2204 Issues Related to Human Sexuality and Gender Identity, Chapter 20 Sexual Dysfunctions, Gender Dysphoria, and Paraphilias, Chapter 27 - Sexual Disorder & Gender Identity

A patient approaches the nurse in the clinic waiting room and says, "I want to talk to you about a sexual matter." The nurse can best facilitate the discussion by: a. saying, "Let's go my office." b. responding, "I want to help. Go ahead; I'm listening." c. telling the patient, "Let's schedule another appointment." d. offering to sit in a corner of the waiting room with the patient.

ANS: A A discussion of sexual concerns requires privacy. Suggesting use of office space is preferable to using the waiting room, where others cannot help but overhear sensitive material. The distracters block communication.

A man says, "I enjoy watching women when I am out in public. I like to go to places where I can observe women crossing their legs in hopes of seeing something good." Which statement about this behavior is most accurate? a. It is a sexual disorder. The behavior is socially atypical. It could disrupt relationships and could be insulting to others. b. It is not a sexual disorder. These events occur in public, where those he observes do not have a reasonable expectation of privacy. c. It is not a sexual disorder. Because it occurs in public areas, this behavior does not hurt others or involve intrusion into the personal space of those observed. d. An action is or is not a sexual disorder depending on applicable local laws, so whether this meets the definition of a sexual disorder depends on the location.

ANS: A A sexual disorder is defined as an activity that is socially atypical, has the potential to disrupt significant relationships, and may result in insult or injury to others. The behavior described constitutes a sexual disorder (voyeurism). Although laws vary, an act does not have to be illegal to constitute a sexual disorder. The fact that the behavior occurs in a public setting could have a bearing on whether it is illegal, but not on whether it is considered to be a sexual disorder.

A 10-year-old boy is diagnosed with gender dysphoria. Which assessment finding would the nurse expect? a. Having tea parties with dolls b. A compromised sexual response cycle c. Identifying with boys who are athletic d. Intense urges to watch his parents have sex

ANS: A An individual with gender dysphoria feels at odds with the roles associated with that gender. A child with this diagnosis is likely to engage in play associated with the opposite gender. The other options are not age appropriate or characteristically seen in children with gender dysphoria.

7. A person with serious and persistent mental illness enters a shelter for the homeless. Which intervention should be the nurse's initial priority? a. Develop a relationship b. Find supported employment c. Administer prescribed medication d. Teach appropriate health care practices

ANS: A Basic psychosocial needs do not change because a person is homeless. The nurse's initial priority should be establishing rapport. Once a trusting relationship is established, then the nurse can pursue other interventions.

9. A homeless patient with serious and persistent mental illness became suspicious and delusional. The patient was given depot antipsychotic medication, and housing for the patient was obtained in a local shelter. After 2 weeks, which statement by the patient indicates significant improvement? a. "I am feeling safe and comfortable here. Nobody bothers me." b. "They will not let me drink. They have many rules in the shelter." c. "Those guys are always watching me. I think someone stole my shoes." d. "That shot made my arm sore. I'm not going to take any more of them."

ANS: A Evaluation of a patient's progress is made based on patient satisfaction with the new health status and the health care team's estimation of improvement. For a formerly delusional patient to admit to feeling comfortable and free of being "bothered" by others denotes an improvement in the patient's condition. The other options suggest that the patient is in danger of relapse.

A nurse is anxious about assessing the sexual history of a patient who is considerably older than the nurse is. Which statement would be most appropriate for obtaining information about the patient's sexual practices? a. "Some people are not sexually active, others have a partner, and some have several partners. What has been your pattern?" b. "Sexual health can reflect a number of medical problems, so I'd like to ask if you have any sexual problems you think we should know about." c. "It's your own business, of course, but it might be helpful for us to have some information about your sexual history. Could you tell me about that, please?" d. "I would appreciate it if you could share your sexual history with me so I can share it with your health care provider. It might be helpful in planning your treatment."

ANS: A Explaining that sexual practices vary helps reduce patient anxiety about the topic by normalizing the full range of sexual practices so that whatever his situation, the patient can feel comfortable sharing it. "It's your business of course..." implies the nurse does not have a valid reason to seek the information and in effect suggests that the patient perhaps should not answer the question. "It might be helpful..." makes the information seem less valid or important for the nurse to pursue and, again, could discourage the patient from responding fully. Asking if the patient has any sexual problems that staff should know about is not unprofessional, but it is a very broad question that may increase a patient's uncertainty about what the nurse wants to hear, thus increasing his anxiety. Defining or giving an example of "sexual problem" would make this inquiry more effective.

14. A patient says, "I often make careless mistakes and have trouble staying focused. Sometimes it's hard to listen to what someone is saying. I have problems putting things in the right order and often lose equipment." Which problem should the nurse document? a. Inattention b. Impulsivity c. Hyperactivity d. Social impairment

ANS: A Inattention refers to the failure to stay focused. A number of the other problems are the result of failure to pay attention, which contributes to problems with organization. Impulsivity refers to acting without thinking through the consequences. Hyperactivity refers to excessive motor activity. Social impairment refers to the failure to use appropriate social skills.

8. A patient who is severely and persistently mentally ill and lives in a homeless shelter has the nursing diagnosis Powerlessness. Which intervention should be included in the plan of care? a. Encourage mutual goal setting. b. Verbally communicate empathy. c. Reinforce participation in activities. d. Demonstrate an accepting attitude.

ANS: A Mutual goal setting is an intervention designed to promote feelings of personal autonomy and dispel feelings of powerlessness. Although it might be easier and faster for the nurse to establish a plan and outcomes, this action contributes to the patient's sense of powerlessness. Involving the patient in decision making empowers the patient and reduces feelings of powerlessness.

An adult seeks treatment for urges involving sexual contact with children. The adult has not acted on these urges but feels shame. Which finding best indicates that this adult is making progress in treatment? The adult: a. consistently avoids schools and shops at malls only during school hours. b. indicates sexual drive and enjoyment from sex have decreased. c. reports an active and satisfying sex life with an adult partner. d. volunteers to become a scout troop leader.

ANS: A One strategy for avoiding acting on inappropriate urges is to avoid environments and circumstances that evoke those urges; for a pedophile this would include avoiding all situations that would likely result in contact with children. Pedophilic disorder is persistent; elimination of fantasies about children would be unrealistic. A person who volunteers to lead a scout troop is placing himself/herself around children. A diminished sex drive or a healthy sex life with an appropriate partner does not necessarily reduce the desire for sexual contact with children.

An adult experienced a myocardial infarction six months ago. At a follow-up visit, this adult says, "I haven't had much interest in sex since my heart attack. I finished my rehabilitation program, but having sex strains my heart. I don't know if my heart is strong enough." Which nursing diagnosis applies? a. Deficient knowledge related to faulty perception of health status b. Disturbed self-concept related to required lifestyle changes c. Disturbed body image related to treatment side effects d. Sexual dysfunction related to self-esteem disturbance

ANS: A Patients who have had a myocardial infarction often believe sexual intercourse will cause another heart attack. The patient has completed the rehabilitation, but education is needed regarding sexual activity. These patients should receive information about when sexual activity may begin, positions that conserve energy, and so forth. The scenario does not suggest self-concept or body image disturbance.

26. A nurse cares for a patient with paraphilia. The nurse expects the health care provider may prescribe which type of medication to reduce paraphilic behaviors? a. Selective serotonin reuptake inhibitor (SSRI) b. Erectile dysfunction medication c. Atypical antipsychotic medication d. Mood stabilizer

ANS: A SSRIs are reported to have a positive effect on paraphilia. The other medications are not indicated for this disorder.

A nurse is performing an assessment for a 59-year-old man who has hypertension. What is the rationale for including questions about prescribed medications and their effects on sexual function in the assessment? a. Sexual dysfunction may result from use of prescription medications for management of hypertension. b. Such questions are an indirect way of learning about the patient's medication adherence. c. These questions ease the transition to questions about sexual practices in general. d. Sexual dysfunction can cause stress and contribute to increased blood pressure.

ANS: A Some of the drugs used to treat hypertension can interfere with normal sexual functioning and lead to sexual disorders. Hypertension itself can lead to acquired erectile dysfunction. It would not be appropriate or necessary to use such inquiries as a lead-in to other sexual health topics. Sexual dysfunction, while stressful, does not cause hypertension.

A newly married woman comes to a gynecology clinic reporting anorexia, insomnia, and extreme dyspareunia that have affected her intimate relationship. What initial intervention should the nurse expect a physician to implement? A. A thorough physical to include gynecological examination B. Referral to a sex therapist C. Assessment of sexual history and previous satisfaction with sexual relationships D. Referral to the recreational therapist for relaxation therapy

ANS: A The nurse should expect the physician to implement a thorough physical to include a gynecological examination to assess for any physiological causes of the client's symptoms. Dyspareunia is recurrent or persistent genital pain associated with sexual intercourse.

In the course of an assessment interview, a female client reveals a history of bisexual orientation. Which action should the nurse initially implement when working with this client? A. Self-assess personal attitudes toward homosexuality. B. Review client's possible childhood sexual abuse history. C. Encourage discussion of aversion to heterosexual relationships. D. Explore client's family history of homosexuality.

ANS: A The nurse should initially self-assess personal attitudes toward homosexuality. The nurse must be able to recognize the potential for negative feelings compromising client care. Unconditional acceptance of each individual is an essential component of compassionate nursing.

A client is diagnosed with sexual aversion disorder. Which symptom of this disorder should the nurse correctly pair with an appropriate therapeutic intervention? A. Avoidance of all genital sexual contact treated by systematic desensitization B. Avoidance of all genital sexual contact treated by medicating with tadalafil (Cialis) C. Anorgasmia treated by vardenafil (Levitra) D. Anorgasmia treated by sensate focus exercises

ANS: A The nurse should recognize that this sexual aversion disorder is characterized by an avoidance of genital sexual contact. Sexual aversion implies anxiety, fear, or disgust in sexual situations. Sexual aversion can be treated by systematic desensitization.

A parent who is very concerned about a 3-year-old son says, "He likes to play with girls' toys. Do you think he is homosexual or mentally ill?" Which response by the nurse most professionally describes the current understanding of gender identity? a. "A child's interest in the activities of the opposite gender is not unusual or related to sexuality. Most children do not carry cross-gender interests into adulthood." b. "It's difficult to say for sure because the research is incomplete so far, but chances are that he will grow up to be a normal adult." c. "The research is incomplete, but many boys play with girls' toys and turn out normal as adults." d. "I am sure that whatever happens, he will be a loving son, and you will be a proud parent."

ANS: A The parent's inquiry is really two questions: (1) whether the child's behavior suggests an increased risk of developing mental illness and (2) what the child's future sexual preference will be. The psychiatric disorder that most directly addresses gender preferences and cross-gender activities is gender identity disorder. Pointing out that cross-gender activities are not necessarily related to gender identity and not likely to be carried into adulthood is supported by current research. Saying the child will grow up to be "normal" implies that to be homosexual is to be abnormal, which reflects a cultural perspective that most professionals would believe to be inappropriate to share in a professional setting. Research provides information about the relationship between cross-gender interests in childhood and adulthood, so a comment that "research is incomplete" is not entirely accurate. Stating that the child is a wonderful boy the father will be proud of, whatever happens, evades the parent's question and suggests that parental bonds should not be affected by gender issues. The nurse has a professional obligation to maintain an objective, therapeutic relationship.

A man who regularly experiences premature ejaculation tells the nurse, "I feel like such a failure. It's so awful for both me and my partner." Select the nurse's most therapeutic response. a. "I sense you are feeling frustrated and upset." b. "Tell me more about feeling like a failure." c. "You are too hard on yourself." d. "What do you mean by awful?"

ANS: A Using reflection and empathy promotes trust and conveys concern to the patient. The distracters do not offer empathy, probe, and offer premature reassurance.

2. An adult patient tells the case manager, "I don't have bipolar disorder anymore, so I don't need medicine. After I was in the hospital last year, you helped me get an apartment and disability checks. Now I'm bored and don't have any friends." Where should the nurse refer the patient? Select all that apply. a. Psychoeducation classes b. Vocational rehabilitation c. Social skills training d. Homeless shelter e. Crisis intervention

ANS: A, B, C The patient does not understand the illness and the need for adhering to the medication regimen. Psychoeducation for the patient (and family) can address this lack of knowledge. Work gives meaning and purpose to life; vocational rehabilitation can assist with this aspect of care. The patient, who considers himself friendless, could also profit from social skills training to improve the quality of interpersonal relationships. Many patients with severe mental illness have such poor communication skills that others are uncomfortable interacting with them. Interactional skills can be effectively taught by breaking down the skill into small verbal and nonverbal components. The patient presently has a home and does not require the services of a homeless shelter. The nurse case manager functions in the role of crisis stabilizer, so no related referral is needed.

1. Which information should a nurse include in health teaching for adults who have with attention deficit hyperactivity disorder (ADHD) and their significant others? Select all that apply. a. Tendency for genetic transmission b. Prevention strategies related to substance abuse c. Negative reinforcement to help modify behaviors d. Psychostimulants for children (rarely effective in adults) e. Cognitive therapy to challenge internalized negative beliefs about self

ANS: A, B, E Evidence suggests that ADHD has a biological basis. This fact can help adults with the disorder to cope with lowered self-esteem that is often the result of negative treatment and a lack of acceptance in childhood. Cognitive therapy is helpful in reframing negative beliefs about self. Adults with ADHD have a higher incidence of substance abuse problems. The other options are untrue.

4. Which statements most clearly indicate that the speaker views mental illness with stigma? Select all that apply. a. "We are all a little bit crazy." b. "If people with mental illness would go to church, their problems would be solved." c. "Many mental illnesses are genetically transmitted. It's no one's fault that the illness occurs." d. "Anyone can have a mental illness. War or natural disasters can be too stressful for healthy people." e. "People with mental illness are lazy. They get government disability checks instead of working."

ANS: A, B, E Stigma is represented by judgmental remarks that discount the reality and validity of mental illness. It is evidenced in stereotypical statements, by oversimplification, and by multiple other messages of guilt or shame.

Which of the following characteristics should a nurse identify as "normal" in the development of human sexuality for an 11-year-old child? (Select all that apply.) A. The child experiments with masturbation. B. The child may experience homosexual play. C. The child shows little interest in the opposite sex. D. The child shows little concern about physical attractiveness. E. The child is unlikely to want to undress in front of others.

ANS: A, B, E The nurse should identify that experimenting with masturbation and homosexual play and not wanting to undress in front of others are characteristics that are normal in the development of human sexuality in an 11-year-old child. Interest in the opposite sex usually increases during this age, and children often become self-conscious about their bodies.

24. Before working with patients regarding sexual concerns, a prerequisite for providing nonjudgmental care is: a. sympathy b. assertiveness training c. sexual self-awareness d. effective communication

ANS: C Only when a nurse has accepted his or her own feelings and values related to sexuality can he or she provide fully nonjudgmental care to a patient. If the nurse is uncomfortable, the patient might misinterpret discomfort as disapproval. The distracters are not prerequisites.

A nurse assesses a patient diagnosed with pedophilic disorder. Which findings are most likely? Select all that apply. a. Childhood history of attention deficit hyperactivity disorder (ADHD) b. A poorly managed endocrine disorder c. History of brain injury d. Cognitive distortions e. Grandiosity

ANS: A, C, D Attention deficit hyperactivity disorder (ADHD) in childhood, substance abuse, phobic disorders, and major depression/dysthymia are strongly associated with paraphilic disorders. Errors in thought make it seem acceptable for deviant and destructive sexual behaviors to occur. Patients who have experienced head trauma with damage to the frontal lobe of the brain may display symptoms of promiscuity, poor judgment, inability to recognize triggers that set off sexual desires, and poor impulse control. Endocrine problems are not associated with pedophilic disorder. Self-confidence is lacking; therefore, grandiosity would not be expected.

3. Which economic factors are most critical to the success of discharge planning for a patient with severe and persistent mental illness? Select all that apply. a. Access to housing b. Individual psychotherapy c. Income to meet basic needs d. Availability of health insurance e. Ongoing interdisciplinary evaluation

ANS: A, C, D The success of discharge planning requires careful attention to the patient's economic status. Access to housing is the first priority of the seriously mentally ill, and lack of income and health insurance is a barrier to effective treatment and rehabilitation. Although important aspects of ongoing care of the seriously mentally ill patient, ongoing interdisciplinary evaluation and individual psychotherapy are not economic factors.

2. Severe and persistent mental illness is characterized as a: a. mental illness of longer than 2 weeks' duration b. major chronic mental illness marked by significant functional impairments c. mental illness accompanied by physical impairment and severe social problems d. major mental illness that cannot be treated to prevent deterioration of cognitive and social abilities

ANS: B "Severe and persistent mental illness" has replaced the phrase "chronic mental illness." Global impairments in function are evident, including social skills. Physical impairments may be present. Severe mental illness can be treated, but remissions and exacerbations are part of the course of the illness.

A recently widowed client reports a fear of intimacy due to an inability to achieve and sustain an erection. He has become isolative, has difficulty sleeping, and has recently lost weight. Which correctly written nursing diagnosis should be prioritized for this client? A. Risk for situational low self-esteem AEB inability to achieve an erection B. Sexual dysfunction R/T dysfunctional grieving AEB inability to experience orgasm C. Social isolation R/T low self-esteem AEB refusing to engage in dating activities D. Disturbed body image R/T penile flaccidity AEB client statements

ANS: B Based on the client's symptoms, the nurse should prioritize the nursing diagnosis of sexual dysfunction R/T dysfunctional grieving AEB inability to experience orgasm. The nurse should assess the client's mood and level of energy because depression and fatigue can decrease desire for participation in sexual activity.

22. An adult man tells the nurse, "All my life, I have felt and acted like a woman while living in the body of a man. For the past year, I have lived and dressed as a woman. I'm changing jobs to protect my new identity." Which request is the patient likely to make to the health care provider? a. "Can you refer me for psychological testing?" b. "Will you prescribe estrogen therapy?" c. "Will you alter my medical records?" d. "What should I tell my parents?"

ANS: B Before sexual reassignment surgery, the step that follows living as a member of the other sex is hormone therapy. The patient's decision to live as a woman makes this a natural request. Psychological testing occurs before sexual reassignment surgery, often after hormone therapy has begun. The patient has likely told his parents by this point.

18. An adult with attention deficit hyperactivity disorder (ADHD) says, "I've always been stupid. I never had friends when I was a child. My parents often punished me because I made mistakes. Now, I can't keep a job." The nurse managing care should first consider: a. Aversive therapy to extinguish negative behaviors b. Cognitive therapy to help address internalized beliefs c. Group therapy to allow comparison of feelings with others d. Vocational counseling to identify needed occupational skills

ANS: B Cognitive therapy and knowledge of ADHD will make it possible for the patient to reframe the past and present in a more positive and realistic light and to challenge internalized false beliefs about self. Aversive therapy would not be useful for the patient. Group therapy may be valuable later to allow for the testing of new coping behaviors in a safe environment. Vocational counseling can help the patient explore suitable career options while pursuing treatment.

15. A nurse prepares for an initial interview with a patient with suspected adult ADHD. Questions should be focused to elicit information about which problem? a. Headaches b. Inattention c. Sexual impulses d. Trichotillomania

ANS: B Inattention usually persists from childhood into adult ADHD, although hyperactivity, impulsivity, and social impairments may also be present. Headaches would not be expected. Sexual impulses may be affected by adult ADHD, but this area is assessed later. Trichotillomania refers to pulling out one's hair as a tension-relieving behavior.

A woman tells the nurse, "My partner is frustrated with me. I don't have any natural lubrication when we have sex." What type of sexual disorder is evident? a. Genito-Pelvic Pain/Penetration Disorder b. Female Sexual Interest/Arousal Disorder c. Hypoactive Sexual Desire Disorder d. Female Orgasmic Disorder

ANS: B One feature of female sexual interest/arousal disorder relates to inability to maintain physiologic requirements for intercourse. For women, this includes problems with lubrication and swelling. The patient's description does not meet criteria for diagnoses in the distracters.

A respected school coach was arrested after a student reported the coach attempted to have sexual contact. Which nursing action has priority in the period immediately following the coach's arrest? a. Determine the nature and extent of the coach's sexual disorder. b. Assess the coach's potential for suicide or other self-harm. c. Assess the coach's self-perception of problem and needs. d. Determine whether other children were harmed.

ANS: B Pedophiles and other persons with paraphilic disorders can be at increased risk of self-harm associated with the guilt, shame, and anger they feel about their behavior and its effect on their families, victims, and victims' families. They also face considerable losses, such as the end of their careers or the loss of freedom to imprisonment. Thus, safety is the priority issue for assessment. Determining the nature and extent of the patient's disorder and related patient perceptions would be appropriate but not the highest priority for assessment. Investigating whether other victims exist is a matter for law enforcement rather than health care personnel. See relationship to audience response question.

17. The treatment team believes medication will help a patient diagnosed with adult attention deficit hyperactivity disorder (ADHD). Which class of medications does the nurse expect will be prescribed? a. Benzodiazepines b. Psychostimulants c. Antipsychotics d. Anxiolytics

ANS: B Psychostimulants, such as methylphenidate and amphetamines, provide the basis for treatment of both adult and childhood ADHD. They are the most commonly used medications; therefore the nurse could expect the health care provider to prescribe a drug in this class. None of the other drugs listed as options have proven useful in the treatment of ADHD.

An adult consulted a nurse practitioner because of an inability to achieve orgasm for 2 years, despite having been sexually active. This adult was frustrated and expressed concerns about the relationship with the sexual partner. Which nursing diagnosis is most appropriate for this scenario? a. Defensive coping b.Sexual dysfunction c. Ineffective sexuality pattern d. Disturbed sensory perception, tactile

ANS: B Sexual dysfunction is the most appropriate nursing diagnosis for a patient who is experiencing a problem affecting one or more phases of arousal. This is the primary problem reported by this patient. Ineffective sexuality pattern, since it is due to sexual dysfunction, is secondary to the absence of orgasms. The patient has not indicated she does not become aroused, just that she cannot achieve orgasm. Disturbed sensory perception may be part of the etiology, but the problem is sexual dysfunction. There is no evidence of defensive coping.

19. A new staff nurse tells the clinical nurse specialist, "I'm unsure about my role when patients bring up sexual problems." Which information should the clinical nurse specialist provide? All nurses: a. qualify as sexual counselors. Each has knowledge about the biopsychosocial aspects of sexuality throughout the life cycle. b. should be able to screen for sexual dysfunction and give basic information about sexual feelings, behaviors, and myths. c. should defer questions about sex to other health care professionals because of their limited knowledge of sexuality. d. who are interested in sexual dysfunction can provide sex therapy for individuals and couples.

ANS: B The basic education of nurses provides information sufficient to qualify as a generalist to assess for sexual dysfunction and perform health teaching. Taking a detailed sexual history and providing sex therapy require additional training in sex education and counseling. Nurses with basic education are not qualified to be sexual counselors; additional education is necessary. The registered nurse may provide basic information about sexual function, but complex questions may require referral.

A new staff nurse tells the clinical nurse specialist, "I am unsure about my role when patients bring up sexual problems." The clinical nurse specialist should give clarification by saying, "All nurses: a. qualify as sexual counselors. Nurses have knowledge about the biopsychosocial aspects of sexuality throughout the life cycle." b. should be able to screen for sexual dysfunction and give basic information about sexual feelings, behaviors, and myths." c. should defer questions about sex to other health care professionals because of their limited knowledge of sexuality." d. who are interested in sexual dysfunction can provide sex therapy for individuals and couples."

ANS: B The basic education of nurses provides information sufficient to qualify the generalist to assess for sexual dysfunction and perform health teaching. Taking a detailed sexual history and providing sex therapy requires additional training in sex education and counseling. Nurses with basic education are not qualified to be sexual counselors. Additional education is necessary. A registered nurse may provide basic information about sexual function, but complex questions may require referral.

10. For patients with severe and persistent mental illness, what is the major advantage of case management? A case manager can: a. modify traditional psychotherapy. b. more efficiently use resources as the only manager responsible for coordinating services. c. focus on social skills training and self-esteem building. d. bring groups of patients together to discuss common problems.

ANS: B The case manager not only provides entrance into the system of care, but he or she also coordinates the multiple referrals that so often confuse the patient who is severely and persistently mentally ill and the patient's family. Case management promotes the efficient use of services. The other options are lesser advantages or may be irrelevant.

6. A patient living independently has command hallucinations to report terrorism to the Federal Bureau of Investigation (FBI) and to shout warnings to neighbors. After a short hospitalization, the patient is prohibited from returning to the apartment. The landlord says, "You can't come back here. You cause too much trouble." What problem is the patient experiencing? a. Grief b. Stigma c. Homelessness d. Lack of insurance parity

ANS: B The inability to obtain shelter because of negative attitudes about mental illness is an example of stigma. Stigma is defined as damage to reputation, shame, and ridicule society places on mental illness. Data are not present to identify grief as a patient problem. Data also do not suggest that the patient is actually homeless. Insurance parity is not relevant to this scenario.

A 52-year-old client states, "My husband is upset because I don't enjoy sex as much as I used to." Which priority client data should a nurse initially collect? A. History of hysterectomy B. Date of last menstrual cycle C. Use of birth control methods D. History of thought disorder

ANS: B The nurse should assess the client's last menstrual cycle to determine if the client is experiencing the onset of menopause. Menopause usually occurs around the age of 50. The decrease in estrogen can result in multiple symptoms including a decrease in biological drives and sexual activity.

A nurse is counseling a client diagnosed with transgenderism. Which characteristic would differentiate this disorder from transvestic fetishism? A. Clients diagnosed with transvestic fetishism are dissatisfied with their gender, whereas clients diagnosed with transgenderism are not. B. Clients diagnosed with transgenderism are dissatisfied with their gender, whereas clients diagnosed with transvestic fetishism are not. C. Clients diagnosed with transgenderism never engage in cross-dressing, whereas clients diagnosed with transvestic fetishism do. D. Clients diagnosed with transvestic fetishism never engage in cross-dressing, whereas clients diagnosed with transgenderism do.

ANS: B The nurse should identify that clients diagnosed with transgenderism are dissatisfied with their gender, whereas clients diagnosed with transvestic fetishism are not. Both clients diagnosed with transgenderism and transvestic fetishism may participate in cross-dressing.

A nurse is assessing a client diagnosed with pedophilia. What would differentiate this sexual disorder from a sexual dysfunction? A. Symptoms of sexual dysfunction include inappropriate sexual behaviors, whereas symptoms of a sexual disorder include impairment in normal sexual response. B. Symptoms of a sexual disorder include inappropriate sexual behaviors, whereas symptoms of sexual dysfunction include impairment in normal sexual response. C. Sexual dysfunction can be caused by increased levels of circulating androgens, whereas levels of circulating androgens do not affect sexual disorders. D. Sexual disorders can be caused by decreased levels of circulating androgens, whereas levels of circulating androgens do not affect sexual dysfunction.

ANS: B The nurse should identify that pedophilia is a sexual disorder in which individuals partake in inappropriate sexual behaviors. Sexual dysfunction involves impairment in normal sexual response. Pedophilia involves having sexual urges, behaviors, or sexually arousing fantasies involving sexual activity with a prepubescent child.

A woman consults the nurse practitioner because she has not achieved orgasm for 2 years, despite having been sexually active. This is an example of: a. Paraphilic Disorder. b. Female Orgasmic Disorder. c. Genito-Pelvic Pain/Penetration Disorder. d. Female Sexual Interest/Arousal Disorder.

ANS: B The persistent inhibition of orgasm is a form of sexual dysfunction called female orgasmic disorder. Genito-pelvic pain/penetration disorder applies to painful intercourse. The patient has not indicated that her interest in sexual activity is diminished, so female sexual interest/arousal disorder does not apply. Paraphilic disorder is not applicable.

A man who reports frequently experiencing premature ejaculation tells the nurse, "I feel like such a failure. It's so awful for both me and my partner. Can you help me?" Select the nurse's best response. a. "Have you discussed this problem with your partner?" b."I can refer you to a practitioner who can help you with this problem." c. "Have you asked your health care provider for prescription medication?" d. "There are several techniques described in this pamphlet that might be helpful."

ANS: B The primary role of the nurse is to perform basic assessment and make appropriate referrals. The other options do not clarify the nurse's role.

A nursing instructor is teaching about the various categories of paraphilia. Which of the following categories are correctly matched with expected behaviors? (Select all that apply.) A. Exhibitionism: Mary models lingerie for a company that specializes in home parties. B. Voyeurism: John is arrested for peering in a neighbor's bathroom window. C. Frotteurism: Peter enjoys subway rush-hour female contact that results in arousal. D. Pedophilia: George can experience an orgasm by holding and feeling shoes. E. Fetishism: Henry masturbates into his wife's silk panties.

ANS: B, C, E Categories of paraphilia include voyeurism (observing unsuspecting people who are naked, dressing, or engaged in sexual activity), frotteurism (touching or rubbing against a nonconsenting person), fetishism (using nonliving objects in sexual ways), and pedophilia (recurrent sexual urges involving sexual activity with a prepubescent child). Exhibitionism is a paraphilia but involves the urge to show one's genitals to unsuspecting strangers.

A nurse is working with a client diagnosed with pedophilia. Which client outcome is appropriate for the nurse to expect during the first week of hospitalization? A. The client will verbalize an understanding of the importance of follow-up care. B. The client will implement several relapse-prevention strategies. C. The client will identify triggers that lead to inappropriate behaviors. D. The client will attend aversion therapy groups.

ANS: C During the first week of hospitalization, identifying triggers that lead to inappropriate behaviors is an appropriate outcome for a client diagnosed with pedophilia. Pedophilia involves intense sexual urges, behaviors, or fantasies involving sexual activity with a prepubescent child.

25. An adult has been feeling significant tension since losing a home through foreclosure. This person goes to a park, feeds the birds, and then impulsively exposes himself to a group of parents and children. Which term applies to this behavior? a. Voyeurism b. Dyspareunia c. Exhibitionism d. Sexual masochism

ANS: C Exhibitionism is obtaining sexual pleasure from exposing one's genitalia to unsuspecting strangers. Voyeurism refers to obtaining sexual pleasure from observing people who are naked. Dyspareunia refers to painful intercourse. Sexual masochism refers to deriving sexual pleasure from being humiliated, beaten, or otherwise made to suffer.

11. The father of a child with schizophrenia says, "I lost my job, so we have no health insurance." The mother says, "I must watch this child all the time. Without supervision, our child becomes violent and destroys furniture." The sibling says, "My parents don't pay very much attention to me." These comments signify: a. life-cycle stressors b. psychobiologic issues c. family burden of mental illness d. stigma associated with mental illness

ANS: C Family burden refers to the meaning that the experience of living with a person who is mentally ill has for families. The stressors mentioned are not related to live-cycle issues. The stressors described are psychosocial. Stigma refers to shame and ridicule associated with mental illness.

An adult consulted a nurse practitioner because of an inability to achieve orgasm for 2 years, despite having been sexually active. This adult was frustrated and expressed concerns about the relationship with the sexual partner. Which documentation best indicates the treatment was successful? a. "No complaints related to sexual function; to return next week." b. "Patient reports achieving orgasm last week; seems very happy." c. "Reports satisfaction with sexual encounters; feels partner is supportive." d. "Reports achieving orgasm occasionally; relationship with partner is adequate."

ANS: C Human sexuality, sexual expression, and expectations related to sexuality vary tremendously from person to person and across cultures. Therefore, the best indication of satisfactory treatment is that the patient is satisfied with what has been achieved. In this instance, "Patient reports satisfaction with sexual encounters; feels partner is supportive" best indicates that the patient is satisfied, and both presenting issues are progressing in a positive manner. Achieving orgasm once or occasionally may or may not represent satisfactory progress to the patient. "No complaints" does not necessarily mean that satisfaction exists.

1. Health maintenance and promotion efforts for patients with severe and persistent mental illness should include education about the importance of regular: a. home safety inspections b. monitoring of self-care abilities c. screening for cancer, hypertension, and diabetes d. determination of adequacy of a patient's support system

ANS: C Individuals with severe mental illness have an increased prevalence of medical disorders. Patients should be taught the importance of regular visits to a primary care physician for screening for these illnesses. Home safety inspections are more often suggested for patients with physical impairments. Caregivers and family members usually evaluate self-care abilities, rather than the patient. Assessment of a patient's support system is not usually considered part of health promotion and maintenance.

4. Which nursing diagnosis is likely to apply to an individual with severe and persistent mental illness who is homeless? a. Insomnia b. Substance abuse c. Chronic low self-esteem d. Impaired environmental interpretation syndrome

ANS: C Many individuals with severe mental illness do not live with their families and are homeless. Life on the street or in a shelter has a negative influence on the individual's self-esteem, making this nursing diagnosis one that should be considered. Insomnia may be noted in some patients but is not a universal problem. Substance abuse is not an approved North American Nursing Diagnosis Association (NANDA) International diagnosis. Impaired environmental interpretation syndrome refers to persistent disorientation, which is not observed in a majority of the homeless.

Which characteristic fits the usual profile of an individual diagnosed with pedophilic disorder? a. Homosexual b. Ritualistic behaviors c. Seeks access to children d. Self-confident professional

ANS: C Persons with pedophilic disorder usually place themselves in jobs, activities, or relationships that provide easy access to children. They often become trusted by both parents and children. The other characteristics have no particular relationship to pedophilic disorder.

A patient's medical record documents sexual masochism. This patient derives sexual pleasure: a. from inanimate objects. b. by inflicting pain on a partner. c. when sexually humiliated by a partner. d. from touching a non-consenting person.

ANS: C Sexual masochism is sexual pleasure derived from being humiliated, beaten, or otherwise made to suffer. The distracters refer to fetishism, sexual sadism, and frotteurism.

A female client on an inpatient unit enters the day area for visiting hours dressed in a see-through blouse and wearing no undergarments. Which intervention should be a nurse's first priority? A. Discuss with the client the inappropriateness of her attire. B. Avoid addressing her attention-seeking behavior. C. Lead the client back to her room and assist her to choose appropriate clothing. D. Restrict client to room until visiting hours are over.

ANS: C The most appropriate intervention by the nurse is to lead the client back to her room and assist her to choose appropriate clothing. The client could be exhibiting signs of exhibitionism which is characterized by urges to expose oneself to unsuspecting strangers.

A client is diagnosed with female sexual aversion disorder. In addition to systematic desensitization techniques, which medication therapy could accompany this intervention? A. Quetiapine (Seroquel) B. Phenelzine (Nardil) C. Amoxapine (Asendin) D. Carbamazepine (Tegretol)

ANS: C The nurse should identify that medication therapy of amoxapine could complement systematic desensitization techniques. Amoxapine is a heterocyclic antidepressant that can assist in reduction of anxiety.

27. A patient with severe and persistent mental illness who recently moved to a homeless shelter says, "My life is out of control. I'm like a leaf at the mercy of the wind." The nurse formulates the diagnosis Powerlessness. Outcomes will focus on: a. Instilling hope b. Controlling anxiety c. Planning activities d. Developing personal autonomy

ANS: D

21. A patient tells the nurse, "My sexual functioning is normal when my partner wears lace. Without it, I'm not interested in sex." This comment evidences: a. exhibitionism b. voyeurism c. pedophilia d. fetishism

ANS: D A person with a sexual fetish finds it necessary to have some external object present, in fantasy or in reality, to be sexually satisfied. Exhibitionism refers to exposing one's genitalia publicly. Voyeurism refers to viewing others in intimate situations. Pedophilia refers to the preference for having sexual relations with a child.

13. An adult says, "When I was a child, I took medication because I couldn't follow my teachers' directions. I stopped taking it when I was about 13. I still have trouble getting organized, which causes difficulty doing my job." Which disorder is most likely? a. Stress intolerance disorder b. Generalized anxiety disorder c. Borderline personality disorder d. Adult attention deficit hyperactivity disorder (ADHD)

ANS: D Adult ADHD is usually diagnosed in early life and treated until adolescence. Treatment is often stopped because professionals think the disorder resolves itself because the hyperactive impulsive behaviors may diminish; the inattentive and disorganized behaviors tend to persist, however. Stress intolerance disorder is not found in the DSM-IV-TR. The scenario description is inconsistent with generalized anxiety disorder and borderline personality disorder.

20. Which nursing action should occur first when preparing to work with a patient who has a problem of sexual functioning? a. Acquiring knowledge of the patient's sexual roles and preferences b. Developing an understanding of human sexual responses c. Assessing the patient's sexual functioning d. Clarifying the nurse's own personal values

ANS: D Before a nurse can be helpful to patients with sexual dysfunction, he or she must be aware of and comfortable with his or her own feelings about sex and sexuality. Nurses must be comfortable with the idea that patients have a right to their own values and must avoid criticism and censure.

Which nursing action should occur first regarding a patient who has a problem of sexual dysfunction or sexual disorder? The nurse should: a. develop an understanding of human sexual response. b. assess the patient's sexual functioning and needs. c. acquire knowledge of the patient's sexual roles. d. clarify own personal values about sexuality.

ANS: D Before one can be helpful to patients with sexual dysfunctions or disorders, the nurse must be aware of his or her own feelings and values about sex and sexuality. Nurses must keep their personal beliefs separate from their patient care in order to remain objective, professional, and effective. Nurses must be comfortable with the idea that patients have a right to their own values and must avoid criticism and censure. The other options are indicated as well, but self-awareness must precede them to provide the best care.

While performing an assessment, the nurse says to a patient, "While growing up, most of us heard some half-truths about sexual matters that continue to puzzle us as adults. Do any come to your mind now?" The purpose of this question is to: a. identify areas of sexual dysfunction for treatment. b. determine possible homosexual urges. c. introduce the topic of masturbation. d. identify sexual misinformation.

ANS: D Misinformation about normal sex and sexuality is common. Lack of knowledge may affect an individual's sexual adjustment. Once myths have been identified, the nurse can give information to dispel the myth.

Which statement about paraphilic disorders is accurate? a. Paraphilic behavior is controllable by willpower, but most persons with these disorders fail to do so. b. Persons with paraphilic disorders rarely experience shame and are not distressed by their acts. c. Persons with paraphilic disorders prey primarily on female children between the ages of 12 and 15 years. d. Acts of paraphilia are common because persons with the disorders commit the acts repeatedly, but paraphilic disorders are uncommon.

ANS: D Paraphilic disorders are uncommon; however, because persons with these disorders repeatedly enact behaviors associated with their disorders, paraphilic acts are relatively common. The majority of victims of pedophiles are males in early adolescence; those pedophiles who prefer females usually prefer prepubescent children. Some persons with paraphilic disorders experience shame and are at higher risk for suicide due to the stigma, shame, and embarrassment. Biological and psychological drives underlying paraphilic behavior can be very strong and often are not controllable by willpower alone. Persons with paraphilic disorders have difficulty controlling their behavior, even when very motivated to do so.

3. A 37-year-old is involuntarily committed to outpatient treatment after sexually molesting a 12-year-old child. The patient says, "That girl looked like she was 19 years old." Which defense mechanism is this patient using? a. Denial b. Identification c. Displacement d. Rationalization

ANS: D Rationalization is used to justify upsetting behaviors by creating reasons that would allow the individual to believe that the behaviors were warranted or appropriate. The patient is justifying the molestation of a minor. Denial is used to avoid dealing with the problems and responsibilities related to one's behaviors. Identification is incorporating the image of an emulated person and then acting, thinking, and feeling like that person. Displacement is the discharge of pent-up feelings onto something or someone else in the environment that is less threatening than the original source of the feelings.

12. The parent of an adult who is severely and persistently mentally ill asks the nurse, "Why are you making a referral to that vocational rehabilitation program? My child won't ever be able to hold a job." Which is the nurse's best reply? a. "We make this referral to continue eligibility for federal funding." b. "Are you concerned that we're trying to make your child too independent?" c. "If you think the program would be detrimental, we can postpone it for a time." d. "Most patients are capable of employment at some level, competitive or supported."

ANS: D Studies have shown that most patients who complete vocational rehabilitation programs are capable of some level of employment; also they demonstrate significant improvement in assertiveness and work behaviors, as well as decreased depression.

When planning care for a client diagnosed with female sexual arousal disorder, what should a nurse document as an expected outcome of senate focus exercises? A. To initiate immediate orgasm B. To reduce anxiety by eliminating physical touch C. To focus on touching breasts and genitals D. To reduce goal-oriented demands of intercourse

ANS: D The expected outcome of senate focus exercises is to reduce goal-oriented demands of intercourse. Senate focus exercises consist of touching and being touched by another with attention focused on the physical sensations encountered. Erotic contact is gradually increased, leading to the possibility of sexual intercourse. The reduction in demands reduces performance pressures and anxiety associated with possible failure.

A psychiatric nursing instructor is teaching about the psychological effects of the diagnosis of a sexually transmitted disease (STD). Which student statement indicates that further instruction is needed? A. "STDs carry strong connotations of illicit sex and considerable social stigma." B. "STDs can cause insanity." C. "The diagnosis of HIV can generate hopelessness and helplessness." D. "Antibiotics administered in the early stages can cure all STDs."

ANS: D The instructor should identify the need for further instruction if a student states that antibiotics can cure all STDs. STDs refer to infections that are contracted primarily through sexual activities or intimate contact. An example of an incurable STD is HIV. STDs are at epidemic levels in the United States.

16. A nurse prepares a plan of care for a patient with adult attention deficit hyperactivity disorder (ADHD). Which intervention should be included? a. Remind the patient of priorities and deadlines. b. Teach work-related skills such as basic computer literacy. c. Establish penalties for failing to organize and prioritize tasks. d. Give encouragement and strategies for managing and organizing.

ANS: D The nurse's major responsibilities lie with encouraging the patient to learn and use necessary skills, assisting the patient to stay on task. The nurse is not an ever-present taskmaster or disciplinarian. The nurse does not teach work-related skills; vocational staff members assume those types of tasks.

5. A patient with schizophrenia tells the community mental health nurse, "I threw away my pills because they interfere with God's voice." The nurse identifies the cause of the patient's ineffective management of the medication regime as: a. inadequate discharge planning b. poor therapeutic alliance with clinicians c. dislike of the side effects of antipsychotic medications d. impaired reasoning secondary to the schizophrenia

ANS: D The patient's ineffective management of the medication regime is most closely related to impaired reasoning. The patient believes in being an exalted personage who hears God's voice, rather than an individual with a serious mental disorder who needs medication to control symptoms. Data do not suggest that any of the other factors often relate to medication nonadherence.

A man with hypospadias tells the nurse, "Intercourse with my new bride is painful." Which term applies to the patient's complaint? a. Delayed ejaculation b. Erectile dysfunction c. Premature ejaculation d. Genito-pelvic pain/penetration disorder

ANS: D This sexual pain is genito-pelvic pain/penetration disorder and may occur in men or women. The individual feels pain in the genitals during intercourse. Erectile or ejaculation problems are not evident. See relationship to audience response question.

A patient tells the nurse that his sexual functioning is normal when his wife wears short, red camisole-style nightgowns. He states, "Without the red teddies, I am not interested in sex." The nurse can assess this as consistent with: a. exhibitionism. c. frotteurism. b. voyeurism. d. fetishism.

ANS: D To be sexually satisfied, a person with a sexual fetish finds it necessary to have some external object present, in fantasy or in reality. Frotteurism involves deriving sexual pleasure from rubbing against others surreptitiously. Exhibitionism is the intentional display of the genitalia in a public place. Voyeurism refers to viewing others in intimate situations.

The male manager of a health club placed a hidden video camera in the women's locker room and recorded several women as they showered and dressed. The disorder most likely represented by this behavior is: a. homosexuality. b. exhibitionism. c. pedophilia. d. voyeurism.

ANS: D Voyeurism is achieving sexual pleasure through the viewing of others in intimate situations, such as undressing, bathing, or having sexual relations. A homosexual individual would be interested in watching members of the same sex, and homosexuality is not typically associated with voyeurism. Exhibitionists are interested in exposing their genitals to others. Pedophiles seek sexual contact with children.

23. The manager of a health club put a hidden camera in the women's locker room and videotaped women as they showered and dressed. Which sexual dysfunction is evident? a. Frotteurism b. Exhibitionism c. Pedophilia d. Voyeurism

ANS: D Voyeurism is the viewing of others in intimate situations such as undressing, bathing, or having sexual relations. Voyeurs are often called "peeping Toms." Frotteurism is touching or rubbing against a nonconsenting person to achieve sexual gratification. Exhibitionists are interested in exposing their genitals to others. Pedophiles seek sexual contact with prepubescent children.