Ch 5, 6, & 9 STI's, breast cancer and violence
A nurse is assessing a survivor of intimate partner violence. During the interview, the nurse determines that the survivor's partner is using power and control over the client through coercion and threats. Which client statement would lead the nurse to suspect this? "He tells me that he'll tell child services I'm a bad mother." "He always tells me that the abuse never happened." "He acts like he's the master of his castle and I'm his servant." "He tells me who I can and cannot see."
"He tells me that he'll tell child services I'm a bad mother." Explanation: The statement about telling child services that the client is a bad mother reflects coercion and threats. The statement about the abuse never happening reflects power and control through minimizing, denying, and blaming. The statement about whom the client can and cannot see reflects power and control through the use of isolation. The statement about the partner being the master of his castle reflects power and control through the use of the male privilege.
At a class for new mothers, the nurse notes that the participants need more teaching when one of the mothers makes which comment? "I can use warm compresses to ease the discomfort." "I have been using a breast pump after feeding my baby." "Breastfeeding every four hours appears to help." "I have to stop breastfeeding because of mastitis."
"I have to stop breastfeeding because of mastitis." Explanation: The nurse should teach the women about the etiology of mastitis and encourage breast-feeding, emphasizing that it is safe for infants. Continued emptying of the breast or pumping improves the outcome, decreases the duration of symptoms, and decreases the incidence of breast abscess.
The nurse is caring for a 52-year-old woman whose sisters and mother died of breast cancer. The client states, "My doctor wants me to take tamoxifen to help prevent breast cancer. What do you think?" What would be the nurse's best response? "Tamoxifen reduces the incidence." "We call this drug a chemotherapy agent." "I would recommend raloxifene." "Tamoxifen prevents osteoporosis."
"Tamoxifen reduces the incidence." Explanation: Tamoxifen is referred to as a chemopreventive agent, not a chemotherapeutic agent. It does prevent osteoporosis, but this response does not address breast cancer prevention. Raloxifene is another drug that shows promise as a chemopreventive agent. Tamoxifen reduces breast cancer incidence by 49%
At what age should a woman with no risk factors begin mammography screening for breast cancer?
40 Explanation: Every woman should begin annual mammography to detect breast cancer at the age of 40. Women who have certain risk factors may begin screening earlier.
The nursing student is studying violence and abuse against the older woman. While researching it, she learns that laws require health care professionals to report elder or vulnerable person abuse. How many states currently have these laws? 32 52 40 50
50 Explanation: All fifty states have laws requiring health care professionals to report elder or vulnerable person abuse
A female client is prescribed metronidazole for the treatment of trichomoniasis. Which instruction should the nurse give the client undergoing treatment? Use condoms during sex. Avoid alcohol. Avoid extremes of temperature to the genital area. Increase fluid intake.
Avoid alcohol. Explanation: The nurse should counsel the client taking metronidazole to avoid alcohol during the treatment because mixing the two causes severe nausea and vomiting. Avoiding extremes of temperature to the genital area is a requirement for clients with genital ulcers, not trichomoniasis. The nurse should instruct the client to avoid sex, regardless of using condoms, until she and her sex partners are cured, that is, when therapy has been completed and both partners are symptom-free. It is not required to increase fluid intake during treatment
When considering the hormonal changes that occur, the nurse should encourage which diagnostic screening for a postmenopausal woman? Serum potassium level Fasting blood sugar Bone calcium level Red blood cell count
Bone calcium level Explanation: Menopause is associated with loss of many of the effects of estrogen and progesterone on the body, including retention of calcium in the bones. None of the remaining options are directly related either estrogen or progesterone.
Assessment of a client reveals evidence of a cystocele. The nurse interprets this as which of the following? Downward displacement of the cervix Herniation of the rectum into the vagina Protrusion of intestinal wall into the vagina Bulging of the bladder into the vagina
Bulging of the bladder into the vagina Explanation: A cystocele is the bulging of the bladder into the vagina. A rectocele is a herniation of the rectum into the vagina. An enterocele is a protrusion of the intestinal wall into the vagina. An uterovaginal prolapse is the downward displacement of the cervix anywhere from low in the vagina to outside the vagina.
Mammography is recommended for a client diagnosed with intraductal papilloma. Which factor should the nurse ensure when preparing the client for a mammography? Client is just going to start her menses. Client has not applied deodorant on the day of testing. Client has taken an aspirin before the testing. Client has not consumed fluids 1 hour before testing
Client has not applied deodorant on the day of testing. Explanation: When preparing a client for mammography, the nurse should ensure the client has not applied deodorant or powder on the day of testing because these products can appear on the X-ray film as calcium spots. It is not necessary for the client to avoid fluid intake 1 hour prior to testing. Mammography has to be scheduled just after the client's menses to reduce chances of breast tenderness, not when the client is going to start her menses. The client can take aspirin or acetaminophen after the completion of the procedure to ease any discomfort, but these medications are not taken before mammography.
A nurse is caring for a female client undergoing radiation therapy after her breast surgery. The client is refusing to eat and states she does not have a desire to eat at this time. Which action should the nurse do first? Continue to monitor the client. Notify the health care provider. Begin parenteral nutrition. Assess the client's BMI
Continue to monitor the client. Explanation: A nurse would monitor for signs of anorexia as it is a likely side effect of radiation therapy, along with swelling and heaviness of the breast, local edema, inflammation, and sunburn-like skin changes. The nurse would continue to monitor the client since this is a common, expected side effect of radiation
Which hormones are not released during childhood? Thyroid Gonadotropin-releasing hormone (GnRH) Parathyroid Growth hormone (GH)
Gonadotropin-releasing hormone (GnRH) Explanation: The developing hypothalamus is sensitive to the androgens released by the adrenal glands and does not release GnRH during childhood. As the hypothalamus matures, it loses its sensitivity to the androgens and starts to release GnRH.
A pregnant client has been diagnosed with gonorrhea. Which nursing interventions should be performed to prevent gonococcal ophthalmia neonatorum in the baby? Administer cephalosporins to mother during pregnancy. Administer an antiretroviral syrup to the newborn. Perform cesarean birth to prevent infection. Instill a prophylactic agent in the eyes of the newborn.
Instill a prophylactic agent in the eyes of the newborn. Explanation: To prevent gonococcal ophthalmia neonatorum in the baby, the nurse should instill a prophylactic agent in the eyes of the newborn. Cephalosporins are administered to the mother during pregnancy to treat gonorrhea but not to prevent infection in the newborn. Performing a cesarean birth will not prevent gonococcal ophthalmia neonatorum in the newborn. An antiretroviral syrup is administered to the newborn only if the mother is human immunodeficiency virus-positive and will not help prevent gonococcal ophthalmia neonatorum in the baby.
A nurse who is conducting sessions on preventing the spread of sexually transmitted infections (STIs) discovers that there is a very high incidence of hepatitis B in the community. Which measure should the nurse take to ensure the prevention of the disease? Educate about risks of injecting drugs. Ensure that the drinking water is disease free. Educate teenagers to delay onset of sexual activity. Instruct people to get vaccinated for hepatitis B.
Instruct people to get vaccinated for hepatitis B. Explanation: The nurse should instruct all community members to get vaccinated for prevention of hepatitis B. Ensuring that drinking water is disease free and educating people about the risks involved with injecting drugs may help prevent hepatitis A, not hepatitis B. Delaying the start of sexual activity by teenagers may not protect them from hepatitis B in the long run.
A woman is crying because she just recently received the results of her biopsies, and they confirm that she has invasive breast cancer. Which response by the nurse is the most appropriate? Listen to the woman talk, and remain silent for a while "I know a great support group you can join." "You'll beat this thing, I know it. You are very strong." "I'm sure you are going to be fine. You are in great hands."
Listen to the woman talk, and remain silent for a while Explanation: When a woman first receives the devastating news of the diagnosis of cancer, most often the best response is to allow the woman to express her feelings and concerns before speaking. Giving her false reassurances is not therapeutic and can break reliability and trust in a provider/patient relationship. Attempting to give her information about groups or next steps before she is in a state to take it in is also nontherapeutic.
Which drug is the most effective treatment for trichomoniasis? Clindamycin Miconazole Metronidazole Clotrimazole
Metronidazole Explanation: The most effective treatment for trichomoniasis is metronidazole. Miconazole, clindamycin, and clotrimazole are not the most effective treatment for trichomoniasis.
A client reports lumpy, tender breasts, particularly during the week before menses. She reports pain that often dissipates after the onset of menses. The nurse suspects the client has fibrocystic breast changes. Which should the nurse do next? Schedule the client for cryoablation. Have the client follow up in 1 week. Determine if the client has had a mammography. Perform a breast examination.
Perform a breast examination. Explanation: To determine if the client is experiencing fibrocystic breast changes, the nurse must first examine the client's breasts. It is not important to know if the client has a mammography at this time. Cryoabation is done to remove a tumor.
A client reports lumpy, tender breasts, particularly during the week before menses. She reports pain that often dissipates after the onset of menses. The nurse suspects the client has fibrocystic breast changes. Which should the nurse do next? Have the client follow up in 1 week. Determine if the client has had a mammography. Schedule the client for cryoablation. Perform a breast examination.
Perform a breast examination. Explanation: To determine if the client is experiencing fibrocystic breast changes, the nurse must first examine the client's breasts. It is not important to know if the client has a mammography at this time. Cryoabation is done to remove a tumor
The nurse is preparing a teaching plan for a client with a vulvovaginal infection. Which of the following would be least appropriate for the nurse to include? Wearing cotton underwear that is loose-fitting and allows for air flow Performing douching with a dilute vinegar solution twice a day Refraining from unprotected sexual intercourse with partners Maintaining a reclining position for 30 minutes after inserting vaginal medication
Performing douching with a dilute vinegar solution twice a day Explanation: Research has shown that douching provides no benefit in the prevention or care of vulvovaginal infections. Douching usually is unnecessary because daily baths or showers and proper hygiene after voiding and defecation keep the perineal area clean. In addition, douching tends to eliminate normal flora, reducing the body's ability to ward off infection. Repeated douching may result in vaginal epithelial breakdown and chemical irritation. The client should recline for approximately 30 minutes after inserting any vaginal medication to prevent the medication from escaping from the vagina. Loose-fitting cotton underwear is advised rather than tight-fitting synthetic, nonabsorbent, heat-retaining underwear. Unprotected sexual intercourse is associated with risks and should be avoided.
The nurse is caring for a client who is seeking care after being raped. What is the primary reason the nurse does not leave the client alone during the emergency room stay? Promotes the client's sense of safety Assures the nurse will be available to meet the client's needs Helps guarantee proper attention to the preservation of evidence Provides the opportunity for the client to validate feelings
Promotes the client's sense of safety Explanation: The nurse's first responsibility is to provide the client a safe environment both physically and emotionally. Staying with the client will help promote a sense of safety. Although the other options may result from the nurse's presence, the primary goal is safety.
During fetal development, the descent of the testes into what structure helps prevent injury to the sperm-producing cells? Scrotum Epididymis Urethra Vas deferens
Scrotum Explanation: During fetal development, the testes migrate down the abdomen and descend into the scrotum outside the body. There they are protected from the heat of the body to prevent injury to the sperm-producing cells.
After teaching a class on the female reproductive system, the nurse determines that the teaching was successful when the class identifies what as a primary function of the ovaries? Carrying the ovum to the endometrium Secretion of mucus that supplies lubrication for intercourse Location for implantation of a fertilized ovum Secretion of estrogen and progesterone
Secretion of estrogen and progesterone Explanation: The ovaries have two primary functions: development and release of the ovum and secretion of estrogen and progesterone. The fallopian tubes are responsible for conveying the ovum from the ovary to the uterus and sperm from the uterus toward the ovary. The Bartholin glands, when stimulated, secrete mucus that supplies lubrication for intercourse. The uterus is the site of implantation of a fertilized ovum.
A small amount of breast milk is obtained for culture and sensitivity testing from a client with mastitis. The nurse would expect the results to identify which organism as the most likely cause? Chlamydia trachomatis Staphylococcus aureus group A streptococcus Escherichia coli
Staphylococcus aureus Explanation: The most common causative microorganism associated with mastitis is Staphylococcus aureus. Chlamydia is a sexually transmitted infection. Streptococcus is commonly associated with strep throat. E. coli is a common cause of urinary tract infections
The nurse is assessing a woman who is a victim of intimate partner violence and recognizes a belief that is common among victims of abuse. Which belief would the nurse most likely identify? The situation will never get better. The woman can leave at any time. The woman is inadequate in some way. The woman recognizes she is a victim.
The woman is inadequate in some way. Explanation: Some women believe that the abuse is caused by a personality flaw or inadequacy in her. The victims rarely describe themselves as abused and believe if they can do as the abuser has asked, things will get better. Few believe they can leave.
A nurse is speaking to a local women's group about the various types of cancer affecting the female reproductive tract. The nurse explains that ovarian cancer is the leading cause of death from gynecologic malignancies based on the understanding that this type of cancer does which of the following? Spreads more easily than other female reproductive cancers Typically manifests with vague symptoms resulting in late diagnosis Arises from extremely rare types of cells that are resistant to treatment Is closely associated with highly resistant sexually transmitted infections
Typically manifests with vague symptoms resulting in late diagnosis Explanation: Tumors of the ovary have been lethal largely because they present with nonspecific symptoms and therefore, frequently are far advanced and inoperable by the time they are diagnosed. Ease of spread and types of cells involved are not reasons underlying the fatal nature of this type of cancer. Ovarian cancer is not associated with sexually transmitted infections. Cervical cancer is linked to human papilloma virus infection.
A nurse is caring for a client positive for human immunodeficiency virus. The client is on triple-combination highly active antiretroviral therapy (HAART). What should the nurse include in the teaching plan when educating the client about the treatment? (Select all that apply.) Successful antiretroviral therapy may prevent acquired immunodeficiency syndrome (AIDS). Ensure that the client understands the dosing regimen and schedule. Exposure of fetus to antiretroviral agents is completely safe. Unpleasant side effects such as nausea and diarrhea are common. Provide written materials describing diet, exercise, and medications.
Unpleasant side effects such as nausea and diarrhea are common. Provide written materials describing diet, exercise, and medications. Ensure that the client understands the dosing regimen and schedule. Explanation: The nurse should ensure that the client understands the dosing regimen and schedule. The client should be informed that unpleasant side effects such as nausea and diarrhea are common. The nurse should provide written material describing diet, exercise, and medications to promote compliance and ensure a healthy lifestyle. There is no evidence to suggest that exposure of the fetus to antiretroviral agents during pregnancy is completely safe in the long run. HIV is a lifelong condition, and antiretroviral therapy may delay the onset of AIDS but not prevent it.
A 13-year-old immigrant from Asia is admitted to the health care facility with vaginal bleeding. A genital examination reveals unhealed circumcision wounds. The client can understand limited English but cannot speak the language fluently. The service of an interpreter is employed. What should the nurse keep in mind when interacting with this client? Condemn the cultural practice, and explain why it is wrong to the client. She is still a child, so the nurse should convey important information in precise medical terms to ease understanding. Use pictures and diagrams to supplement the questions and answers of the client's understanding. Allow the interpreter to question the client directly to assist with data gathering.
Use pictures and diagrams to supplement the questions and answers of the client's understanding. Explanation: The nurse should use pictures and diagrams to ensure that the client understands what is being asked and explained. Instead of using medical terms, the nurse should use simple, accurate terms as much as possible. Condemning the practice will only alienate the girl and serve no useful purpose.
Which statement is false regarding screening for intimate partner violence in women? Women tend to fit a profile of abuse, and victims tend to share similar physical characteristics. An elderly female may be a victim of intimate partner violence. Screening should be routinely done at every visit. Although women who are abused may exhibit certain behavior patterns, all women should be screened for intimate partner violence.
Women tend to fit a profile of abuse, and victims tend to share similar physical characteristics. Explanation: Women do not typically fit a physical profile, and any woman can be a victim of abuse. Therefore, all women, even elderly women, should be screened at every visit.
The nurse working with women who have been abused recognizes that the abuser's swearing, promising, or threatening to hit the victim is categorized as which type of abuse? sexual emotional physical financial
emotional Explanation: Promising, swearing, or threatening to hit the victim is a form of emotional abuse.
A client is considering breast augmentation. What would the nurse recommend to the client to ensure that there are no malignancies? mammogram ultrasound breast biopsy mastopexy
mammogram Explanation: When caring for a client considering breast augmentation, the nurse should provide her with a general guideline to have a mammogram to verify that there are no malignancies. Mastopexy involves a breast lift for drooping breasts. Ultrasound or breast biopsy would not be necessary unless there was evidence of a problem
A parent at an educational session on sexually transmitted infections (STIs) asks the nurse if there are vaccines available to prevent STIs. What is the nurse's best response? "At present there are no vaccines available to prevent STIs." "Researchers have developed a vaccine to prevent human immunodeficiency virus." "There is a vaccine to prevent herpes simplex virus." "A vaccine has been approved vaccines to prevent the human papillomavirus."
"A vaccine has been approved vaccines to prevent the human papillomavirus." Explanation: Vaccine-preventable STIs can be effectively prevented through preexposure vaccination. Vaccines are under development or are undergoing clinical trials for certain STIs, including HIV and HSV. The only vaccines currently available are for prevention of HAV, HBV, and HPV infection. Vaccination efforts focus largely on integrating the use of these available vaccines into STI prevention and treatment activities.
The nursing instructor overhears students discussing their recent lecture topic of abuse and realizes that they need clarification when she hears a student make which statement? "Abuse occcurs only in heterosexual relationships." "Violence against gay relationships may go unreported for fear of harassment." "Abuse occurs in both heterosexual and homosexual relationships." "Violence against lesbian relationships may go unreported for fear of harassment."
"Abuse occcurs only in heterosexual relationships." Explanation: The statement that needs clarification is that abuse occurs only in heterosexual relationships. It occurs in gay and lesbian relationships as well.
A woman diagnosed with breast cancer is to undergo a lumpectomy followed by radiation therapy. When reviewing the treatment plan with the client, the nurse determines that the woman has understood the information based on which client statement? "After the lumpectomy, I'll have to wait about 6 months before I can begin to receive the radiation." "The radiation will be targeted to the area near my underarm to get at the lymph nodes." "After they remove the tumor and some of the normal tissue, I'll start radiation in about 2 to 4 weeks." "I'll have a portion of my breast removed, and then they'll do high-dose radiation in the operating room."
"After they remove the tumor and some of the normal tissue, I'll start radiation in about 2 to 4 weeks." Explanation: Women undergoing breast-conserving therapy receive radiation after lumpectomy with the goal of eradicating residual microscopic cancer cells to limit locoregional recurrence. In women who do not require adjuvant chemotherapy, radiation therapy typically begins 2 to 4 weeks after surgery to allow healing of the lumpectomy incision site. Radiation is administered to the entire breast at daily doses over a period of several weeks. Breast-conserving surgery, the least invasive procedure, is the wide local excision (or lumpectomy) of the tumor along with a 1-cm margin of normal tissue.
A woman diagnosed with breast cancer is to undergo a lumpectomy followed by radiation therapy. When reviewing the treatment plan with the client, the nurse determines that the woman has understood the information based on which client statement? "The radiation will be targeted to the area near my underarm to get at the lymph nodes." "After the lumpectomy, I'll have to wait about 6 months before I can begin to receive the radiation." "After they remove the tumor and some of the normal tissue, I'll start radiation in about 2 to 4 weeks." "I'll have a portion of my breast removed, and then they'll do high-dose radiation in the operating room."
"After they remove the tumor and some of the normal tissue, I'll start radiation in about 2 to 4 weeks." Explanation: Women undergoing breast-conserving therapy receive radiation after lumpectomy with the goal of eradicating residual microscopic cancer cells to limit locoregional recurrence. In women who do not require adjuvant chemotherapy, radiation therapy typically begins 2 to 4 weeks after surgery to allow healing of the lumpectomy incision site. Radiation is administered to the entire breast at daily doses over a period of several weeks. Breast-conserving surgery, the least invasive procedure, is the wide local excision (or lumpectomy) of the tumor along with a 1-cm margin of normal tissue.
The nurse is performing an admission interview with a new client diagnosed with acute coronary syndrome. For the nurse to obtain information and allow the client free verbalization, which question would elicit the most information? "Could you tell me more about how you are feeling right now?" "Did you take any medication when you had the pain?" "Have you ever had chest pain prior to this admission?" "I have had chest pain before, and it is really scary!"
"Could you tell me more about how you are feeling right now?" Explanation: Using an open-ended question is the most effective way to elicit further conversation and information. Asking the client to tell the nurse more about how they are feeling does not allow for a yes or no response, such as asking if the client had chest pain prior to the admission or if the client took any medication during the pain. When the nurse informs the client about chest pain that was experienced by the nurse, it takes the focus off of the client and does not obtain information that could be helpful.
A nurse is interviewing a client who is a survivor of abuse. The client is telling the nurse about how the violence occurred. Which statement would the nurse interpret as reflecting phase three of the cycle of violence? "He yells at me for not having dinner waiting for him when he came home." "He threw me against the wall and started punching my face." "He tells me that he is sorry and that he will never hit me again." "He calls me stupid and incompetent, asking himself why he ever married me."
"He tells me that he is sorry and that he will never hit me again." Explanation: During phase three of the cycle, the perpetrator becomes kind, contrite, and loving, begging for forgiveness and promising never to inflict abuse again until the next time. The actual violence occurs in phase two. Yelling at the client for not having dinner ready and calling her stupid and incompetent reflect phase one or tension building.
A community health nurse is conducting an educational session at a local community center on sexually transmitted infections (STIs). The nurse considers the session successful when participants identify which statement as correct? "Human papillomavirus is the cause of essentially all cases of cervical cancer." "At least antibiotics will cure a sexually transmitted infection." "Gonorrhea and syphilis are an infection seen only in men." "STIs can't be transmitted through oral sexual intercourse."
"Human papillomavirus is the cause of essentially all cases of cervical cancer." Explanation: Clinical studies have confirmed that HPV is the cause of essentially all cases of cervical cancer, which is the fourth most common cancer in women in the United States. Up to 95% of cervical squamous cell carcinomas and nearly all preinvasive cervical neoplasms are caused by the HPV. Antibiotics will only cure those STIs caused from a bacterial infections. A viral STI infection is a lifetime infection. Gonorrhea and syphilis affects both men and women. Sexually transmitted infections (STIs) are infections of the reproductive tract caused by microorganisms transmitted through oral sexual intercourse.
At a class for new mothers, the nurse notes that the participants need more teaching when one of the mothers makes which comment? "I have been using a breast pump after feeding my baby." "I can use warm compresses to ease the discomfort." "I have to stop breastfeeding because of mastitis." "Breastfeeding every four hours appears to help."
"I have to stop breastfeeding because of mastitis." Explanation: The nurse should teach the women about the etiology of mastitis and encourage breast-feeding, emphasizing that it is safe for infants. Continued emptying of the breast or pumping improves the outcome, decreases the duration of symptoms, and decreases the incidence of breast abscess.
A nurse educator is presenting to a prenatal class ways in which to prevent common yeast infections that may occur during pregnancy. Which statement made by participants indicates that the teaching has been effective? "Daily baths rather than showers will soothe irritation in the genital area." "Douching daily is recommended to keep the vaginal track clean." "I need to reduce my dietary intake of simple sugars and soda." "If I dry my underwear in a cool dryer, it kills the yeast on it."
"I need to reduce my dietary intake of simple sugars and soda." Explanation: Genital/vulvovaginal candidiasis (yeast) infections nursing management includes the teaching of preventive measures to women with frequent vulvovaginal candidiasis infections, including: reducing dietary intake of simple sugars and soda; avoid douching (which washes away protective vaginal mucus); shower rather than taking tub baths; dry underwear in a hot dryer to kill the yeast that clings to the fabric.
A nurse is teaching personal hygiene care techniques to a client with genital herpes. Which statement by the client indicates the teaching has been effective? "I can pour hydrogen peroxide and water over my lesions." "I will apply a water-based lubricant to my lesions." "I should rub rather than scratch in response to itching." "I will wear loose cotton underwear."
"I will wear loose cotton underwear." Explanation: Wearing loose cotton underwear promotes drying and helps avoid irritation of the lesions. The use of lubricants is contraindicated because they can prolong healing time and increase the risk of secondary infection. Lesions should not be rubbed or scratched because of the risk of tissue damage and additional infection. Cool, wet compresses can be used to soothe the itch. The use of hydrogen peroxide and water on lesions is not recommended.
After teaching a woman about breast self-examination, the nurse understands that the teaching was successful when the woman makes which statement? "I'll do the check about a week after my period." "I will check my breasts every other week." "I'll feel my breasts using my thumb and index finger." "I don't have to check under my arm if I don't feel any breast lumps."
"I'll do the check about a week after my period." Explanation: Breast self-examination is best performed a week after menses, when swelling has subsided. Breast self-examination is typically performed every month. Both the breast area and the area between the breast and underarm, including the underarm itself, should be part of breast self-examination. The woman should use the pads of her three middle fingers for palpation.
A victim of rape is prescribed emergency contraception. After teaching the client about this therapy, the nurse determines that the teaching was effective based on which client statement? "I need to take 3 doses over the next several days." "The medication will cause me to have an abortion." "I can wait until tomorrow morning to start taking it." "It contains high doses of a typical birth control pill"
"It contains high doses of a typical birth control pill" Explanation: Emergency contraceptive pills involve high doses of the same oral contraceptives that millions of women take every day. The emergency regimen consists of one dose taken within 72 to 120 hours of the unprotected intercourse. Emergency contraception works by preventing ovulation, fertilization, or implantation. It does not disrupt an established pregnancy and should not be confused with mifepristone (RU-486), a drug approved by the Food and Drug Administration for abortion in the first 49 days of gestation. Emergency contraception is most effective if is taken within 12 hours of the rape; it becomes less effective with every 12 hours of delay thereafter.
While performing a clinical breast examination, the nurse notes a firm and rubbery nodule that is well circumscribed and moves freely. How should the nurse counsel the client? "It's most likely a fibroadenoma, but we may need to do a biopsy." "This is a normal breast finding, and you don't have to worry about it." "You may have breast cancer." "This could be a fibrocystic breast change, but we may need to do a biopsy."
"It's most likely a fibroadenoma, but we may need to do a biopsy." Explanation: This description most closely matches a fibroadenoma, but diagnostic imaging and even biopsy are warranted to confirm and rule out a cancerous tumor. The nurse should never tell the client that she may have cancer because this will only cause anxiety
A nurse has just finished a presentation about intimate partner violence at a local group meeting. The nurse determines that more teaching is needed based on which group statement? "I've heard getting pregnant can make the situation worse." "Drugs and alcohol can really make the situation much worse." "It's only women that get hurt. Men are the ones doing all the hurting." "That was interesting. It's scary because it can happen anywhere, even here. "
"It's only women that get hurt. Men are the ones doing all the hurting." Explanation: Violence occurs in all socioeconomic classes and all genders. Although women are victims of violence more frequently than men, the prevalence of violence among men nonetheless represents a significant public health concern. One out of every 4 men has experienced rape, physical violence, and/or stalking by an intimate partner in their lifetime. Alcohol and drugs can make the situation worse. . Pregnancy is a time of unique vulnerability to intimate partner violence (IPV) victimization because of changes in women's physical, social, emotional, and economic needs during pregnancy. Although the true prevalence of violence during pregnancy is unclear, research suggests it is substantial and often continues into the postpartum period.
A woman has just confided in the nurse that her partner slapped and kicked her that morning. What is the best response by the nurse? "Oh my goodness, I cannot believe that happened to you. You poor thing, I feel terrible for you." "Maybe he didn't mean to do it. Have you talked with him about it?" "It's very brave of you to tell me all this. Help is available if you choose it." "Is this the first and only time he has done anything?"
"It's very brave of you to tell me all this. Help is available if you choose it." Explanation: When talking with a woman who is a victim of intimate partner violence, it is important not to uses expressions of emotionality or judgement such as, "Oh my goodness" or "I feel terrible for you." It is also important to validate the victim's story and tell her you believe what happened. Encouraging her to say more while informing her that help is available is the best therapeutic answer.
Which statement made by a male who has a history of abusing his partner reflects a known factor that is characteristic of this behavior? "My mother was the disciplinarian in our family." "My classmates always called me a bully." "Sports like football and soccer are my life." "It was just mom and me after dad died."
"My classmates always called me a bully." Explanation: Risk factors for intimate partner violence in men include taking aggression out on others while growing up as demonstrated by bullying. A male-dominated family life is considered a relationship factor that may trigger such violence. A preference for sports, such as football and soccer, are not considered risk factors for partner violence.
A nurse is providing care to a client with pediculosis pubis. Which information would the nurse include when teaching the client about this condition? "Your partner doesn't need treatment at this time." "Wash your bed linens in bleach and cold water." "Remove the nits with a fine-toothed comb." "Take the antibiotic until you feel better."
"Remove the nits with a fine-toothed comb." Explanation: The nurse should instruct the client to remove the nits from the hair using a fine-toothed comb. Permethrin cream and lindane shampoo are used as treatment, not antibiotics. Bedding and clothing should be washed in hot water to decontaminate it. Sexual partners should be treated also, as well as family members who live in close contact with the infected person.
The nurse is caring for a 52-year-old woman whose sisters and mother died of breast cancer. The client states, "My doctor wants me to take tamoxifen to help prevent breast cancer. What do you think?" What would be the nurse's best response? "We call this drug a chemotherapy agent." "I would recommend raloxifene." "Tamoxifen reduces the incidence." "Tamoxifen prevents osteoporosis."
"Tamoxifen reduces the incidence." Explanation: Tamoxifen is referred to as a chemopreventive agent, not a chemotherapeutic agent. It does prevent osteoporosis, but this response does not address breast cancer prevention. Raloxifene is another drug that shows promise as a chemopreventive agent. Tamoxifen reduces breast cancer incidence by 49%.
A 20-year-old female comes to the sexual health clinic for follow up related to a positive test for the human papillomavirus (HPV). The client asks the nurse, "Is there anything I can do to get rid of this?" What is the nurse's best response? "This can be cured with medications such as the recombinant human papillomavirus quadrivalent vaccine." "The lumps on your cervix can be cured by cryosurgery." "The health care provider will prescribe antibiotics to cure this infection." "There is currently no medical treatment to cure HPV."
"There is currently no medical treatment to cure HPV." Explanation: It is a lifelong recurrent viral disease treated but not cured with medical treatment. Immunization regimes such as the recombinant human papillomavirus quadrivalent vaccine are for HPV prevention not cure. Cryosurgery will eliminate HPV warts but not cure it. Antibiotics will not be effective for a virus.
A female client with genital herpes is prescribed acyclovir as treatment. After teaching the client about this treatment, which statement by the client indicates effective teaching? "This drug will help reduce my risk for a recurrence after discontinuing it." "The severity of future attacks will be much less after using this drug." "This drug will help to suppress any symptoms of the infection." "If I use this drug, I will be cured of the infection."
"This drug will help to suppress any symptoms of the infection." Explanation: No cure exists, but antiviral drug therapy helps to reduce or suppress symptoms, shedding, and recurrent episodes. Advances in treatment with acyclovir 400 mg orally three times daily for 7 to 10 days, famciclovir 250 mg orally three times daily for 7 to 10 days, or valacyclovir 1 g orally twice daily for 7 to 10 days have resulted in an improved quality of life for those infected with HSV. However, according to the CDC, these drugs neither eradicate latent virus nor affect the risk, frequency, or severity of recurrences after the drug is discontinued.
How should the nurse counsel a postpartum client on how to prevent mastitis? "Sterilize your bottles and pump equipment after each use." "Be sure to keep your breasts covered when you are not feeding or pumping." "If you notice that your breast is warm, hard, or red, stop feeding on that side and pump from that breast instead." "Wash your hands thoroughly, and let your breasts dry after each feeding."
"Wash your hands thoroughly, and let your breasts dry after each feeding." Explanation: Handwashing is one of the best ways to prevent infection. If the woman feels that her breast is warm, hard, or red, she should increase the amount of breastfeeding from that side. It is not necessary to sterilize bottles and pumping equipment after each use. Normal dish washing is sufficient. Keeping the breasts exposed to the air to dry will aid in preventing infection.
How should the nurse counsel a postpartum client on how to prevent mastitis? "Be sure to keep your breasts covered when you are not feeding or pumping." "Sterilize your bottles and pump equipment after each use." "If you notice that your breast is warm, hard, or red, stop feeding on that side and pump from that breast instead." "Wash your hands thoroughly, and let your breasts dry after each feeding."
"Wash your hands thoroughly, and let your breasts dry after each feeding." Explanation: Handwashing is one of the best ways to prevent infection. If the woman feels that her breast is warm, hard, or red, she should increase the amount of breastfeeding from that side. It is not necessary to sterilize bottles and pumping equipment after each use. Normal dish washing is sufficient. Keeping the breasts exposed to the air to dry will aid in preventing infection
A school health nurse is providing education to a group of adolescents regarding the proper procedure for male condom use. The nurse knows the teaching has been effective when which statement is made by a student? "Withdraw the penis erect, holding the condom firmly against the penis." "Use only petroleum-based lubricants, such as body lotion or massage oil." "It is important to put the condom on just before the penis is erect." "Ensure your condom is always available, so store condoms in your wallet."
"Withdraw the penis erect, holding the condom firmly against the penis." Explanation: The teaching guidelines for proper condom use include: ensure the condom has been stored in a cool, dry place away from direct sunlight. Do not store condoms in wallet; put the condom on before any genital contact; put the condom on when penis is erect; ensure adequate lubrication during intercourse. If external lubricants are used, use only water-based lubricants. Oil-based or petroleum-based lubricants, such as body lotion or massage oil, can weaken latex condoms. Withdraw while penis is still erect, and hold condom firmly against base of penis. Remove carefully to ensure no semen spills out.
How should the nurse instruct a woman to perform a breast self-examination? Select all that apply. "Look for any changes in shape, size, contour, or symmetry between the breasts, as well as any skin discoloration." "You will need to visually inspect both breasts and palpate them for changes." "It doesn't matter which pattern you use to palpate the breast as long as you cover the entire breast." "Use the pads of your first two fingers on the right hand for the right breast." "Use two different degrees of pressure: light for the skin and hard for the bone."
"You will need to visually inspect both breasts and palpate them for changes." "Look for any changes in shape, size, contour, or symmetry between the breasts, as well as any skin discoloration." "It doesn't matter which pattern you use to palpate the breast as long as you cover the entire breast." Explanation: To palpate the breasts, the woman should use the pads of three fingers from the opposite hand to the opposite breast (left to right). The nurse should instruct the woman to do three different levels of pressure, light (skin and tissue), medium (tissue), and hard (bone).
A nurse is preparing a presentation on breast cancer for a local community group. When describing the age group estimated to have the highest risk, which group would the nurse cite? 30 to 39 years of age 60 to 69 years of age 50 to 59 years of age 40 to 49 years of age
60 to 69 years of age Explanation: The age group estimated to be at highest risk for breast cancer is ages 60 to 69 with an estimated risk of 1 out of 29. Those between ages 30 and 39 years have a 1 in 233 chance; those between ages 40 and 49 years have a 1 in 69 chance; and those between ages 50 and 59 have a 1 in 42 chance.
A nurse is preparing a presentation on breast cancer for a local community group. When describing the age group estimated to have the highest risk, which group would the nurse cite? 40 to 49 years of age 30 to 39 years of age 60 to 69 years of age 50 to 59 years of age
60 to 69 years of age Explanation: The age group estimated to be at highest risk for breast cancer is ages 60 to 69 with an estimated risk of 1 out of 29. Those between ages 30 and 39 years have a 1 in 233 chance; those between ages 40 and 49 years have a 1 in 69 chance; and those between ages 50 and 59 have a 1 in 42 chance.
A nurse is preparing for a class discussion on sexually transmitted infections (STIs) to be given at a local high school. Which would the nurse include as a discussion priority? College students are more likely to engage in risky sexual behaviors leading to an STI. Adolescents and young adults are the largest age group diagnosed with an STI. Adults aged 21 to 30 years are at greater risk of contracting an STI. More single mothers are diagnosed with an STI causing sterility.
Adolescents and young adults are the largest age group diagnosed with an STI. Explanation: Individuals aged 15 to 24 years represent almost half of all cases of new STIs. Four in ten sexually active teen girls, not single mothers, have an STI that can cause infertility. In the United States, teens who are sexually active, not college-aged students, experience high rates of STIs.
A nurse is working at a cancer treatment center and is developing programs for specific ethnic groups related to breast cancer. The nurse would target which ethnic group because it has the highest breast cancer mortality rate in the United States? African American Caucasian Native American Hispanic
African American Explanation: Although the incidence of breast cancer is highest in Caucasians, African American women have a higher breast cancer mortality rate at every age and a lower survival rate than any other racial or ethnic group.
A nurse is developing a plan of care for a woman who is a victim of abuse. Which action would be most appropriate for the nurse to include in the plan? Allow the woman to participate in her care. Take the lead in providing the interventions quickly. Provide an overview of the procedures to be done. Make the decisions for the woman.
Allow the woman to participate in her care. Explanation: Active participation in care is critical because it promotes feelings of control. The victim should be allowed to actively participate in her care and decision making. The nurse should offer step-by-step explanations of procedures to alleviate her fears and to demonstrate a caring attitude. The nurse should let the woman set the pace of the nursing interventions.
A nurse is performing a physical examination of a pregnant woman. As she is examining her, she notices a bruise on her abdomen. Which action should the nurse take? Make a note in the client's chart regarding the finding, and plan to observe for other signs of abuse in the future. Ask the client to account for the bruise. Assume that the bruise is from intimate partner violence, and call the police while the client is still in the room. Assume that the bruise is from an accident and not worry about it.
Ask the client to account for the bruise. Explanation: Many women seen in emergency departments are there because they have been maltreated by their intimate partner. Common injuries suffered include burns, lacerations, bruises, and head injuries. Asking all women at physical examinations to account for any bruise they have helps detect physical maltreatment. The nurse should not assume that the bruise is just the result of an accident or that it is the result of intimate partner violence; she should question the client to learn more. Depending on how the client responds, it may be appropriate to make a note in the client's chart or to take some other action to help protect the client.
A woman comes to a local community health care facility with her partner. She has a broken arm and bruises on the face that she reports were caused by a fall. The nature of the injuries, however, causes the nurse to be convinced that this is a case of physical abuse. Which intervention should the nurse perform? Question the client about the injury in front of the partner. Tell the partner to leave the room immediately. Ask the partner directly if he was responsible. Attempt to interview the woman in private.
Attempt to interview the woman in private. Explanation: If the nurse suspects physical abuse, the nurse should attempt to interview the woman in private. Many abusers will not leave their partners for fear of being reported. The nurse should use subtle ways of doing this, such as telling the woman a urine specimen is required and showing her the way to the restroom, providing the nurse and client some private time. Asking the partner directly if he was responsible will not help because the partner may not admit his culpability. Telling the partner to leave the room immediately may rouse the suspicions of the partner. Questioning the client about the injury in front of the partner may trigger another abusive episode and should be avoided. Precaution should be taken to prevent the abuser from punishing the woman when she returns home.
After teaching a client diagnosed with candidiasis about preventative measures, the nurse determines that the teaching was effective when the client states she will take which action? Avoid exposure to sun. Avoid tight pants. Exercise to prevent fatigue. Use sunscreen regularly.
Avoid tight pants. Explanation: The nurse should inform the client to avoid tight pants to prevent recurrence of candidiasis. Clients with systemic lupus erythematosus are advised to avoid exposure to sun, use sunscreen regularly, and exercise to prevent fatigue
A client is receiving ceftriaxone as treatment for gonorrhea. What would be most important for the nurse to emphasize to the client? Avoiding alcohol consumption Reporting signs of an oral yeast infection Taking the drug on an empty stomach Using a sunscreen when outside
Avoiding alcohol consumption Explanation: If alcohol is ingested when taking ceftriaxone, the client can experience a disulfiram-like reaction. Therefore the nurse would need to emphasize avoiding alcohol consumption. Taking the drug on an empty stomach may be appropriate but not the most important consideration. Using a sunscreen would be appropriate if the client was receiving doxycycline or tetracycline. Reporting the appearance of an oral yeast infection would be appropriate for a client receiving tetracycline.
When preparing for a class on breast cancer, the nurse should explain which nonmodifiable risk factors? Select all that apply. failing to breastfeed infants high-fat dietary intake menarche at age 11 being a 52-year-old female BRCA-1 gene
BRCA-1 gene menarche at age 11 being a 52-year-old female Explanation: Risk factors can be divided into those that cannot be changed (nonmodifiable) and that that can (modifiable). Nonmodifiable risk factors include gender, age (>50 years old), genetic mutations, personal history of ovarian or colon cancer, early menarche (<12 years old) and race (higher in Caucasian women) just to name a few. Failing to breastfeed, high fat dietary intake, and lack of exercise are examples of modifiable risk factors.
When preparing for a class on breast cancer, the nurse should explain which nonmodifiable risk factors? Select all that apply. failing to breastfeed infants menarche at age 11 high-fat dietary intake being a 52-year-old female BRCA-1 gene
BRCA-1 gene menarche at age 11 being a 52-year-old female Explanation: Risk factors can be divided into those that cannot be changed (nonmodifiable) and that that can (modifiable). Nonmodifiable risk factors include gender, age (>50 years old), genetic mutations, personal history of ovarian or colon cancer, early menarche (<12 years old) and race (higher in Caucasian women) just to name a few. Failing to breastfeed, high fat dietary intake, and lack of exercise are examples of modifiable risk factors.
A young client desires to know her risk of developing breast carcinoma. She has a positive family history of breast carcinoma. The nurse would suggest that she should undergo which diagnostic test? BRCA-1 genetic marker DNA ploidy status digital mammography fine-needle biopsy
BRCA-1 genetic marker Explanation: Individuals with BRCA1 and BRCA2 mutations have a 75% lifetime risk of breast cancer and a 30% lifetime risk of ovarian cancer. The genetic influences of BRCA1 and BRCA2 are recognized to be a risk factor for developing breast carcinoma among family members. DNA ploidy status is used to confirm a malignant breast mass. Digital mammography is used to screen for breast masses. A fine-needle biopsy is used to identify if a mass is benign or malignant.
A nurse is completing a health history with a newly admitted client. During the interview, the client presents with an angry affect and states, "If my doctor did a good job, I would not be here right now!" What is the nurse's best response? Smile and say, "Don't worry, I am sure the physician is doing a good job." Stand and say, "I can see this interview is making you uncomfortable, so we can continue later." Be silent and allow the client to continue speaking when ready. Nod and say, "I agree. If I were you, I would get a new doctor."
Be silent and allow the client to continue speaking when ready. Explanation: When clients are angry or crying, the best nursing response is to remain nonjudgmental, allow them to express their emotions, and return later with a follow-up regarding their legitimate complaints. Therefore, staying silent and allowing the client to continue speaking when ready is the most appropriate response in this scenario. Giving false reassurance, agreeing, giving advice, or avoiding the subject are traps that block or hinder verbal communication.
A client is being discharged from the gynecological unit after treatment for an acute pelvic inflammatory disease (PID). What priority instruction regarding disease management should the nurse include? Discuss the necessity of completing the antibiotic therapy. Provide the client with brochures on sexually transmitted disease prevention. Arrange for follow-up visits to her health care provider. Refer the client to the women's sexual health clinic.
Discuss the necessity of completing the antibiotic therapy. Explanation: It is the priority that the client understands the need to finish the antibiotic therapy required to treat PID in order to eradicate the offending bacterial infection. The STI brochures may be appropriate, but they are not the priority and neither is arranging for follow-up health care provider visits. If the client can access the women's health clinic, a referral can be made, but it is not the priority.
A 52-year-old female client with an estrogen receptors positive (ER+) breast cancer is undergoing hormonal therapy. While taking a selective estrogen receptor modulator (SERM), the client begins to experience hot flashes. What should the nurse do next? Notify the client's health care provider. Document the hot flash in the client's chart. Instruct the client to stop taking the SERM. Assess the client's blood pressure.
Document the hot flash in the client's chart. Explanation: When caring for a client who is being administered selective estrogen receptor modulator, the nurse should monitor for side effects such as hot flashes, vaginal discharge, bleeding, and cataract formation. Hot flashes are an expected side effect of SERM; therefore, the nurse should document the finding in the chart.
When describing the process of fertilization, the nurse would explain that it normally occurs in which structure? Endometrium Fallopian tube Vagina Cervix
Fallopian tube Explanation: Fertilization normally occurs in the fallopian tube. Once fertilized the ovum proceeds down the uterus and attaches itself in the endometrium. The vagina and cervix are not involved in fertilization.
A nurse caring for a 43-year-old client explains to the client that ovarian functions gradually decrease around this age. What is the implication of decreased ovarian function? Changes in sexual response Susceptibility to fractures Increases the risk of heart disease Inability to become pregnant
Inability to become pregnant Explanation: Because of the decrease in ovarian functions, the client loses the ability to become pregnant. Loss of estrogen makes the client susceptible to fractures and also increases the risk of heart disease. Changes in sexual response are usually related to physical changes in the vagina.
A client at 34 weeks' gestation has recently been diagnosed with human immunodeficiency virus (HIV). The client asks how HIV would be transmitted to the newborn. Which statement would be the nurse's best response? "The risk of your newborn being infected with HIV infection is about 1%." "It is not transmitted to your newborn as it is protected in the uterus." "It is only transmitted through the birth canal so a cesarean birth will be scheduled." It is recommended to formula-feed your newborn as it is transmitted through your breast milk."
It is recommended to formula-feed your newborn as it is transmitted through your breast milk." Explanation: An infected mother can transmit HIV infection to her newborn before or during birth and through breastfeeding.The risk of perinatal transmission of HIV from an infected mother to her newborn is about 25%. This risk falls to less than 1% if the mother receives antiretroviral therapy during pregnancy. HIV can be spread to the infant through breastfeeding. HIV-infected mothers should be counseled to avoid breastfeeding and use formula instead.
A nurse is reviewing various treatment methods with a client diagnosed with a cystocele. Which of the following would the nurse describe as a nonsurgical method? Select all that apply. Culporrhaphy Pessary Kegel exercises Perineorrhaphy Colpexin sphere
Kegel exercises Pessary Colpexin sphere Explanation: Nonsurgical methods for managing a cystocele include Kegel exercises to strengthen the pelvic floor muscles, pessaries to maintain position of the pelvic organs, and a Colpexin sphere, which supports the pelvic floor muscles and facilitates their exercise. A colporrhaphy is a surgical procedure. A perineorraphy is a surgical procedure used to repair perineal lacerations.
Which instruction should be given to a woman newly diagnosed with genital herpes? Use a water-soluble lubricant for relief of pruritus. Have your partner use a condom when lesions are present. Limit stress and emotional upset as much as possible. Obtain a Papanicolaou (Pap) test every 3 years
Limit stress and emotional upset as much as possible. Explanation: Stress, anxiety, and emotional upset seem to predispose a client to recurrent outbreaks of genital herpes. Sexual intercourse should be avoided during outbreaks, and a condom should be used between outbreaks; it is not known whether the virus can be transmitted at this time. During an outbreak, creams and lubricants should be avoided because they may prolong healing. Because a relationship has been found between genital herpes and cervical cancer, a Pap test is recommended every year.
The nurse who works in a woman's health clinic correctly identifies which key objectives for 2020 National Health Goals that addresses violence against women? Select all that apply. Reduce the annual rate of rape or attempted rape. Increase the rate of women's depression. Reduce the rate of physical assault by current or former intimate partners. Increase the rate of women's consumed calories. Reduce the amount of sodium added to prepared foods.
Reduce the rate of physical assault by current or former intimate partners. Reduce the annual rate of rape or attempted rape. Explanation: Two of the 42 objectives are to reduce the rate of physical assault by current or former intimate partners and to reduce the annual rate of rape or attempted rape. It would be desirable to decrease the rate of depression, decrease caloric intake due to the high incidence of obesity, and reduce sodium in diets but these are not goals of the 2020 National Health Goals.
A perimenopausal woman informs the nurse that she is having irregular vaginal bleeding. What should the nurse encourage the patient to do? Mention it to her physician during her next annual examination. Disregard this phenomenon because it is common during this life stage. See her gynecologist as soon as possible. Stop taking her Premarin (hormonal therapy).
See her gynecologist as soon as possible. Explanation: All women should be encouraged to have annual checkups, including a gynecologic examination. Any woman who is experiencing irregular bleeding should be evaluated promptly.
A nurse is communicating the plan of care to a client who is cognitively impaired. Which nursing actions facilitate this process? Select all that apply. The nurse maintains eye contact with the client. The nurse gives lengthy explanations of the care that will be given. The nurse shows patience with the client and gives the client time to respond. The nurse keeps communication simple and concrete. The nurse communicates in a busy environment to hold the client's attention. If there is no response, the nurse does not repeat what is said and takes a break.
The nurse maintains eye contact with the client. The nurse shows patience with the client and gives the client time to respond. The nurse keeps communication simple and concrete. Explanation: There are several nursing actions that would be appropriate to facilitate. The nurse would maintain eye contact with the client. The nurse shows patience and gives the client time to respond. The nurse keeps communication simple and concrete. The nurse would not communicate in a busy environment because this could be distracting to the client. The nurse would not give lengthy explanations to the client regarding the care to be given. The nurse would repeat the information if no response was shared by the client.
At a health education class for teenagers, the nurse discusses the sexually transmitted infection chlamydia trachomatis. Which information would the nurse most likely include? This infection is lifelong as it cannot be treated with medication. Antiviral drug regimes will cure this infection. The new recombinant human papillomavirus vaccine will prevent the infection. This infection is the most common infectious cause of infertility.
This infection is the most common infectious cause of infertility. Explanation: The young have the most to lose from acquiring STIs, since they may not reach their full reproductive potential. In women, chlamydia is linked with cervicitis, salpingitis, ectopic pregnancy, pelvic inflammatory disease, and infertility. It is likely the most common infectious cause of infertility in women. Recombinant human papillomavirus vaccine is for the HPV STI. Antibiotics will cure this STI only.
A nurse is caring for a client who was raped at gunpoint. The client does not want any photos taken of her injuries. The client also does not want the police to be informed about the incident even though state laws require reporting life-threatening injuries. Which intervention should the nurse perform to document and report the findings of the case? Document only descriptions of medical interventions taken. Obtain photos to substantiate the client's case in a court of law. Respect the client's opinion and avoid informing the police. Use direct quotes and specific language.
Use direct quotes and specific language. Explanation: The nurse should use direct quotes and specific language as much as possible when documenting. The nurse should not obtain photos of the client without informed consent. The nurse should, however, document the refusal of the client to be photographed. Documentation must include details as to the frequency and severity of abuse and the location, extent, and outcome of injuries, not just a description of the interventions taken. The nurse is required by law to inform the police of any injuries that involve knives, firearms, or other deadly weapons or that present life-threatening injuries.
A 13-year-old immigrant from Asia is admitted to the health care facility with vaginal bleeding. A genital examination reveals unhealed circumcision wounds. The client can understand limited English but cannot speak the language fluently. The service of an interpreter is employed. What should the nurse keep in mind when interacting with this client? She is still a child, so the nurse should convey important information in precise medical terms to ease understanding. Allow the interpreter to question the client directly to assist with data gathering. Condemn the cultural practice, and explain why it is wrong to the client. Use pictures and diagrams to supplement the questions and answers of the client's understanding.
Use pictures and diagrams to supplement the questions and answers of the client's understanding. Explanation: The nurse should use pictures and diagrams to ensure that the client understands what is being asked and explained. Instead of using medical terms, the nurse should use simple, accurate terms as much as possible. Condemning the practice will only alienate the girl and serve no useful purpose.
A nurse is caring for a client who has just given birth to a baby. Which information should the nurse give the client regarding hepatitis B vaccination for the baby? Vaccine is administered only after the infant is at least 6 months old. Vaccine may not be safe for underweight or premature babies. Vaccine consists of a series of three injections given within 6 months. Vaccine is required only if mother is identified as high-risk for hepatitis B.
Vaccine consists of a series of three injections given within 6 months. Explanation: The hepatitis B vaccine consists of a series of three injections given within 6 months. The vaccine is safe and well tolerated by most babies, including those who are underweight or premature. Vaccines are given after birth in most hospitals, not 6 months later. All babies are vaccinated, not just those whose mothers are identified as at high risk for hepatitis.
In which client would the nurse suspect cancer? a 25-year-old with multiple small, round, and smooth lesions on both breasts that are painful during menstruation a 45-year-old with thickening in one breast with nipple irritation and retraction and a pink discharge a 40-year-old with nipple retraction and a watery discharge a 30-year-old with a mobile, rubbery, firm, well-circumscribed, nontender lump
a 45-year-old with thickening in one breast with nipple irritation and retraction and a pink discharge Explanation: The 25-year-old most likely has fibrocystic breast changes. The 30-year-old most likely has a fibroadenoma. The 40-year-old most likely has an intraductal papilloma. Further assessment is needed to confirm each of these, but this is what the nurse would first suspect.
The nurse is working with a perpetrator of abuse. The nurse educates the perpetrator that the behavior can be changed with intervention based on the understanding that it is: a learned behavior. caused by a disease. caused by a psychiatric condition. an inherited behavior.
a learned behavior. Explanation: Violence is a learned behavior that, without intervention, is self-perpetuating.
A client has been admitted with primary syphilis. Which signs or symptoms should the nurse expect to see with this diagnosis? a painless genital ulcer that appeared about 3 weeks after unprotected sex copper-colored macules on the palms and soles that appeared after a brief fever one or more flat, wartlike papules in the genital area that are sensitive to touch patchy hair loss and red, broken skin involving the scalp, eyebrows, and beard areas
a painless genital ulcer that appeared about 3 weeks after unprotected sex Explanation: A painless genital ulcer is a symptom of primary syphilis. Macules on the palms and soles after fever are indicative of secondary syphilis, as is patchy hair loss. Wartlike papules are indicative of genital warts
A nurse is attempting to complete an admission database. While taking the history, the nurse notices the client appears uncomfortable and slightly tachypneic. The nurse should: allow the client to set the pace. use only open-ended questions. tell the client to rest and allow a family member to answer. ask questions as quickly as possible.
allow the client to set the pace. Explanation: It would be ineffective to rush through a list of questions when obtaining a nursing history; it is more effective to let the client set the pace. Let the client know at the beginning of the interaction if time is limited so that the client does not feel that you are rushing because of a lack of concern or personal interest. Open-ended questions do not apply to "yes or no" answers. The client should be the person answering the questions unless unable to.
A 24-year-old female presents with vulvar pruritus accompanied by irritation, pain on urination, erythema, and an odorless, thick, acid vaginal discharge. She denies sexual activity during the last six months. Her records show that she has diabetes mellitus and uses oral contraceptives. Which category of antimicrobial medication is most likely to clear her symptoms? a quinolone antibiotic a penicillin antibiotic an azole antifungal agent an antiviral agent
an azole antifungal agent Explanation: The character of the discharge and the lack of recent sexual activity suggest infection with Candida, which can exist asymptomatically and flare up only if conditions, such as an imbalance in normal vaginal flora resulting from antibiotic treatment, diabetes, or oral contraceptive use, enable the fungus to proliferate. Candidiasis responds well to treatment with azole antifungal agents.
A client diagnosed with breast cancer is receiving chemotherapy. The nurse assesses the client for possible side effects of this therapy. Which side effect would the nurse report immediately to the health care provider? nausea diarrhea bone marrow suppression stomatitis
bone marrow suppression Explanation: Typical side effects include nausea and vomiting, diarrhea or constipation, hair loss, weight loss, stomatitis, fatigue, and immunosuppression. The most serious is bone marrow suppression (myelosuppression). This causes an increased risk of infection, bleeding, and a reduced red blood cell count, which can lead to anemia.
A nurse is caring for a client in the clinic. Which sign or symptom may indicate that the client has gonorrhea? diffuse skin rash dry, hacking cough painless chancre burning on urination
burning on urination Explanation: Burning on urination may be a symptom of gonorrhea or urinary tract infection. A dry, hacking cough is a sign of a respiratory infection, not gonorrhea. A diffuse rash may indicate secondary stage syphilis. A painless chancre is the hallmark of primary syphilis. It appears wherever the organisms enter the body, such as on the genitalia, anus, or lips.
A client is being treated for gonorrhea. Which agent would the nurse expect the primary care provider to prescribe? tetracycline levofloxacin ceftriaxone penicillin
ceftriaxone Explanation: The microorganism N. gonorrhoeae has become increasingly resistant to penicillin and tetracyclines, and fluoroquinolones (such as levofloxacin). Therefore, the current CDC (2006) recommendation for treating gonorrhea is a single intramuscular dose of a broad-spectrum cephalosporin such as ceftriaxone.
A nurse is required to assess a client reporting unusual vaginal discharge for bacterial vaginosis. For which classic manifestation of this condition should the nurse assess? characteristic "stale fish" odor dysfunctional uterine bleeding erythema in the vulvovaginal area heavy yellow discharge
characteristic "stale fish" odor Explanation: Symptoms of bacterial vaginosis include a characteristic "stale fish" odor and thin, white homogeneous vaginal discharge, not heavy yellow discharge. Dysfunctional uterine bleeding is a sign of chlamydia, not bacterial vaginosis. Erythema in the vulvovaginal area is a symptom of vulvovaginal candidiasis, not bacterial vaginosis.
A nursing diagnosis of Risk for impaired tissue integrity would be most appropriate for which client? client with endometriosis client with a vaginal packing in place client having reconstructive breast surgery client taking oral contraceptives
client having reconstructive breast surgery Explanation: Reconstructive breast surgery places the client at risk for insufficient blood supply to the muscle graft and skin, which can lead to tissue necrosis. Endometriosis or oral contraceptives are not generally associated with altered tissue perfusion. Pressure from vaginal packing can sometimes put pressure on the bladder neck and interfere with voiding.
A nurse touches the client's hand while discussing his diagnosis. This action is a(an): translation. communication channel. dynamic process. auditory channel.
communication channel. Explanation: Communication channel is the carrier of the message; touch can be a channel.
A nurse is conducting a discussion group at a local women's health center about violence and women. The nurse would include that women are at a higher risk for violence at which time? during pregnancy if they leave the abuser on paydays during winter
during pregnancy Explanation: Women are at a higher risk for violence during pregnancy. Recent research findings indicate that having children does not protect women. They are more vulnerable during this time, and the abusers take advantage of it.
Which finding would the nurse most likely find in a male diagnosed with a chlamydia trachomatis infection? hematuria erectile dysfunction painful ejaculation dysuria
dysuria Explanation: A male with the diagnosis of chlamydia will first experience dysuria as the primary symptom. The other symptoms listed do not correlate to men with the diagnosis of chlamydia
When developing a program for STI prevention, which action would need to be done first? interfering with the mode of transmission educating on how to promote sexual health getting individuals to change their behaviors increasing the availability of resources
educating on how to promote sexual health Explanation: The key to successful treatment and prevention of STIs is education to promote sexual health. Behavior changes, increasing the availability of resources, and interfering with modes of transmission are important, but all of these require education.
The primary care provider has just informed the client that her breast biopsy is positive for carcinoma. One of the nurse's first responsibilities is to assist with: education. psychiatric issues. treatment. telling the client her options.
education. Explanation: The primary care provider will ultimately be responsible for treatment and deciding the client's options. The nurse will assist by helping the woman to prioritize the voluminous amount of information given to her so she can make informed decisions. The nurse should prepare an individual packet of information and review it with the client
The primary care provider has just informed the client that her breast biopsy is positive for carcinoma. One of the nurse's first responsibilities is to assist with: telling the client her options. treatment. education. psychiatric issues.
education. Explanation: The primary care provider will ultimately be responsible for treatment and deciding the client's options. The nurse will assist by helping the woman to prioritize the voluminous amount of information given to her so she can make informed decisions. The nurse should prepare an individual packet of information and review it with the client.
Which type of elder abuse involves harm of self-worth? neglect emotional abandonment physical
emotional Explanation: The six types of elder abuse are physical (injury by hitting, kicking, pushing, slapping, burning, and so on), sexual (unconsented sexual act), emotional (harm of self-worth or emotional well-being), neglect (failure to meet the older adult's basic needs of shelter, food, and so on), abandonment (leaving an older adult alone and no longer providing care), and financial (illegally misusing money, property, or assets).
The nurse who counsels women who suffer from abuse understands that abuse can come in which different forms? Select all that apply. sexual abuse emotional abuse financial abuse spiritual abuse physical abuse
emotional abuse physical abuse financial abuse sexual abuse Explanation: Abusers may use whatever it takes to control a situation—from emotional abuse to physical assault. The different types of abuse include emotional, physical, financial, and sexual. Although a person could put down someone's religion and/or keep them from worshipping, there is not a distinct abuse labeled as spiritual abuse at this time.
The nurse who counsels women who suffer from abuse understands that abuse can come in which different forms? Select all that apply. spiritual abuse financial abuse physical abuse emotional abuse sexual abuse
emotional abuse physical abuse financial abuse sexual abuse Explanation: Abusers may use whatever it takes to control a situation—from emotional abuse to physical assault. The different types of abuse include emotional, physical, financial, and sexual. Although a person could put down someone's religion and/or keep them from worshipping, there is not a distinct abuse labeled as spiritual abuse at this time.
While caring for a client who is being treated for severe pelvic inflammatory disease (PID), the nurse insists on keeping the client in a semi-sitting position. The nurse advises this in order to: facilitate pelvic drainage and minimize the upward extension of the infection. facilitate easy distraction of the client. prevent movement that may increase pain. prevent nosocomial infections to other clients.
facilitate pelvic drainage and minimize the upward extension of the infection. Explanation: While caring for a client hospitalized with PID, the nurse has to reduce the risk of the systemic spread of pathogenic microorganisms. The client must be advised to keep the upper body elevated; this facilitates pelvic drainage and minimizes the upward extension of infection.
A nurse is assigned to educate a group of women on cancer awareness. Which risk factors for breast cancer are modifiable? Select all that apply. early menarche or late menopause not having children until after age 30 postmenopausal use of estrogen and progestins previous abnormal breast biopsy failing to breastfeed for up to a year after pregnancy
failing to breastfeed for up to a year after pregnancy postmenopausal use of estrogen and progestins not having children until after age 30 Explanation: The modifiable risk factors for breast cancer are postmenopausal use of estrogen and progestins, not having children until after the age of 30, and failing to breastfeed for up to a year after pregnancy. Early menarche or late menopause and previous abnormal breast biopsy are the nonmodifiable risk factors for breast cancer.
What is the most common breast mass in women? intraductal papilloma mastitis fibroadenoma duct ectasia
fibroadenoma Explanation: A fibroadenoma is a benign mass in the breast. It is the most common breast mass among women.
What is the most common breast mass in women? fibroadenoma duct ectasia intraductal papilloma mastitis
fibroadenoma Explanation: A fibroadenoma is a benign mass in the breast. It is the most common breast mass among women
Which occurrence is a biologic indicator of posttraumatic stress disorder (PTSD)? flashbacks memory difficulties auditory hallucinations a feeling of unreality about oneself
flashbacks Explanation: Biologic indicators, such as elevated pulse and blood pressure, sleep and appetite disturbances, exaggerated startle responses, flashbacks, and nightmares, may suggest PTSD or depression. Signs and symptoms of dissociation include memory difficulties, a feeling of unreality about oneself or events, a feeling that a familiar place is strange and unfamiliar, auditory and visual hallucinations, and evidence of having done things without remembering them
Which occurrence is a biologic indicator of posttraumatic stress disorder (PTSD)? auditory hallucinations a feeling of unreality about oneself flashbacks memory difficulties
flashbacks Explanation: Biologic indicators, such as elevated pulse and blood pressure, sleep and appetite disturbances, exaggerated startle responses, flashbacks, and nightmares, may suggest PTSD or depression. Signs and symptoms of dissociation include memory difficulties, a feeling of unreality about oneself or events, a feeling that a familiar place is strange and unfamiliar, auditory and visual hallucinations, and evidence of having done things without remembering them.
A nurse is caring for clients who have a history of genital herpes infection. The client most at risk for an outbreak of genital herpes is the client who reports: headache and fever. dysuria and lymphadenopathy. genital pruritus and paresthesia. vaginal and urethral discharge.
genital pruritus and paresthesia. Explanation: Pruritus and paresthesia as well as redness of the genital area are prodromal symptoms of recurrent herpes infection. These symptoms occur 30 minutes to 48 hours before the lesions appear. Headache and fever are symptoms of viremia associated with the primary infection. Vaginal and urethral discharge is also a local sign of primary infection. Dysuria and lymphadenopathy are local symptoms of primary infection that may also occur with recurrent infection.
A nurse needs to assess a female client for primary stage herpes simplex virus (HSV) infection. For which symptom related to this condition should the nurse assess? rashes on the face genital vesicular lesions loss of hair or alopecia yellow-green vaginal discharge
genital vesicular lesions Explanation: Genital herpes simplex is characterized by lesions, frequently located on the vulva, vagina, and perineal areas. Rashes on the face are not symptoms of HSV. Alopecia is one of the symptoms of syphilis not of primary HSV. Vaginal discharge during the primary stage of herpes is mucopurulent not yellow-green.
A young woman comes to the walk-in clinic seeking treatment for chronic chlamydia trachomatis. Which finding is most likely because it often correlates with this diagnosis? anemic disorder central nervous system disorder gonorrhea liver disease
gonorrhea Explanation: There is a common co-infection of chlamydia and gonorrhea when chlamydia is not treated with the necessary antibiotic medication combination. Anemia does not correlate with chlamydia, and there is no evidence that it precipitates liver disease. CNS disorders would be from syphilis.
A young refugee has come to the clinic for medical care. On examination, the nurse discovers she underwent female genital cutting as a young girl. The nurse recognizes this practice is primarily based on: her religion. her culture. her choice. punishment.
her culture. Explanation: The exact origins of FGC are not known. It is not mandated by any religion and predates both Christianity and Islam. In various cultures, it can indicate different purposes, such as a rite of passage, to decrease a woman's sexual desires, or ensure her chastity.
The nurse is reviewing the history and physical exam of a woman who has come to the clinic for a routine physical. Which factor would the nurse identify as increasing the client's risk for breast cancer? 39 years of age Asian race history of ovarian cancer menarche at age 14
history of ovarian cancer Explanation: A personal history of ovarian cancer is considered a risk factor for breast cancer. Typically, breast cancer is associated with aging (women over 50 years of age). Breast cancer is more common in Caucasian women, but African-American women are more likely to die of it. Early menarche (before 12 years of age) or late onset of menopause (after age 55 years) is associated with an increased risk for breast cancer.
The nurse is reviewing the history and physical exam of a woman who has come to the clinic for a routine physical. Which factor would the nurse identify as increasing the client's risk for breast cancer? Asian race 39 years of age history of ovarian cancer menarche at age 14
history of ovarian cancer Explanation: A personal history of ovarian cancer is considered a risk factor for breast cancer. Typically, breast cancer is associated with aging (women over 50 years of age). Breast cancer is more common in Caucasian women, but African-American women are more likely to die of it. Early menarche (before 12 years of age) or late onset of menopause (after age 55 years) is associated with an increased risk for breast cancer.
The nurse is aware of three different phases in the cycle of violence. Which is not one of those phases? battering incident tension-building phase hopeless stage honeymoon phase
hopeless stage Explanation: Women abused by their intimate partners appear hopeless. They often exhibit behaviors that demonstrate depression and ambivalence toward their abuser. However, hopelessness is not part of the cycle of violence. With the cycle of violence there is often a pattern: a tension-building phase, a battering incident, and a honeymoon phase
The nurse is aware of three different phases in the cycle of violence. Which is not one of those phases? battering incident honeymoon phase tension-building phase hopeless stage
hopeless stage Explanation: Women abused by their intimate partners appear hopeless. They often exhibit behaviors that demonstrate depression and ambivalence toward their abuser. However, hopelessness is not part of the cycle of violence. With the cycle of violence there is often a pattern: a tension-building phase, a battering incident, and a honeymoon phase.
A group of students is reviewing class material on sexually transmitted infections in preparation for a test. The students demonstrate understanding of the material when they identify which cause of condylomata? human papillomavirus Treponema pallidum Haemophilus ducreyi bacillus herpes virus
human papillomavirus Explanation: Genital warts or condylomata are caused by the human papilloma virus (HPV). Herpes virus causes genital herpes. Treponema pallidum is the cause of syphilis. Haemophilus ducreyi bacillus is the cause of chancroid.
What is the most common viral infection? trichomoniasis chlamydia gonorrhea human papillomavirus (HPV)
human papillomavirus (HPV) Explanation: HPV infection is the most common viral infection. Millions of Americans are infected with HPV, many unaware that they carry the virus.
A nurse communicating with a client states, "I will be changing your dressing, but we have plenty of time to talk first." She is already wearing sterile gloves and a mask and is busy working with her back to the client. The nurse is conveying a (an) functional focus. congruent relationship. incongruent relationship. therapeutic relationship.
incongruent relationship. Explanation: What the nurse is communicating verbally and nonverbally are incongruent with each other. Even though the nurse is verbally saying that he or she has time to talk, the nurse's nonverbal actions demonstrate that he or she is ready to perform the procedure. In addition, the back turned to the client while speaking demonstrates closed communication.
The nurse is providing care to a client who has had surgery as treatment for breast cancer. The nurse would be alert for the development of which complication? fibroadenoma breast abscess fibrocystic breast disease lymphedema
lymphedema Explanation: Lymphedema occurs in some women after breast cancer surgery. It causes disfigurement and increases the lifetime potential for infection and poor healing. Fibrocystic breast disease and fibroadenoma are two benign breast conditions that occur usually in premenopausal woman. Breast abscess is the infectious and inflammatory breast condition that is common among breastfeeding mothers.
The nurse is providing care to a client who has had surgery as treatment for breast cancer. The nurse would be alert for the development of which complication? fibrocystic breast disease breast abscess lymphedema fibroadenoma
lymphedema Explanation: Lymphedema occurs in some women after breast cancer surgery. It causes disfigurement and increases the lifetime potential for infection and poor healing. Fibrocystic breast disease and fibroadenoma are two benign breast conditions that occur usually in premenopausal woman. Breast abscess is the infectious and inflammatory breast condition that is common among breastfeeding mothers.
A nurse is preparing a presentation for a health fair about preventing breast cancer. Which suggestion would the nurse include? increasing the intake of caffeinated drinks opting for estrogen only replacement therapy during menopause delaying having children until after age 30 maintaining an ideal weight
maintaining an ideal weight Explanation: Maintaining an ideal weight decreases the risk of breast cancer. Having no children or having children after age 30 is associated with an increased risk for breast cancer. Some breast tumors are hormone dependent, such that estrogen (or progesterone) enhances tumor growth. Women are advised to avoid the consumption of alcohol, not caffeine, because alcohol correlates with an increased risk of breast cancer.
A client is considering breast augmentation. What would the nurse recommend to the client to ensure that there are no malignancies? mastopexy ultrasound breast biopsy mammogram
mammogram Explanation: When caring for a client considering breast augmentation, the nurse should provide her with a general guideline to have a mammogram to verify that there are no malignancies. Mastopexy involves a breast lift for drooping breasts. Ultrasound or breast biopsy would not be necessary unless there was evidence of a problem
A woman who is 6 months postpartum calls the clinic and reports flu-like symptoms, an elevated temperature, and pain and redness throughout her left breast. What would the nurse suspect first? intraductal papilloma mastitis inflammatory breast cancer duct ectasia
mastitis Explanation: These symptoms most closely resemble mastitis. Mastitis usually occurs in the postpartum period while the woman is still breastfeeding. Mastitis is usually unilateral and is seen as a red, painful breast with elevated temperature and flu-like symptoms
A young woman presents with vaginal itching and irritation of recent onset. Her labia are swollen, and she has a frothy yellowish discharge with an unpleasant smell and a pH of 6.8. She has been celibate during the last six months and has been taking antibiotics for a throat infection. Which medication is most likely to clear her symptoms? valacyclovir azithromycin penicillin metronidazole
metronidazole Explanation: The character of the discharge, lack of recent sexual activity, and current antibiotic treatment point to infection with Trichomonas vaginalis, which can exist asymptomatically and flare up only if conditions, such as an imbalance in normal vaginal flora resulting from antibiotic treatment, enable the protozoan to proliferate. Trichomoniasis responds well to treatment with metronidazole.
Which medication is the most effective treatment for trichomoniasis? penicillin G benzathine azithromycin doxycycline metronidazole
metronidazole Explanation: The most effective treatment for trichomoniasis is metronidazole and tinidazole. Penicillin G benzathine is used for syphilis. Doxycycline and azithromycin are used in the treatment of chlamydia.
A male client appears in the walk-in clinic and requests treatment for trichomoniasis as his girlfriend was recently diagnosed with it. What medication would the health care provider most likely prescribe? penicillin G clotrimazole metronidazole acyclovir
metronidazole Explanation: Trichomoniasis is a common vaginal infection with the therapeutic management of metronidazole or tinidazole for both partners. Trichomoniasis is a common, curable sexually transmitted infection (STI) caused by a parasitic protozoa called Trichomonas.
What is the medication of choice for early syphilis? penicillin G benzathine ceftriaxone doxycycline tetracycline
penicillin G benzathine Explanation: A single dose of penicillin G benzathine intramuscular injection is the medication of choice for early syphilis or early latent syphilis of less than 1 year's duration. Clients who are allergic to penicillin are usually treated with doxycycline or tetracycline. Ceftriaxone is not the medication of choice for syphilis.
The nurse is preparing to administer medication therapy to a woman diagnosed with syphilis. The nurse would expect to administer: metronidazole. penicillin G. doxycycline. miconazole.
penicillin G. Explanation: Penicillin G is the drug of choice for treating syphilis. Miconazole is used to treat candidiasis. Metronidazole is used to treat trichomoniasis. Doxycycline is used to treat chlamydia.
When caring for an abused woman, the nurse uses the ABCDES framework to provide interventions. Which components are part of this framework? Select all that apply. reassurance that the woman is not alone in this situation clear documentation of the nurse's perception of the abuse plan of action and resources for safety for when the woman decides to leave maintenance of confidentiality of the information reported education about the cycle of violence and its escalation expression of the belief that there may be a reason for the violence
reassurance that the woman is not alone in this situation maintenance of confidentiality of the information reported education about the cycle of violence and its escalation plan of action and resources for safety for when the woman decides to leave Explanation: Use of the ABCDES framework provides direction: reassuring the woman that she is not alone; informing her of the belief that violence is not acceptable in any situation; ensuring her that information reported is confidential; documenting information factually and accurately; educating the woman about the cycle of violence and its escalation; and ensuring the woman's safety by providing her with resources and a plan of action to carry out when she decides to leave. Expressing an opinion that there may be a reason for the violence is never appropriate nor is documenting the nurse's own perception of what happened.
A nurse is caring for a client who presents with a skin infection. While obtaining the client's medical history, it is determined that the client is an intravenous drug abuser. To foster effective communication, the nurse should: ask the client for a urine specimen for urine drug abuse screening. remain honest, open, and frank. consult with the social worker regarding inpatient drug rehabilitation. ask if the client realizes the infection is a direct result of the drug abuse.
remain honest, open, and frank. Explanation: One key factor to effective communication is to be open, accepting, frank, respectful, and without prejudice. When a client feels that a nurse is being judgmental, the client might withhold significant information. You need to develop sensitivity to the unique challenges presented by each client. A urine drug screen may eventually be ordered but is not necessary at this time. There is no evidence the client wants drug rehabilitation at this time. There is no evidence that the skin infection is secondary to the drug abuse.
A woman is scheduled to undergo a modified radical mastectomy. Which information would the nurse include when describing this surgery to the client? sparing of the pectoral muscles and axillary lymph nodes wide excision of the tumor along with a 1-cm margin of normal tissue removal of breast tissue, axillary nodes, and some chest muscles the resulting concave appearance of the anterior chest
removal of breast tissue, axillary nodes, and some chest muscles Explanation: A modified radical mastectomy involves removal of breast tissue, the axillary nodes, and some chest muscles but not the pectoralis major muscle. The surgery will not produce a concave anterior chest. With a simple mastectomy, all breast tissue, the nipple, and the areola are removed, but the axillary nodes and pectoral muscles are spared. A lumpectomy, or breast-conserving surgery, involves the wide local excision of the tumor along with a 1-cm margin of normal tissue
A nurse working with abused women recognizes that one of the best interventions is to: confront the abuser. strengthen the woman's sense of control over her life. send the victim directly to a shelter for her safety. file charges against the abuser immediately.
strengthen the woman's sense of control over her life. Explanation: Providing reassurance and support to the victim of abuse is key. Appropriate actions can help victims to express their thoughts and feelings in constructive ways, manage stress, and move on with their lives. These victims need to understand that they are in control, and strengthening this understanding will greatly improve their chances of making changes.
A nurse is describing the cycle of violence to a group of women at a community clinic. The nurse determines that the women have understood the information when they identify which phase as usually lasting the longest? explosion of violence honeymoon acute battering tension building
tension building Explanation: Of the phases, the first phase, tension building, is usually the longest. Acute battering, in which there is the explosion of violence, and the honeymoon phase are not typically as long.
The nursing instructor is teaching about violence and informs the students about which of its distinct phases? Select all that apply. tension-building phase prehoneymoon phase honeymoon phase courting phase acute battering phase
tension-building phase acute battering phase honeymoon phase Explanation: In an abusive relationship, the cycle of violence comprises three distinct phases: the tension building phase, the acute battering phase, and the honeymoon phase.
The nursing instructor is teaching about violence and informs the students about which of its distinct phases? Select all that apply. acute battering phase courting phase prehoneymoon phase honeymoon phase tension-building phase
tension-building phase acute battering phase honeymoon phase Explanation: In an abusive relationship, the cycle of violence comprises three distinct phases: the tension building phase, the acute battering phase, and the honeymoon phase
Nurses sometimes have difficulty assessing women for violence. Which model refers to the screen protocol used to be the most thorough when assessing for violence? the SBAR model the SAVE model the RACE model the FACE model
the SAVE model Explanation: The SAVE model is a screening protocol that nurses can use when assessing women for violence. It stands for screen, ask, validate and evaluate. The SBAR is a reporting tool used by nurses when handing off clients. The FACE model is a pain scale used to evaluate pain in children. The RACE model is used when there is a fire.
The nurse is assessing a 15-year-old female who reports extreme itching in the genital area, dysuria, and foul-smelling, yellow, foamy, vaginal discharge. What would most likely be responsible for these symptoms? human papillomavirus herpes simplex II syphilis trichomoniasis
trichomoniasis Explanation: Trichomoniasis symptoms are vulvar itching and a malodorous foamy yellow vaginal discharge.
Copious amounts of frothy, greenish vaginal discharge would be a symptom of which infection? trichomoniasis gonorrhea candidasis Gardnerella vaginalis vaginitis
trichomoniasis Explanation: The discharge associated with infection caused by Trichomonas organisms is homogenous, greenish gray, watery, and frothy or purulent. The discharge associated with candidiasis is thick, white, and resembles cottage cheese in appearance while that associated with infection due to G. vaginalis is thin and grayish white, with a marked fishy odor. With gonorrhea, vaginal discharge is purulent when present but, in many women, gonorrhea produces no symptoms
The generation-to-generation continuum of violence refers to the fact that: violence is a learned behavior, and children who witness abuse are more likely to become abusers themselves. children who grow up in abusive homes almost always become abusers themselves unless they have professional intervention. violence is an innate behavior, and children become abusers because of external factors in their environment more often than in their family. children who grow up in an abusive home are less likely to be abusers themselves because they see first hand the devastation that violence can cause.
violence is a learned behavior, and children who witness abuse are more likely to become abusers themselves. Explanation: Violence is a learned behavior. Many abusers were abused themselves as children; however, not all children who were abused become abusers.
A woman comes to the clinic reporting intense pruritus and a thick curd-like vaginal discharge. On examination, white plaques on observed on the vaginal wall. The nurse suspects which condition? chlamydia trichomoniasis vulvovaginal candidiasis bacterial vaginosis
vulvovaginal candidiasis Explanation: Pruritus, a thick, curd-like vaginal discharge, and white plaques on the vaginal wall are characteristic of vulvovaginal candidiasis. Trichomoniasis is characterized by a heavy yellow or green or gray frothy or bubbly discharge. Bacterial vaginosis is characterized by a thin white homogeneous vaginal discharge. Chlamydia is usually manifested by a mucopurulent vagina discharge.
When teaching a woman diagnosed with genital ulcers, the nurse would include which measure? applying ice packs to the area for comfort drying lesions with a hair dryer set on high refraining from using condoms during sexual intercourse washing hands with soap and water after touching lesions
washing hands with soap and water after touching lesions Explanation: Hand washing with soap and water after touching lesions is essential to avoid autoinoculation. Extremes of temperature, such as ice or hot packs, to the genital area should be avoided. Drying the lesions is appropriate, but the hair dryer should be set on a low setting. Condoms should be used with all new or noninfected partners.
As part of a presentation on breast cancer being given to a local woman's group, the nurse describes the need for early detection through screening. Applying the guidelines from the American Cancer Society, the nurse would emphasize which recommendation? mammograms every 3 years for women between the ages of 20 and 39 years clinical breast examinations every 2 years for women over age 30 yearly mammograms for women over age 40 breast self-examination at least yearly for women over age 20
yearly mammograms for women over age 40 Explanation: The American Cancer Society recommends yearly mammograms for women over age 40. Clinical breast examinations are recommended every year starting at age 40. According to the American Cancer Society Breast Cancer Screening Guidelines, breast self-examination is optional.