaching to a client about the manifestations of uterine prolapse. Which of
the following statements by the client should indicate to the nurse a need for further teaching?
A. The symptoms can get worse with penile penetration during intercourse.
B. A sensation of pressure in the pelvis can occur
C. Low back pain can occur frequently
D. Feces can be present in the vagina correct answers D. Feces can be present in the vagina
Rationale: The presence of feces in the vagina is a manifestation of a genital fistula. This
statement indicates a need for further teaching.
A nurse is presenting educational materials for a group of middle-aged clients about menopausal
hormone therapy following total hysterectomy. Which of the following information should the
nurse include in the information?
A. Take at different times of the day
B. Take an extra dose if missed a day
,C. Prevents from having cerebral hemorrhage
D. Prevents osteoporotic fractures correct answers D. Prevents osteoporotic fractures
Rationale: Menopausal hormone therapy may decrease and protect the client from osteoporotic
fracture due to the preservation of bone mineral density.
During ambulation to the bathroom, a postpartum client experiences a gush of dark red blood
that soon stops. On assessment, a nurse finds the uterus to be firm, midline, and at the level of
the umbilicus. Which of the following findings should the nurse interpret this data as being?
A. Evidence of a possible vaginal hematoma
B. An indication of a cervical or perineal laceration
C. A normal postural discharge of lochia
D. Abnormally excessive lochia rubra flow correct answers C. A normal postural discharge of
lochia
A nurse is completing postpartum discharge teaching to a client who had no immunity to rubella
and was given a measles, mumps, and rubella (MMR) vaccine. Which of the following
statements by the client indicates understanding of the teaching?
A. "I will need to use contraception for 1-3 months before considering getting pregnant again."
B. "I need a second vaccination during my postpartum visit."
C. "I was given the vaccine because my baby is O-positive blood type."
D. "I will be tested in 3 months to see if I have developed immunity." correct answers A. "I will
need to use contraception for 1-3 months before considering getting pregnant again."
A nurse is performing a fundal assessment for a client who is 2 days postpartum and observes the
perineal pad for lochia. She notes the pad to be saturated approximately 12 cm with lochia that is
bright red and contains small clots. Which of the following findings should the nurse document?
A. Moderate lochia rubra
, B. Large lochia rubra
C. Light lochia rubra
D. Scant lochia serosa correct answers B. Large lochia rubra
A nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed
with mastitis. Which of the following instructions would be included on the list? Select all that
apply
A. Wear a supportive bra
B. Rest during the acute phase
C. Maintain a fluid intake of at least 3000 ml
D. Continue to breast-feed if the breasts are not too sore.
E. Take the prescribed antibiotics until the soreness subsides.
F. Avoid decompression of the breasts by breast-feeding or breast pump. correct answers A, B, C,
D
A nurse is teaching a postpartum client about breast-feeding. Which of the following instructions
should the nurse include?
A. The diet should include additional fluids
B. Prenatal vitamins should be discontinued
C. Soap should be used to cleanse the breasts.
D. Birth control measures are unnecessary while breast-feeding. correct answers A. The diet
should include additional fluids
A client who is breast-feeding her newborn infant is experiencing nipple soreness. To relieve the
soreness, the nurse suggests that the client:
A. Encourage rotating breast-feeding positions with each feeding
