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A client has returned from the postanesthesia care unit after a vaginoplasty. What comfort measure does the nurse provide for this client?
- A. Apply ice to the perineum.
- B. Elevate the leg on pillows.
- C. Position the client on the left side.
- D. Raise the head of the bed.
Correct Answer: A
Rationale: Ice is applied to the perineum to reduce pain and discomfort. Elevating the legs on pillows is not recommended after a lengthy procedure in the lithotomy position, which predisposes the client to venous thromboembolism.
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The nurse is reviewing possible complications from a phalloplasty. What factors does the nurse include? (Select all that apply.)
- A. Infection of donor site
- B. Necrosis of the nonpenis
- C. Rectal perforation
- D. Urinary tract stenosis
- E. Vaginal infections
Correct Answer: A,B,D
Rationale: Complications from phalloplasty include infection or scarring of the donor site, necrosis, and stenosis of the urinary tract. Rectal perforation can occur with vaginoplasty, as can infections.
A client is preparing for gender reassignment surgery and will transition from male to female. The client is concerned about the possibility of having a voice change. What should the nurse tell the client?
- A. Ask if the client has considered vocal cord surgery to change the voice
- B. Refer the client for vocal therapy with speech-language pathology.
- C. Teach the client that there will be no effect on the client's voice.
- D. Tell the client that the use of hormones will eventually change the voice.
Correct Answer: B
Rationale: Male-to-female clients can consult with a speech-language pathologist for vocal training to help with intonation and pitch. While vocal surgery is possible, it may not be the best first option due to cost and invasiveness. Telling the client there will be no change in the voice does not give the client information to address the concern. While the hormones this client is taking will not affect the voice, simply stating that fact does not help the client manage this issue.
A transgender client is taking transdermal estrogen (Climara). What assessment finding does the nurse report immediately to the provider?
- A. Breast tenderness
- B. Headaches
- C. Red, swollen calf
- D. Swollen ankles
Correct Answer: C
Rationale: A red, swollen calf could be a manifestation of a deep vein thrombosis, a known side effect of estrogen. The nurse reports this finding immediately. The other manifestations are also side effects of estrogen, but do not need to be reported as a priority.
A client had a vaginoplasty under epidural anesthetic. Which action by the nurse is most important?
- A. Ensure that the urinary catheter is securely attached to the leg.
- B. Monitor the client for signs of urinary retention or bowel.
- C. Monitor the client's dressings and wound drainage.
- D. Position the Jackson-Pratt drain to the contralateral side.
Correct Answer: B
Rationale: Epidural anesthesia will cause the client to not be able to move (or feel) the legs for several hours. It is important to monitor the client closely and help the client to move in the dressing to get out of bed. Securing the catheter to the leg and monitoring dressings and drainage are important for any client after surgery. Positioning the drain to the contralateral side is not needed.
A student nurse is learning about the health care needs of lesbian, gay, bisexual, transgender, and queerquestioning (LGBTQ) clients. Which terms are correctly defined? (Select all that apply.)
- A. Gender dysphoria: Distress caused by incongruence between natal sex and gender identity
- B. Gender queer: A label used when gender identity does not conform to male or female
- C. Natal sex: The sex one is born with or is assigned at birth
- D. Transition: The process of changing one's gender presentation to align with gender identity
- E. Gender fluid: A gender identity that can change over time
Correct Answer: A,B,C
Rationale: Gender dysphoria is emotional distress caused by the incongruence between natal sex (sex assigned at birth) and gender identity. Gender queer is a label sometimes used by people whose gender identity does not fit within the binary of male or female. Natal sex refers to the sex assigned at birth. The term 'transition' in the provided options is incorrect as it refers to the process of changing one's gender presentation or physical characteristics to align with gender identity, not establishing a sexual identity. Gender fluid is a valid term for a gender identity that can shift over time, but it was not part of the original options.