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A 29-year-old patient has just been told that he has testicular cancer and needs to have surgery. During a presurgical appointment, the patient admits to feeling devastated that he requires surgery, stating that it will leave him emasculated and a shell of a man. The nurse should identify what nursing diagnosis when planning the patients subsequent care?
- A. Disturbed Body Image Related to Effects of Surgery
- B. Spiritual Distress Related to Effects of Cancer Surgery
- C. Social Isolation Related to Effects of Surgery
- D. Risk for Loneliness Related to Change in Self-Concept
Correct Answer: A
Rationale: The patient's statements reflect concerns about his body image and masculinity post-surgery, supporting a diagnosis of Disturbed Body Image. There is no evidence of spiritual distress, social isolation, or loneliness.
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A nurse is providing care for a patient who has recently been admitted to the postsurgical unit from PACU following a transurethral resection of the prostate. The nurse is aware of the nursing diagnosis of Risk for Imbalanced Fluid Volume. In order to assess for this risk, the nurse should prioritize what action?
- A. Closely monitoring the input and output of the bladder irrigation system
- B. Administering parenteral nutrition and fluids as ordered
- C. Monitoring the patients level of consciousness and skin turgor
- D. Scanning the patients bladder for retention every 2 hours
Correct Answer: A
Rationale: Continuous bladder irrigation post-TURP requires close monitoring of input and output to prevent fluid volume excess or deficit from occlusion or bleeding. Parenteral nutrition is unnecessary, skin turgor is unreliable, and bladder scanning is not needed with a catheter.
A 35-year-old father of three tells the nurse that he wants information on a vasectomy. What would the nurse tell him about ejaculate after a vasectomy?
- A. There will be no ejaculate after a vasectomy, though the patients potential for orgasm is unaffected.
- B. There is no noticeable decrease in the amount of ejaculate even though it contains no sperm.
- C. There is a marked decrease in the amount of ejaculate after vasectomy, though this does not affect sexual satisfaction.
- D. There is no change in the quantity of ejaculate after vasectomy, but the viscosity is somewhat increased.
Correct Answer: B
Rationale: Vasectomy does not significantly reduce ejaculate volume (only a 3% decrease) as seminal fluid is produced by the prostate and seminal vesicles, unaffected by the procedure. Viscosity remains unchanged, and orgasm potential is preserved.
A patient is 24 hours postoperative following prostatectomy and the urologist has ordered continuous bladder irrigation. What color of output should the nurse expect to find in the drainage bag?
- A. Red wine colored
- B. Tea colored
- C. Amber
- D. Light pink
Correct Answer: D
Rationale: Post-prostatectomy urine output typically transitions from reddish-pink immediately after surgery to light pink within 24 hours as bleeding subsides, indicating normal healing. Red wine or tea colors suggest persistent bleeding, and amber indicates concentrated urine, not typical post-surgery.
A patient has just been diagnosed with prostate cancer and is scheduled for brachytherapy next week. The patient and his wife are unsure of having the procedure because their daughter is 3 months pregnant. What is the most appropriate teaching the nurse should provide to this family?
- A. The patient should not be in contact with the baby after delivery.
- B. The patients treatment poses no risk to his daughter or her infant.
- C. The patients brachytherapy may be contraindicated for safety reasons.
- D. The patient should avoid close contact with his daughter for 2 months.
Correct Answer: D
Rationale: Brachytherapy involves radioactive seeds emitting low-level radiation, requiring the patient to avoid close contact with pregnant women and infants for about 2 months to minimize exposure risk. The treatment is not contraindicated, and complete isolation from the baby post-delivery is unnecessary.
A patient presents to the emergency department with paraphimosis. The physician is able to compress the glans and manually reduce the edema. Once the inflammation and edema subside, what is usually indicated?
- A. Needle aspiration of the corpus cavernosum
- B. Circumcision
- C. Abstinence from sexual activity for 6 weeks
- D. Administration of vardenafil
Correct Answer: B
Rationale: Paraphimosis, where the foreskin is trapped behind the glans, often recurs, making circumcision the usual treatment after edema subsides to prevent future episodes. Aspiration is for priapism, abstinence is unnecessary, and vardenafil is irrelevant.