After 12 months of cessation of menses, which of the following assessment findings in a client who is taking hormone replacement therapy should the nurse report to the physician immediately?
Answer : D
Uterine bleeding on combination hormone replacement therapy, after 12 months of menses cessation, indicates an increased risk of carcinoma and should be reported to the physician immediately.
Breast tenderness, weight gain, and fluid retention are all routine side effects of hormone replacement therapy. They should be noted in the record and reported to the physician, but they are not urgent.
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?
Answer : D
Rhytidectomy is the procedure for removing excess skin from the face and neck. It is commonly called a face-lift.
Dermabrasion involves the spraying of a chemical to cause light freezing of the skin, which is then abraded with sandpaper or a revolving wire brush. It is used to remove facial scars, severe acne, and pigment from tattoos.
Rhinoplasty is performed to improve the appearance of the nose and involves reshaping the nasal skeleton and overlying skin.
Blepharoplasty is the procedure that removes loose and protruding fat from the upper and lower eyelids.
All of the following are clinical manifestations indicating male climacteric except __________.
Answer : B
The likelihood of fathering children does decrease with aging and decreased testosterone production, but men do not lose their ability to reproduce during the climacteric.
Many men do not experience any physical symptoms of climacteric but some men do report hot flashes, headaches, and heart palpitations, among other symptoms.
When a middle-age woman says to the nurse, "I"™m really worried about menopause. When my mom went through it, she got really depressed."
The nurse"™s best response is __________.
Answer : C
Choice "It sounds like you are worried that you might become depressed during menopause." not only acknowledges the client"™s fear but invites more disclosure and discussion. Reflective listening is very therapeutic and in this case acknowledges the woman"™s unspoken fear that she might become depressed like her mother. When her fears have been acknowledged and she feels that the nurse understands, she will be more open to the teaching or interventions to follow.
It is a myth that menopause causes depression, but to say that to this client does not acknowledge the fear she shared with the nurse and gives the impression the nurse doesn"™t care about her concern. It closes down communication.
It is also true that menopause is a normal developmental process. This can certainly be used in teaching but not to address her immediate concern; the client might feel the nurse doesn"™t think her concern is appropriate because menopause is normal.
If women experience depression during menopause, it is usually due to social stresses such as loss of loved ones, loss of roles, caregiver demands, and physical problems. Choice "When women experience depression during menopause it is usually because of social stresses." is true but is a nontherapeutic response in this situation.
When a woman is receiving postpartum epidural morphine, the nurse should plan to observe for which of the following side effects to occur within the first 3 hours?
Answer : B
A side effect of postpartum epidural morphine is the onset of itching within 3 hours of injection and lasting up to 10 hours.
Nausea and vomiting might occur 4-7 hours after injection.
Urinary retention is a side effect of postpartum epidural morphine but is not assessed as such within the first 3 hours.
Somnolence is a rare side effect.
The teaching plan for a postpartum client who is about to be discharged should include which of the following instructions?
Answer : D
The vaginal discharge after birth is called lochia, and it changes from red (rubra) to serosa (clear) on the third postpartum day. If it returns to red or contains clots, it could signal impending hemorrhage or infection and the physician should be notified.
It is not normal for the breasts to be tender. If the breasts become engorged, they might be tender and the mother might need to be given additional instructions on breast care. Tenderness, redness, and fatigue are clinical manifestations of mastitis and should be reported to the physician.
A woman should void in normal patterns and frequency after birth. Increased frequency is a sign of a urinary tract infection and should be reported to the physician.
By the time of discharge, the woman"™s temperature should be normal. Elevations should be reported to the physician.
The parents of a 2-year-old child ask the nurse how they can teach their child to quit taking toys away from other children.
Which of the following statements by the nurse offers the parents the best explanation of their child"™s behavior?
Answer : A
Two-year-old children are very egocentric. They believe everything and everyone is concerned about them. They believe other children want them to have their toys. This is different than believing they can make other children want them to have all the toys, as in magical thinking, which normally occurs in preschool-age children.
Toddlers are very negative, but this is expressed by refusal of requests made to them.
Domestic imitation does occur in preschool-age children, but it refers to the imitation of household chores and roles performed by adults, not the imitation of other children.
Which of the following infant behaviors demonstrates the concept of object permanence?
Answer : B
Object permanence occurs when the infant learns that something/someone still exists even though they might not be able to see it/them. This develops between 9 and 10 months of age. If the infant cries when his mother leaves the room, it might be because he believes she is no longer in the house when he can"™t see her. If an infant picks up another toy after the one he is playing with rolls under the couch and the infant fails to look for it, he believes the toy that rolled under the couch no longer exists.
Patty-cake is a game infants engage in but, it has nothing to do with object permanence.
An infant game that does show object permanence is peek-a-boo. In this game, an infant continues to hunt for a hidden face because he believes it is still there.
Which of the following home-care strategies is most likely to negatively impact the body image of a client with Cushing"™s syndrome?
Answer : C
All of the strategies listed are included in home care for the client with Cushing"™s syndrome. Choice "wearing a medical ID indicating Cushing"™s syndrome" is the best answer because wearing a medical ID is a visible sign that something is wrong and a constant reminder to the client that he or she has a loss of body function.
Choice "providing safety measures to prevent falls" might enhance body image because it prevents falls that could cause further injury and debilitation.
Taking medications as prescribed should enhance body image because it decreases the symptoms present.
Having regular health assessments indicates an enhanced body image because it signals the desire to take care of the body and keep it at its best.
When a client who is 25 years of age asks the nurse when she should seek fertility counseling, the best response by the nurse is __________.
Answer : D
The guidelines for a fertility workup are to refer after the couple has not conceived after one year of unprotected intercourse. So, Choice "Fertility counseling should be sought when you have been unable to conceive after 1 year of unprotected intercourse." is technically correct, but it doesn"™t consider the immediate need for the couple to have some counseling.
Choice "We can give you some guidance now on how to increase your chances of conceiving and then refer you if it doesn"™t happen within a year." is the best answer because it gives the couple guidance now and the referral at the appropriate time.
If the woman is over the age of 35, an earlier referral, at six to nine months of unprotected intercourse, is appropriate.
It is true that the average time it takes a 25-year-old woman to conceive is 5.3 months, but that does not address the concern the client is expressing. Choice "We can give you some guidance now on how to increase your chances of conceiving and then refer you if it doesn"™t happen within a year." is still the most caring and correct answer.
Couples conceive within the first month of unprotected intercourse 20% of the time.
When a couple experiencing infertility presents for a fertility workup, which of the following procedures should the nurse prepare the couple to have first?
Answer : B
Because semen analysis is the least invasive of the tests listed and because in 35% of the cases the infertility is related to a male factor, semen analysis should be one of the first diagnostic tests performed.
Hysterosalpingography fills the uterus and fallopian tubes with a radiopaque substance that can be seen with an X ray. It demonstrates tubal patency or any distortion of the uterine cavity.
Endometrial biopsy provides information about the effects of progesterone after ovulation and the endometrial receptivity.
Transvaginal ultrasound is mostly used in the treatment of infertility. For diagnosis it allows the endocrinologist to evaluate the developing follicle, assess oocyte maturity, and diagnose luteal phase defects.
Hysterosalpingography, endometrial biopsy and transvaginal ultrasound are more invasive, require greater expertise to evaluate and treat, and are more costly.
If the semen analysis is normal, the couple can expect to progress through these tests as well.
If a client has chronic renal failure, which of the following sexual complications is the client at risk of developing?
Answer : B
Untreated chronic renal failure causes decreased testosterone levels, atrophy of testicles, and decreased spermatogenesis.
Retrograde ejaculation is not a complication of chronic renal failure. It is a complication of transurethral resection of the prostate.
In chronic renal failure, the testicles atrophy; they do not hypertrophy. Chronic renal failure produces a state of depression, not euphoria.
When an elder client asks the nurse whether he will be capable of sexual activity in old age, the best response by the nurse is __________.
Answer : A
To provide the best response, the nurse must identify what the elder is asking. Concern is being expressed about whether elders can engage in sexual activity.
The most therapeutic response by the nurse is Choice "Elder adults are psychologically and physically capable of engaging in sexual activity regardless of age- related changes.". In this choice, the nurse acknowledges that elders can physically engage in sexual activity and have no psychological barriers to the same.
All of the other choices contain facts but are not the best initial response. Choice "Elder adults are psychologically and physically capable of engaging in sexual activity regardless of age-related changes." opens the conversation for the expression of further concerns about sexual issues.
Choice "If you haven"™t been sexually active throughout your life, you will not be able to participate in sexual activity in old age." is true; past sexual function is predictive of sexual function in elder adults. An elder adult must have been sexually active as a younger adult to engage in intercourse in old age. This does not mean, however, that the elder adult cannot experience sexual intimacy in other ways.
The need for intimacy is especially important for elder adults. If they have lost meaningful relationships or are having difficulty with intercourse, they might be able to experience intimacy through touch. As males age, they find it takes longer to achieve an erection, but that when it"™s achieved, the erection lasts longer. In addition, elder males require direct stimulation to achieve an erection.
The teaching plan for gay or lesbian parents who want to disclose their homosexuality to their children should include all of the following instructions except
Answer : D
Children of gay and lesbian parents should be reassured that their relationship with their parent will not change because of the discussion.
Choices "disclose the information before the child knows or suspects", "be comfortable with your sexual preference first" and "have the discussion in a quiet place where interruptions are unlikely" are all important aspects of the disclosure.
As children grow, they might have additional questions. Preschool children might not understand the absence of a father or mother. Schoolage children might be troubled that their family isn"™t like their friends"™ families. Adolescents might become reluctant to discuss it or accept it even though they expressed acceptance at an earlier age. In general the earlier children are informed, the easier it is for them to accept and assimilate the information. Nurses need to be nonjudgmental and learn how to express and accept these differences so that they can keep the nurse-child-family relationship intact.
When a client describes their family as having multiple wives, all of whom are sisters, married to one man, the nurse documents the family structure as?
Answer : B
The practice of polygamy refers to having multiple wives or husbands.
When there are multiple wives who are sisters, the polygamy is designated as soronal.
When the wives are not sisters it is nonsororal.
Polyandry refers to multiple husbands and is rare. Some cultures practice a polygamy designated as sororate.
Sororate polygamy specifies that a husband must marry his wife"™s sister if she dies. These marriages are successive rather than concurrent.