NCLEX Review: Priority Concepts: Sexuality and Reproduction: Sexuality
The client has undergone mastectomy. The nurse determines that the client is making the best adjustment to the loss of the breast if which behavior is observed? Refusing to look at the wound Reading the postoperative care booklet Asking for pain medication when needed Participating in the care of the surgical drain
Participating in the care of the surgical drain The client demonstrates the best adaptation by participating in her own care. This would include care of surgical drains that are in place for a short time after discharge. Refusing to look at the wound indicates no adaptation to the loss. Reading the postoperative care booklet is useful but is not the best of the options presented here. Asking for pain medication is an action-oriented option, but it does not relate to acceptance of the loss of the breast.
A 10-year-old girl who has been referred for evaluation for drawing sexually explicit scenes in her textbooks says to the psychiatric nurse, "I just felt like it." Which response is therapeutic for the nurse to make in order to assess abuse-related symptoms? "Well, a picture paints a thousand words." "You just felt like destroying your textbooks?" "Your parents and teachers are very concerned about your drawings." "I am concerned about you. Are you now or have you ever been abused?"
"I am concerned about you. Are you now or have you ever been abused?" The behaviors that this child engaged in are a warning signal of distress. The correct option is the only one that specifically addresses abuse. In option 1, the nurse is insensitive, sarcastic, and intrusive. In option 2, the nurse is assessing the client's destructive behaviors, not the possible sexual abuse history. In option 3, although the nurse is trying to assess the client's abuse-related symptoms, the nurse uses indirect means rather than straightforward expressions of the nurse's concern.
The nursing student is asked to describe the size of the uterus in a nonpregnant client. Which statement by the student related to the uterus in a nonpregnant client is correct? "The uterus weighs approximately 2 oz." "The uterus weighs approximately 2.2 lb." "The uterus has a capacity of about 50 mL." "The uterus is round and weighs approximately 1000 g."
"The uterus weighs approximately 2 oz." Before conception, the uterus is a small, pear-shaped cavity contained entirely in the pelvic cavity. Before pregnancy, the uterus weighs approximately 60 g (2 oz) and has a capacity of about 10 mL (⅓ oz). At the end of pregnancy, the uterus weighs approximately 1000 g (2.2 lb) and has sufficient capacity for the fetus, placenta, and amniotic fluid.
The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam? After a shower or bath While standing to void After having a bowel movement While lying in bed before arising
After a shower or bath The nurse needs to teach the client how to perform a testicular self-examination (TSE). The nurse should instruct the client to perform the exam on the same day each month. The nurse should also instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm. Palpation is easier and the client will be better able to identify any abnormalities. The client would stand to perform the exam, but it would be difficult to perform the exam while voiding. Having a bowel movement is unrelated to performing the TSE.
The home health care nurse is visiting a client who has undergone a mastectomy. The nurse determines that the client demonstrates greatest adjustment to the loss of the breast if which behavior is noted? The client looks at the surgical site. The client performs the prescribed arm exercises. The client takes the pain medication as prescribed. The client has read all of the postoperative materials provided by the hospital nurse.
The client looks at the surgical site. Of the options provided, the client behavior in the correct option demonstrates the greatest adaptation or adjustment (looking at the surgical site). This indicates that the client has acknowledged and is beginning to cope with the loss of the breast. Reading postoperative care booklets and performing prescribed exercises indicate an interest in self-care and are positive signs indicating adjustment. Taking pain medication is not related to adjustment to the loss of the breast.
A pregnant client has been instructed on the prevention of genital tract infections. Which client statement indicates an understanding of these preventive measures? "I can douche anytime I want." "I can wear my tight-fitting jeans." "I should avoid the use of condoms." "I should wear underwear with a cotton panel liner."
"I should wear underwear with a cotton panel liner." Wearing items with a cotton panel liner allows for air movement in and around the genital area. Douching is to be avoided. Wearing tight clothing can irritate the genital area and does not allow for air circulation. Condoms should be used to minimize the spread of genital tract infections.
A nurse is caring for a pregnant woman who has herpes genitalis. The nurse provides instructions to the woman about treatment modalities that may be necessary for this condition. Which statement made by the woman indicates an understanding of these treatment measures? "I do not need to abstain from sexual intercourse." "I need to use vaginal creams after I douche every day." "I need to douche and perform a sitz bath three times a day." "It may be necessary to have a cesarean section for delivery."
"It may be necessary to have a cesarean section for delivery." If a woman has an active lesion, either recurrent or primary at the time of labor, delivery should be by cesarean. Women are advised to abstain from sexual contact while the lesions are present. If it is an initial infection, the woman should continue to abstain from sexual intercourse until the cultures are negative because prolonged viral shedding may occur. Douches are contraindicated, and the genital area should be kept clean and dry to promote healing.
A 55-year-old male client confides in the nurse that he is concerned about his sexual function. What is the nurse's best response? "How often do you have sexual relations?" "Please share with me more about your concerns." "You are still young and have nothing to be concerned about." "You should not have a decline in testosterone until you are in your 80s."
"Please share with me more about your concerns." The nurse needs to establish trust when discussing sexual relationships with men. Open the conversation with broad statements to determine the true nature of the client's concerns. The frequency of intercourse is not a relevant first question to establish trust. Testosterone declines with the aging process.
The home health care nurse is providing instructions to a client after a vulvectomy. Which instruction should the nurse provide to the client? "You can engage in sexual activity in 2 weeks." "It is all right to begin to drive a car as long as you do not drive long distances." "Resume activities slowly, keeping in mind that walking is a beneficial activity." "It is important to rest and sit in a chair with your legs elevated as much as possible."
"Resume activities slowly, keeping in mind that walking is a beneficial activity." The client should resume activities slowly, and walking is a beneficial activity. Sexual activity is prohibited for approximately 4 to 6 weeks after surgery. Activities to be avoided include driving, heavy housework, wearing tight clothing, crossing the legs, and prolonged sitting and standing. The client should not be instructed to sit in a chair as much as possible because pressure on the surgical site could lead to complications related to the surgery.
The maternity nursing instructor asks the nursing student to describe Montgomery's tubercles of the breast. The student indicates an understanding of this anatomical structure if the student makes which statement with regard to Montgomery's tubercles? "They are sebaceous glands in the areola." "They are lobes of glandular tissue that secrete milk." "They are ducts containing milk from all areas of the breast." "They are small sacs that contain acinar cells to secrete milk."
"They are sebaceous glands in the areola." Montgomery's tubercles are sebaceous glands located in the areola. They are inactive and not obvious except during pregnancy and lactation, when they enlarge and secrete a substance that keeps the nipple soft. Within each breast are lobes of glandular tissue that secrete milk. Alveoli are small sacs that contain acinar cells to secrete milk. The alveoli drain into lactiferous ducts, which connect to drain milk from all areas of the breast.
A pregnant woman has a positive history of genital herpes but has not had lesions during this pregnancy. What should the nurse should plan to tell the client? "You will be isolated from your newborn infant after delivery." "Vaginal deliveries can reduce neonatal infection risks, even if you have an active lesion at the time." "There is little risk to your newborn infant during this pregnancy, during the birth, and after delivery." "You will be evaluated at the time of delivery for herpetic genital tract lesions, and if any are present, a cesarean delivery will be needed."
"You will be evaluated at the time of delivery for herpetic genital tract lesions, and if any are present, a cesarean delivery will be needed." With active herpetic genital lesions, cesarean delivery can reduce neonatal infection risks. In the absence of active genital lesions, vaginal delivery is indicated unless there are other indications for cesarean delivery. Maternal isolation is not necessary, but cultures should be obtained from potentially exposed newborn infants on the day of delivery.
The nurse is providing instructions to a pregnant client with genital herpes about the measures that are needed to protect the fetus. Which instruction should the nurse provide to the client? Total abstinence from sexual intercourse is necessary during the entire pregnancy. Sitz baths need to be taken every 4 hours while awake if vaginal lesions are present. Daily administration of acyclovir (Zovirax) is necessary during the entire pregnancy. A cesarean section will be necessary if vaginal lesions are present at the time of labor.
A cesarean section will be necessary if vaginal lesions are present at the time of labor. For women with active lesions, either recurrent or primary at the time of labor, delivery should be by cesarean section to prevent the fetus from being in contact with the genital herpes. The safety of acyclovir has not been established during pregnancy, and it should be used only when a life-threatening infection is present. Clients should be advised to abstain from sexual contact while the lesions are present. If this is an initial infection, clients should continue to abstain until they become culture-negative because prolonged viral shedding may occur in such cases. Keeping the genital area clean and dry promotes healing.
The clinic nurse is performing a psychosocial assessment of a client who has been told that she is pregnant. Which assessment finding indicates to the nurse that the client is at risk for contracting human immunodeficiency virus (HIV)? A client who has a history of intravenous drug use A client who has a significant other who is heterosexual A client who has a history of sexually transmitted infections A client who has had one sexual partner for the past 10 years
A client who has a history of intravenous drug use Human immunodeficiency virus (HIV) is transmitted by intimate sexual contact and the exchange of body fluids, exposure to infected blood, and passage from an infected woman to her fetus. Clients who fall into the high-risk category for HIV infection include individuals with persistent and recurrent sexually transmitted infections, individuals who have a history of multiple sexual partners, and individuals who have used intravenous drugs. A client with a heterosexual partner, particularly a client who has had only one sexual partner in 10 years, does not have a high risk for contracting HIV.
The clinic nurse has conducted a health screening clinic to identify clients who are at risk for cervical cancer. The nurse is reviewing the assessment findings in the records of the clients who attended the clinic. Which client is at lowest risk for developing this type of cancer? A multiparity client A single white client A client with a history of chronic cervicitis A client who had early, frequent intercourse with multiple sexual partners
A single white client Risk factors associated with cervical cancer include early, frequent intercourse with multiple sexual partners, multiparity, chronic cervicitis, and a history of genital herpes or human papilloma. Cervical cancer also occurs with higher frequency in African Americans. Regarding the options provided, the single white client is at lowest risk for the development of cervical cancer.
A client with epididymitis is upset about the extent of scrotal edema. Attempts to reassure the client that this condition is temporary have not been effective. The nurse should plan to address which client problem? Pain related to fluid accumulation in scrotum Uneasiness related to inability to reduce scrotal swelling Guilt related to possibility of sterility secondary to scrotal swelling Altered body appearance related to change in appearance of the scrotum
Altered body appearance related to change in appearance of the scrotum Altered body appearance is a problem when the client has either a verbal or a nonverbal response to a change in the structure or the function of a body part. Pain may apply but does not correlate with the information in the question. There are no data in the question that uneasiness, inability to reduce scrotal swelling, or sterility is a client concern.
The nurse is planning to teach a group of adolescents about the use of condoms as part of a risk-reduction program for sexually transmitted infections (STIs). The nurse should plan to include which recommendation in the teaching plan? Condoms should not be lubricated. Use condoms whenever the partner seems "risky." Always apply the condom before inserting the penis into the vagina. Natural membrane condoms can be used because they are just as effective as latex.
Always apply the condom before inserting the penis into the vagina. To be effective, condoms must be applied before any vaginal penetration occurs. A condom must be used with every sexual encounter if it is to be safe. A lubricated condom may be used to increase sensitivity of the glans. Natural membrane condoms are less effective than latex in preventing the spread of some STIs.
The ambulatory care nurse is working with a 22-year-old female client who has been diagnosed with pelvic inflammatory disease (PID). The nurse incorporates which item in a teaching plan for this client? Avoid frequent douching. Undergarments made of nylon are best. Intrauterine devices are a good birth control method. It is necessary to change sanitary pads only every 8 hours.
Avoid frequent douching. The client who has been diagnosed with PID should avoid frequent douching because it decreases the natural flora that controls the growth of infectious organisms. Intrauterine devices increase the client's susceptibility to infection. The client should wear cotton undergarments, and clothes should not fit tightly. Sanitary pads should be changed at least every 4 hours. Tampons should not be used during the acute infection, and some health care providers may recommend avoiding them indefinitely. The client also should avoid strong soaps, sprays, powders, and similar products that will irritate the perineum.
The client seen in the health care clinic has tested positive for gonorrhea. The nurse anticipates that which medication will be prescribed based on this finding? Acyclovir (Zovirax) Ceftriaxone (Rocephin) Azithromycin (Zithromax) Penicillin G benzathine (Bicillin LA)
Ceftriaxone (Rocephin) Treatment for gonorrhea consists of antibiotic therapy, usually with ceftriaxone and doxycycline (Vibramycin). Acyclovir is the treatment for genital herpes simplex virus; azithromycin is the treatment for Chlamydia infection and penicillin G benzathine is the treatment for syphilis.
A male client has a tentative diagnosis of urethritis. The nurse should assess the client for which manifestation of the disorder? Hematuria and pyuria Dysuria and proteinuria Hematuria and urgency Dysuria and penile discharge
Dysuria and penile discharge Urethritis in the male client often results from chlamydial infection and is characterized by dysuria, which is accompanied by a clear to mucopurulent discharge. Because this disorder often coexists with gonorrhea, diagnostic tests are done for both and include culture and rapid assays.
In the prenatal clinic, the nurse is interviewing a new client and obtaining health history information. Which action should the nurse plan to do to elicit the most accurate responses to the questions that refer to sexually transmitted infections? Establish a therapeutic relationship. Use specific closed-ended questions. Omit these types of questions because they are highly personal. Apologize for the embarrassment that these questions will cause the client.
Establish a therapeutic relationship. The initial assessment interview establishes the therapeutic relationship between the nurse and the pregnant woman. It is planned purposeful communication that focuses on specific content. The remaining options are incorrect and would not lend themselves to eliciting accurate information from the client.
The nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of abortion or fetal demise. Using GTPAL, what should the nurse document in the client's chart? G = 3, T = 2, P = 0, A = 0, L = 1 G = 2, T = 1, P = 0, A = 0, L = 1 G = 1, T = 1, P = 1, A = 0, L = 1 G = 2, T = 0, P = 0, A = 0, L = 1
G = 2, T = 1, P = 0, A = 0, L = 1 Pregnancy outcomes can be described with the acronym GTPAL. G is gravidity, the number of pregnancies; T is term births, the number born at term (longer than 37 weeks); P is preterm births, the number born before 37 weeks' gestation; A is abortions or miscarriages, the number of abortions or miscarriages (included in gravida if before 20 weeks' gestation; included in parity [number of births] if past 20 weeks' gestation); and L is the number of current living children. A woman who is pregnant with twins and has a child has a gravida of 2. Because the child was delivered at 38 weeks, the number of term births is 1, and the number of preterm births is 0. The number of abortions is 0, and the number of living children is 1.
A client has been prescribed pindolol (Visken) for hypertension. The nurse provides anticipatory guidance, knowing that which common side effect of this medication may decrease client compliance? Impotence Mood swings Increased appetite Difficulty swallowing
Impotence A common side effect of β-adrenergic blocking agents such as pindolol is impotence. Other common side effects include fatigue and weakness. Central nervous system side effects are rarer and include mental status changes, nervousness, depression, and insomnia. Mood swings, increased appetite, and difficulty swallowing are not side effects of this medication.
A female client seen in the ambulatory care clinic has a history of syphilis infection. The nurse assessing the client for reinfection would expect to observe a lesion on the labia that has which characteristic? Is painless and indurated Has a cauliflower-like appearance Is erythematous and papular in appearance Appears as one or more vesicles that then rupture
Is painless and indurated The characteristic lesion of syphilis is painless and indurated. The lesion is referred to as a chancre. Genital warts are characterized by cauliflower-like growths or growths that are soft and fleshy. Scabies is characterized by erythematous, papular eruptions. Genital herpes is accompanied by the presence of one or more vesicles that then rupture and heal.
The school nurse has conducted a class on testicular self-examination (TSE) at the local high school. The nurse determines that the information was correctly interpreted if one of the students states that which action should be performed? Perform the exam after a cold shower. Expect the exam to be slightly painful. Perform the self-examination every other month. Roll the testicle between the thumb and forefinger.
Roll the testicle between the thumb and forefinger. TSE is an excellent self-screening examination for testicular cancer, which predominantly affects men in their late teens and 20s. The examination is performed once a month, as is breast self-examination. As an aid to remember to do it, the examination should be done on the same day each month. The scrotum is held in one hand, and the testicle is rolled between the thumb and forefinger of the other hand. The examination should not be painful. It is easiest to do either during or after a warm shower (or bath), when the scrotum is relaxed.