Sexuality - Mod 19

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Which finding should the nurse identify as inappropriate sexual​ behavior? (Select all that​ apply.) A. Making sexual statements B. Exposing genitalia C. Pulling at the condom catheter D. Touching the nurse improperly E. Whistling at the nurse

A. Making sexual statements B. Exposing genitalia D. Touching the nurse improperly E. Whistling at the nurse Rationale: Clients who experience alterations in sexuality may act out and demonstrate inappropriate behavior. Findings the nurse can anticipate in a client exhibiting inappropriate sexual behavior include​ whistling, exposing​ genitalia, making sexual​ statements, and touching the nurse improperly. Pulling at a condom catheter may be a result of discomfort.

The nurse is obtaining a history on a​ middle-age female client. Which factor affecting sexual function should the nurse anticipate​ finding? (Select all that​ apply.) A. Menopause B. Sexual orientation experimentation C. Decreased hormone production D. Decreased sexual activity E. Climacteric

A. Menopause C. Decreased hormone production E. Climacteric Rationale: Based on the​ client's age, sexual functioning may be affected by the​ climacteric, menopause, and decreased hormone production. Decreased sexual activity may occur in the older​ adult, and experimentation with sexual orientation occurs more frequently during adolescence.

The nurse is preparing to obtain a history on a new client. Which information should the nurse include that is specific to the sexual​ history? (Select all that​ apply.) A. Past medical history B. Activity level C. Nutritional status D. Psychosocial history E. Relationship status

A. Past medical history D. Psychosocial history E. Relationship status ​Rationale: Information collected during the sexual history includes the​ client's medical​ history, psychosocial​ history, and relationsterm-9hip status. The activity level and nutritional status are not specifically included in the sexual history.

The nurse is preparing information about sexual development for a group of parents with​ school-age children. Which factor does the nurse attribute to​ puberty? (Select all that​ apply.) A. Menstruation beginning about 2 years after breast buds develops in girls B. Nocturnal emissions signaling the beginning of puberty in boys C. Growth of pubic hair D. The beginning of purposeful masturbation E. The appearance of female breast buds

A. Menstruation beginning about 2 years after breast buds develops in girls C. Growth of pubic hair E. The appearance of female breast buds Rationale: Between the ages of 9 and​ 10, evidence of puberty begins. The production of​ testosterone, a hormone from the adrenal​ glands, contributes to the growth of pubic hair in both sexes. Girls develop breast​ buds, or​ thelarche, and menstruation begins about 2 years after the appearance of breast buds. Nocturnal emissions typically begin around age 13 to 15. Puberty typically begins with the development of pubic hair around age 10 in boys.

The nurse is addressing sexual functioning for a male client prescribed an​ anti-anxiety medication. Which information should the nurse include in the​ teaching? (Select all that​ apply.) A. Decreased sexual desire B. Erectile dysfunction C. Painful erection D. Orgasmic dysfunction E. Delayed ejaculation

A. Decreased sexual desire E. Delayed ejaculation ​Rationale: The effects of​ anti-anxiety medications on the sexual function of a male client include delayed ejaculation and decreased sexual desire. A painful erection and erectile dysfunction are adverse effects associated with antidepressants. Orgasmic dysfunction may occur in women.

The nurse suspects that a male client with a sexual disorder is experiencing a problem with elimination. Which assessment finding correlates with the​ nurse's concern? A. Difficulty voiding B. Clear discharge from the penis C. Arthritis in both hips and knees D. Inability to maintain an erection

A. Difficulty voiding ​Rationale: The proximity and interrelatedness of the sexual organs and organs of elimination may lead to difficulties such as urinary retention. The inability to maintain an erection is a problem related to perfusion. Clear discharge from the​ penis, arthritis in the hips and​ knees, and an inability to maintain an erection are not associated with difficulty voiding.

The nurse is caring for a client with erectile dysfunction​ (ED) resulting from vascular and nerve damage. The client relays concern of the inability to express sexual intimacy. Which statement by the nurse will provide support for the​ client? A. ​"We can discuss other ways you can express your​ sexuality." B. ​"We can contact your healthcare provider to see what alternatives you​ have." C. ​"I am going to obtain a prescription for an erectile dysfunction​ medication." D. ​"I encourage you to consider treatment with an​ androgen."

A. ​"We can discuss other ways you can express your​ sexuality." ​Rationale: The statement that will provide the most support to the client that has experienced vascular and nerve damage​ is, "We can discuss other ways you can express your​ sexuality." Androgens are not used for the treatment of ED. A referral does not immediately address the​ client's concern about the inability to express sexual intimacy. An ED medication will not work after nerve damage has occurred.

The nurse is providing teaching to an adolescent female. Which instruction by the nurse promotes safe sexual​ behavior? (Select all that​ apply.) A. ​"You can choose to say​ 'No' to sex even if your​ long-term partner says that your relationship has matured beyond the mutual masturbation​ stage." B. ​"Insist that your sex partner use birth control to reduce the risk of​ HIV." C. ​"Latex condoms lubricated with petroleum jelly provide for comfort and additional barrier​ protection." D. ​"Women can carry and use female​ condoms." E. ​"If your partner insists on having sex even though you​ don't want​ to, you should comply to show you really love​ him."

A. ​"You can choose to say​ 'No' to sex even if your​ long-term partner says that your relationship has matured beyond the mutual masturbation​ stage." D. ​"Women can carry and use female​ condoms." ​ Rationale: The information provided to the adolescent female client that promotes safe sexual behavior includes carrying and using female condoms and encouraging the client in exercising independence in saying yes or no to sex if the​ long-term partner says that the relationship has matured beyond the mutual masturbation stage. Birth control does not reduce the risk of​ HIV, petroleum jelly does not provide additional barrier​ protection, and the client should never feel pressured to have sex to show love to the partner.

A male client is prescribed an androgen drug. The client​ asks, "What can I expect from​ this?" Which response by the nurse is​ accurate? (Select all that​ apply.) A. ​"You may notice a persistent and painful​ erection." B. ​"It will boost your testosterone level to​ normal." C. ​"It will increase your sperm​ count." D. ​"It will decrease your blood​ sugar." E. ​"You will probably notice that you will lose​ weight."

A. ​"You may notice a persistent and painful​ erection." B. ​"It will boost your testosterone level to​ normal." C. ​"It will increase your sperm​ count." Rationale: Androgen drugs are used to treat hypogonadism resulting in insufficient testosterone. They are also used to increase sperm count when low testosterone is the cause. Side effects include​ acne, weight​ gain, priapism​ (persistent and painful erection of the​ penis), and increased blood sugar.

A client calls the nurse into the room and the nurse finds the client naked in bed. Based on the​ client's behavior, which nursing action is​ appropriate? (Select all that​ apply.) A. Ask if the client is ready for morning care. B. Remind the client that clothing is required to be worn during hospitalization. C. Inform the charge nurse of the​ client's behavior. D. Cover the client with a bed sheet. E. Instruct the client that you will come back when the client is dressed.

B. Remind the client that clothing is required to be worn during hospitalization. C. Inform the charge nurse of the​ client's behavior. E. Instruct the client that you will come back when the client is dressed. Rationale: The most appropriate actions would be informing the charge nurse of the​ client's behavior, instructing the client you will return when the client is​ dressed, and reminding the client that clothing is required to be worn during hospitalization. Covering the client with a bedsheet and asking if the client is ready for morning care are not appropriate nursing actions for a client exhibiting inappropriate sexual​ behavior, because they do not directly and assertively address the issue. Next Question

The nurse is reviewing the prescription for laboratory tests on a male client experiencing a sexual disorder. Which laboratory test is​ appropriate? (Select all that​ apply.) A. Hysteroscopic examination B. Serum hormone levels C. Urinalysis D. Complete blood count E. Papanicolaou test

B. Serum hormone levels C. Urinalysis D. Complete blood count ​Rationale: The prescribed laboratory tests that are most appropriate for the male client experiencing a sexual disorder include a​ urinalysis, complete blood​ count, and serum hormone levels. A Papanicolaou test and hysteroscopy examination are tests for a female client.

While conducting a physical​ assessment, the nurse notes a red rash in the axillary region of a young adult client. Which factor may be associated with the assessment​ finding? (Select all that​ apply.) A. Breast malignancy B. Shaving C. Allergies D. Infection of the hair follicles E. Systemic disease

B. Shaving C. Allergies D. Infection of the hair follicles ​Rationale: Redness,​ rash, irritation, or lesions of the axillary region may be due to​ allergies, shaving, or infection of the sweat glands or hair follicles. Systemic disease and breast malignancy do not manifest as an axillary rash.

The nurse is teaching the​ middle-age female client ways to promote healthy sexual functioning. Which client statement indicates an understanding of sexual health​ promotion? A. ​"I will try and get some exercise twice a​ week." B. ​"I will cut back on smoking​ marijuana." C. ​"I will cut down on the amount of fat in my​ diet." D. ​"I will drink only two alcoholic beverages in the​ evening."

C. ​"I will cut down on the amount of fat in my​ diet." Rationale: Healthy sexuality depends upon the implementation of lifestyle choices that support heart​ health, including good nutrition. Lowering the amount of fat in the diet indicates the client understands sexual health promotion. Avoiding tobacco or​ marijuana, exercising​ daily, and avoiding alcohol promote healthy sexual functioning.

The nurse is caring for a​ middle-age female client who​ states, "Sexual intercourse has become​ painful." Which is the best response from the​ nurse? A. ​"Pain is a warning sign that something is​ wrong." B. ​"Pain during sexual activity is normal with​ aging." C. ​"I would like to perform an exam and offer some​ suggestions." D. ​"A sex therapist might be able to help you with your​ problem."

C. ​"I would like to perform an exam and offer some​ suggestions." Rationale: The most appropriate response by the nurse would be to suggest the client undergo an exam before being able to offer any suggestion about decreasing the discomfort during sexual intercourse. Pain with sexual activity is not associated with aging. It is inappropriate to refer to a sex therapist prior to assessing the client.

The nurse should understand that which physiological screening tests for sexual health are appropriate for both men and​ women? (Select all that​ apply.) A. Blood pressure B. Lipid panel C. Physical examination D. ​Prostate-specific antigen E. Mammography

​A. Blood pressure B. Lipid panel C. Physical examination Rationale: The nurse understands that the physiological screening tests for the sexual health of men and women include a lipid​ panel, blood​ pressure, and a physical assessment. Mammography is a specific test for​ women, and​ prostate-specific antigen is a screening for men.

The nurse is caring for an older adult client experiencing discomfort during sexual activity as a result of osteoarthritis. Which nursing intervention is most appropriate for the​ client? A. Discussing the timing of sexual activity. B. Encouraging an increase in routine exercise. C. Incorporating the use of cold compresses on sore joints. D. Encouraging the client to have sex in a​ semi-reclined position.

​A. Discussing the timing of sexual activity. Rationale: The nursing intervention that is most appropriate for the client is to discuss the timing of sexual activity. Sexual activity can take place at a time during the day in which the client is not experiencing much discomfort. An increase in routine exercise may exacerbate the joint pain. Warm compresses on painful joints can be utilized to provide comfort. A​ semi-reclined position is recommended for clients with heart failure that develop fatigue or shortness of breath.

The nurse is caring for a client experiencing sexual difficulty. The client was sexually assaulted in the past. Which intervention is most appropriate for this​ client? A. Requesting a referral for a therapist B. Obtaining a prescription for an LS and FSH level C. Encouraging the client to increase foreplay D. Recommending hormonal replacement therapy

​A. Requesting a referral for a therapist Rationale: The intervention by the nurse that is most appropriate for the client who has a history of sexual assault and is experiencing sexual difficulty is referring the client to a therapist. Based on the​ client's concern and​ history, encouraging the client to increase​ foreplay, obtaining a prescription for LS and FSH​ levels, and hormonal replacement therapies are not appropriate.

A client has been prescribed an​ estrogen-progestin combination contraceptive. The nurse should monitor the client for which​ risk? (Select all that​ apply.) A. Smoking B. Over age 35 C. Menstrual pain D. Acne E. Increased menstrual bleeding

​A. Smoking B. Over age 35 Rationale: A client who smokes or is over 35 years old is at an increased risk of thromboembolic disorders when using an​ estrogen-progestin combination contraceptive.​ Estrogen-progestin combination contraceptives often decrease​ acne, menstrual​ bleeding, and menstrual pain.

The nurse has completed the history of a client who reports erectile dysfunction. Which action should the nurse take next​? A. Provide information on adaptions to the physical impairment. B. Refer the client to a psychotherapist. C. Tell the client that a physical assessment will be performed. D. Teach the client about surgical procedures.

​C. Tell the client that a physical assessment will be performed. Rationale: After obtaining the​ history, the nurse will tell the client that a physical assessment will be performed. An assessment and diagnosis should be formulated prior to referring the client to a psychotherapist or scheduling a surgery. There is no indication the client has any physical impairment.

The nurse is caring for an older adult couple who express concern about the lack of intimacy in their relationship. Which initial strategy should the nurse use to address the​ couple's concern? A. Offer specific suggestions regarding sexual positioning. B. Refer the couple to the healthcare provider for further assessment. C. Determine the history of sexually transmitted diseases. D. Validate desire for sexual activity in older adult couples.

​D. Validate desire for sexual activity in older adult couples. Rationale: The initial strategy that the nurse will use to address the​ couple's concern about the lack of intimacy in their relationship is to ask permission to validate their desire for sexual activity. Older adults often benefit from teaching related to​ sexuality; however, they may be hesitant to bring up sexual topics with the nurse. To help facilitate such​ discussion, the nurse can first validate the older​ adults' desire for sexual activity. Determining a history of sexually transmitted diseases does not address the concern. Offering specific suggestions regarding sexual positioning is an assumption that positioning is the problem. Referral of the couple to their healthcare provider may be appropriate after a thorough history has been obtained.


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