Chapter 27: Women's Health

10. Which information should the nurse stress in teaching a patient how best to relieve the symptoms of premenstrual syndrome (PMS)? a. Decrease her consumption of caffeine. b. Drink a small glass of wine with her evening meal. c. Decrease her fluid intake to prevent fluid retention. d. Eat three large meals a day to maintain glucose levels

ANS: A Caffeine increases irritability, insomnia, anxiety, and nervousness. Alcohol aggravates depression and should be avoided in the patient with PMS. The patient should drink at least 2000 mL of water per day. Six smaller meals a day will help maintain glucose levels and reduce symptoms

14. Which specific instruction should the nurse teach to assist a patient to regain control of her urinary sphincter? a. Perform Kegel exercises. b. Void every hour while awake. c. Drink 8 to 10 glasses of water each day. d. Allow the bladder to become distended before voiding

ANS: A Kegel exercises, tightening and relaxing the pubococcygeal muscle, will improve control of the urinary sphincter. A prescribed schedule may help; however, every hour is too frequent. Restricting fluids will cause bladder irritation, which exacerbates the problem. Drinking adequate fluids will decrease the concentration of urine; however, this intervention will not improve sphincter control. Overdistention of the bladder will result in further stress incontinence.

1. Which piece of the usual equipment setup for a pelvic examination is omitted with a Pap test? a. Lubricant b. Speculum c. Fixative agent d. Gloves and eye protectors

ANS: A Lubricants other than water or water-based lubricants on the cervix interfere with the accuracy of the cytology report. A speculum is necessary to visualize the cervix. A fixative agent is applied to the slide to prevent drying or disruption of the specimen. The examiner should always use standard precautions including gloves and eye protection

1. While interviewing a 48-year-old patient during her annual physical examination, the nurse learns that she has never had a mammogram. The American Cancer Society recommends annual mammography screening starting at age 40. Before the nurse encourages this patient to begin annual screening, it is important for her to understand the reasons why women avoid testing. These reasons include which of the following? (Select all that apply.) a. Fear of x-ray exposure b. Expense of the procedure c. Reluctance to hear bad news d. Having heard that the test is painful e. Belief that lack of family history makes this test unnecessary

ANS: A, B, C, D Fear of x-ray exposure, expense, reluctance to hear bad news, and fear of pain are reasons women avoid having a mammogram done. Although the test is expensive, it is usually covered by health insurance. Many communities offer low-cost or free screening to women without insurance. It is important to acknowledge that some discomfort occurs with screening. Scheduling the test immediately at the end of a period makes it less painful. The risk of radiation exposure is minimal to none. Nurses play a vital role in providing information and reassurance to help women overcome these fears. Even patients with no family history should have a regular screening done. The nurse should emphasize that a combination of breast self-examination and mammography needs to be performed at regular intervals. Women with a family history may need to begin screening at a younger age and have additional testing such as ultrasound performed.

2. Healthy People 2020 goals directed at women's health issues focus on which areas? (Select all that apply.) a. Increased screening for cervical and colorectal cancers b. Reduction of cancer survivor rate based on clinical management treatment c. Decreased morbidity and mortality related to breast cancer d. Reduction in hospitalization for hip fractures in the older female population e. Reduction in deaths associated with cardiovascular causes such as stroke and coronary artery disease (CAD)

ANS: A, C, D, E Healthy People 2020 goals directed at women's health focus on increased access to screening for cervical and colorectal cancers, decreased deaths occurring from breast cancer and heart disease, and decreased hospitalization for hip fractures. A reduction of the cancer survival rate would reflect increased morbidity and mortality.

3. A 38-year-old patient presents to the clinic office complaining of increased bilateral tenderness of her breasts prior to the onset of menses. On questioning the patient, this presentation has occurred off and on for several years; however, the pain has increased. Physical examination reveals lumpy areas bilaterally on the upper outer quadrants of each breast tissue. The areas of concern are approximately 2 cm in size. Based on this assessment, which diagnostic testing would be necessary? (Select all that apply.) a. Ultrasound examination b. Open biopsy c. Fine-needle aspiration (FNA) biopsy d. CBC with differential e. Mammogram

ANS: A, C, E Based on the clinical presentation, the patient may have fibrocystic breast disease. Although this condition is typically benign, the fact that the patient has noted a change in tenderness should be evaluated. Ultrasound, FNA, and mammography may be indicated to provide a baseline for comparison and rule out any malignancy. An open or surgical biopsy is not indicated at the present time but may be needed if the other test results indicate any pathology. Blood work is not indicated at this time relative to the diagnosis.

3. While performing a self-breast exam, the patient notes an area on the right breast that is nodular, with some associated tenderness. This is a new onset finding because the exams were not problematic in the past. The left breast examination is unremarkable. The patient calls to report her findings to the clinical nurse because this is not her typical result. What action should the nurse perform next? a. Refer the patient to an oncologist because the results are suspicious. b. Ask the patient to come in for an office visit so that the findings can be validated but tell her that this information is within the normal range of presentation. c. Have the patient wear a tight-fitting bra and tell her that the tenderness is associated with ovulation and will pass. d. Have the patient repeat the self-breast exam in 2 weeks and call back with findings to provide a basis for comparison.

ANS: B Although these findings are within the normal range of presentation for breast tissue, they are not in the normal presentation for this patient. The patient has called to express concern; therefore, the nurse should have the patient schedule an appointment for assessment and evaluation. There is no need for referral to a specialist at this time. Wearing a tight-fitting bra may help provide support; however, does not address the physical findings and concern of the patient. Repeating the self-breast exam may be required; however, it does not address the patient's current concerns.

8. A benign breast condition that includes dilation and inflammation of the collecting ducts is known as a. fibroadenoma. b. ductal ectasia. c. intraductal papilloma. d. chronic cystic disease

ANS: B Generally occurring in women approaching menopause, ductal ectasia results in a firm irregular mass in the breast, enlarged axillary nodes, and nipple discharge. Fibroadenoma is evidenced by fibrous and glandular tissues. They are felt as firm, rubbery, and freely mobile nodules. Intraductal papillomas develop in the epithelium of the ducts of the breasts; as the mass grows, it causes trauma or erosion within the ducts. Chronic cystic disease causes pain and tenderness. The cysts that form are multiple, smooth, and well delineated.

11. A patient, age 49, confides in the nurse that she has started experiencing pain with intercourse. The patient asks, "Is there anything I can do about this?" The nurse's best response is a. "No, it is part of the aging process." b. "Water-soluble vaginal lubricants may provide relief." c. "You need to be evaluated for a sexually transmitted disease." d. "You may have vaginal scar tissue that is producing the discomfort."

ANS: B Loss of lubrication, with resulting discomfort in intercourse, is a symptom of estrogen deficiency. It is part of the aging process; however, the use of lubrication will help relieve the symptoms. This is a normal occurrence with the aging process and does not indicate an STD. It is caused by loss of lubrication with the decrease in estrogen. Scar tissue problems would have occurred earlier.

6. Which are the most common sites of breast cancer metastasis? a. Kidneys b. Bones and liver c. Heart and blood vessels d. Skin

ANS: B Metastasis occurs when the cancer cells spread by both blood and lymph system to distant organs and to vascular sites, commonly the lungs, liver, bones, and brain. Kidney metastasis is uncommon. Metastasis to the heart and blood vessels is uncommon. Skin cancer is not associated with breast cancer metastasis.

12. Which patient is most likely to develop osteoporosis? a. A 50-year-old patient on estrogen therapy b. A 55-year-old patient with a sedentary lifestyle c. A 65-year-old patient who walks 2 miles each day d. A 60-year-old patient who takes supplemental calcium

ANS: B Risk factors for the development of osteoporosis include smoking, alcohol consumption, sedentary lifestyle, family history of the disease, and a high-fat diet. A number of drug therapies are available to reduce the progression of osteoporosis. Weight-bearing exercises have been shown to increase bone density. Supplemental calcium will help prevent bone loss, especially when combined with vitamin D

2. A 45-year-old patient asks how often she should have a mammogram. The most appropriate answer is a. whenever she feels a lump. b. every year beginning at age 40. c. they are unnecessary until age 50. d. every year if you have risk factors.

ANS: B The American Cancer Society recommends that women have an annual mammogram after 40 years of age. Mammography should be done routinely following the American Cancer Society guidelines. Mammograms are necessary when a woman is in her 40s. Women with high-risk factors may require them more often.

19. You are taking care of a patient who has had a colporrhaphy. Which option would indicate a priority assessment during the postoperative period? a. Documentation of a pessary in the operative procedure notes by the physician b. Removal of vaginal packing as ordered by the physician c. Use of a cell saver for transfusion therapy in the postoperative period d. Order for removal of staples 2 to 3 days post-procedure

ANS: B Vaginal packing is typically used in this type of pelvic surgery. The removal of the packing should be verified and documented. This is the priority assessment. A pessary would be utilized as a nonsurgical intervention for a patient who has had uterine prolapse and was not a surgical candidate based on medical history. A cell saver is used in orthopedic surgeries that are at risk for blood loss so that the patient's own blood can be re-infused based on established protocol. There are no staples used in this type of surgical procedure, which is also known as an A & P (anterior and posterior) repair.

16. The drug of choice to treat a gonorrhea infection is a. penicillin G (Pfizerpen). b. tetracycline (Achromycin). c. ceftriaxone (Rocephin). d. acyclovir (Zovirax).

ANS: C Additional drugs include cefixime (Suprate) or ciprofloxacin (Cipro). Ceftriaxone is effective for treatment of all gonococcal infections. Penicillin G is used most commonly to treat syphilis. Tetracycline is prescribed to treat chlamydial infections. Acyclovir is most commonly used to treat herpes genitalis.

15. The physician diagnoses a 3-cm cyst in the ovary of a 28-year-old patient. You expect the initial treatment to include a. initiating hormone therapy. b. scheduling a laparoscopy to remove the cyst. c. examining the patient after her next menstrual period. d. aspirating the cyst and sending the fluid to pathology.

ANS: C Most ovarian cysts regress spontaneously. Cysts in women of childbearing age may decrease within one cycle, so treatment is not necessary at this point. It is too early to anticipate removal of the cysts. Most ovarian cysts regress spontaneously within one cycle. A transvaginal ultrasound examination will help determine if the cyst is fluid-filled or solid. The cyst can then be removed if warranted.

20. In reviewing genetic testing for a female patient, you note the presence of BRCA1, BRCA2, and CHEK2. How should these findings be interpreted? a. There is no increased likelihood that the patient will develop breast or ovarian cancer. b. There is an increased likelihood only for the development of breast cancer in a woman. c. More information is needed to interpret these findings based on the patient's family history and the patient's current and past medical history. d. A radical bilateral mastectomy is required as soon as possible, since the cancer may have already undergone sub-metastasis

ANS: C The presence of genetic markers (BRCA1, BRCA2, and CHEK2) provides strong indicators of the increased risk for the development of breast cancer in males and females as well as ovarian cancer. It is important to obtain additional information in order that a treatment plan can be developed and implemented to improve patient outcomes. There is an increased likelihood that the patient will develop breast or ovarian cancer. Stating that there is an increased likelihood only for the development of breast cancer in a woman fails to include that men are also at risk of developing breast cancer. At this point, surgical intervention is speculative because the presence of biomarkers does not indicate that sub-metastasis has occurred or that the cancer has even developed.

18. Which treatment option minimizes the development of lymphedema in the surgical management of a patient with breast cancer? a. Radical mastectomy procedure b. Radiation therapy c. Sentinel lymph node mapping d. Ultrasound

ANS: C The use of sentinel lymph node mapping identifies only those affected lymph node tissues that require surgical removal and helps minimize the development of lymphedema in the surgical management of a patient with breast cancer. Radical mastectomy is associated with lymphedema in the postsurgical breast cancer patient because of the removal of lymph node tissue. Radiation therapy is not associated with a decrease in lymphedema for the breast cancer patient. Ultrasound as an intervention does not affect the development of lymphedema.

7. Which sexually transmitted disease can be treated and eradicated? a. Herpes b. AIDS c. Chlamydia d. Venereal warts

ANS: C Treatment options chlamydial bacterial infection include: azithromycin, doxycycline, ofloxacin, levofloxacin, or erythromycin. Concurrent treatment of all sexual partners is necessary to prevent recurrence. Because no cure is known for herpes, treatment focuses on pain relief and preventing secondary infections. Because no cure is known for AIDS, prevention and early detection are the main focus. Condylomata acuminata is caused by the human papillomavirus (HPV). No treatment eradicates the virus; however, there is a vaccine available.

13. A patient with a history of a cystocele should contact the physician if she experiences a. backache. b. constipation. c. urinary frequency and burning. d. involuntary loss of urine when she coughs.

ANS: C Urinary frequency and burning are symptoms of cystitis, a common problem associated with cystocele. Back pain is a symptom of uterine prolapse. Constipation may be a problem for the patient with a rectocele. Involuntary loss of urine during coughing is referred to as stress incontinence and is not an emergency.

4. Findings of a Pap smear exam denote atypical cells of undetermined significance (ASCUS). The Pap test is repeated at 6 months and the same finding of ASCUS is reported. Which therapeutic treatment option would the nurse expect the practitioner to order? a. Mammography b. Bone scan c. Transvaginal ultrasound d. Biopsy

ANS: D Based on the standard of care, a colposcopy or biopsy of the cervix is indicated. A Pap smear is performed to evaluate the cervix. There is no indication that mammography, which is used to assess and evaluate breast tissue, is required. There is no evidence to warrant a bone scan. Although a transvaginal ultrasound might be included in the treatment plan, the Pap smear indicates cervical pathology so a colposcopy or biopsy is indicated.

17. Which option could be used for the treatment and management of a patient who reports mild pain associated with a clinical diagnosis of fibrocystic breast disease? a. Chamomile tea as a relaxant therapy b. Danazol (Danocrine) c. Tamoxifen (Nolvadex) d. Over-the-counter nonsteroidal antiinflammatory drug (NSAID) therapy

ANS: D Because the patient is reporting mild pain, NSAIDs may provide adequate pain relief and comfort. It is recommended that tea, coffee, and/or other stimulants be limited or restricted for patients with fibrocystic breast disease. Danazol is typically used for moderate to severe pain for patients with fibrocystic breast disease because its use is associated with more serious side effects. Danazol should not be used longer than 4 to 6 months. The patient reports mild pain so this would not be warranted. Tamoxifen is a selective estrogen receptor modulator (SERM) used for the treatment of breast cancers and also for moderate to severe pain in fibrocystic breast disease. The patient reports mild pain, so this would not be warranted.

9. Which statement regarding primary dysmenorrhea is most accurate? a. Primary dysmenorrhea is experienced by all women. b. It is unaffected by oral contraceptives. c. It occurs in young multiparous women. d. It may be caused by excessive endometrial prostaglandin.

ANS: D Primary dysmenorrhea is menstrual pain without identified pathology. Some women produce excessive endometrial prostaglandin during the luteal phase of the menstrual cycle. Prostaglandin diffuses into endometrial tissue and causes uterine cramping. Contrary to popular belief, primary dysmenorrhea is not experienced by all women. Oral contraceptives can be a treatment choice if cramps associated with primary dysmenorrhea are debilitating. It most often occurs in young nulliparous women.

5. Which concern is included in the plan of care for the patient who receives HPV (human papillomavirus) vaccine? a. It is available in oral form. b. It involves a series of two injections. c. Injections should be given over a 3-month period. d. The vaccine (Gardasil) should not be given to any patient with a sensitivity to yeast.

ANS: D The vaccine should not be administered to any woman who has a sensitivity to any component of the yeast family. It is available only in injection form. It is given as a series of three injections. The series of three injections should be given over a 6-month period according to Centers for Disease Control and Prevention (CDC) recommendations. Side effects of the vaccine include: headache, fever, nausea, and dizziness.