Sexuality - Mod 19
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.
