Nokea
A 28-year-old client is diagnosed with endometriosis and is experiencing severe symptoms. Which actions by the nurse are the most appropriate at this time? (Select all that apply.)
- A. Reduce the pain by low-level heat.
- B. Discuss in detail the side effects of laparoscopic surgery.
- C. Reduce anxiety by relaxation techniques and education.
- D. Suggest resources such as the Endometriosis Association.
- E. Encourage the client to avoid all physical activity.
Correct Answer: A,C,D
Rationale: With endometriosis, pain is the predominant symptom, with anxiety occurring because of the diagnosis. Interventions should be directed to pain and anxiety relief, such as low-level heat, relaxation techniques, and education about the pathophysiology and possible treatment of endometriosis. The nurse could suggest resources like the Endometriosis Association. Discussing surgical side effects in detail is not appropriate without assessing the client's readiness, and avoiding all physical activity is not recommended as it may not help manage symptoms.
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A postmenopausal client is experiencing low back and pelvic pain, fatigue, and bloody vaginal discharge. What laboratory tests would the nurse expect to see ordered for this client if endometrial cancer is suspected? (Select all that apply.)
- A. Cancer antigens (CA-125)
- B. White blood cell (WBC) count
- C. Hemoglobin and hematocrit (H&H)
- D. Prothrombin time (PT)
Correct Answer: A,C
Rationale: Serum tumor markers such as CA-125 assess for metastasis, especially if elevated. H&H would evaluate the possibility of anemia, a common finding with postmenopausal bleeding with endometrial cancer. WBC count is not indicated since there are no signs of infection. The INR and PT are coagulation tests to measure the time it takes for a fibrin clot to form, used to evaluate coagulation in clients receiving oral warfarin.
A client has just returned from a total abdominal hysterectomy and needs postoperative nursing care. What action can the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Assess heart, toileting, and bowel sounds.
- B. Check the hemoglobin and hematocrit levels.
- C. Evaluate the dressing for drainage.
- D. Monitor the client for a urinary output.
Correct Answer: D
Rationale: The UAP is able to empty the urinary output from the catheter. The nurse would assess the heart, lung, and bowel sounds; check the hemoglobin and hematocrit levels; and evaluate the drainage on the dressing.
A client has recently been diagnosed with stage III endometrial cancer and asks the nurse for an explanation. What response by the nurse is correct about the staging of the cancer?
- A. The cancer has spread to the mucosa of the bowel and bladder.
- B. The cancer now involves the vagina or lymph nodes.
- C. The cancer now involves the cervix.
- D. The cancer is confined to the endometrium.
Correct Answer: B
Rationale: Stage III of endometrial cancer reaches the vagina or lymph nodes. Stage I is confined to the endometrium. Stage II involves the cervix, and stage IV spreads to the bowel or bladder mucosa and/or beyond the pelvis.
The client is emotionally upset about the recent diagnosis of stage IV endometrial cancer. Which action by the nurse is incorrect?
- A. Listen attentively to the client's concerns.
- B. Let the client alone for a long period of reflection time.
- C. Ask friends and relatives to limit their visits.
- D. Tell the client that an emotional response is unacceptable.
- E. Create an atmosphere of acceptance and discussion.
Correct Answer: D
Rationale: Discussion of a client's concerns about the presence of cancer and the potential for recurrence will provide emotional support and allay fears. Coping behaviors are encouraged with the support of friends and relatives. An emotional response should be accepted.
A 20-year-old client is interested in protection from the human papilloma virus (HPV) since she may become sexually active. Which response from the nurse is the most accurate?
- A. You are too old to receive an HPV vaccine.
- B. Either Gardasil or Cervarix can provide protection.
- C. You will need to have three injections over a span of 1 year.
- D. The most common side effect of the vaccine is itching at the injection site.
Correct Answer: B
Rationale: Current HPV vaccines are Gardasil and Cervarix, which should be given before the first sexual contact to protect against the highest risk HPV types associated with cervical cancer. The client is not too old since it is recommended that younger women, 19-26 years, should receive an HPV vaccine. The series consists of three injections over 6 months, not 1 year. Local pain and redness surrounding the injection site are very common, but this does not include itching.