Nokea
A client is being admitted for suspected toxic shock syndrome (TSS). Which of the following would be most important for the nurse to determine?
- A. Existence of menorrhagia
- B. Psychological trauma
- C. Use of superabsorbent tampons
- D. Use of oral contraceptives
Correct Answer: C
Rationale: TSS is commonly associated with the use of superabsorbent tampons that are not changed frequently and internal contraceptives that remain in place longer than necessary. Assessing the use of oral contraceptives, psychological trauma, or menorrhagia is not required for diagnosing the cause of TSS.
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The nurse is collecting assessment data on a client who is reporting a vaginal discharge that is cottage cheese-like in appearance. Which pathogen is the most likely cause for this symptom?
- A. Gonococci
- B. Candida albicans
- C. Trichomonas vaginalis
- D. Gardnerella vaginalis
Correct Answer: B
Rationale: Candida albicans is a yeast infection that presents with a thick, curdy white discharge. Gonococcus is the organism that causes gonorrhea and presents with a yellow, mucoppuntent discharge. Trichomonas vaginalis presents with a foamy, white foul-smelling discharge and Gardnerella vaginalis is a watery, fishy-smelling discharge.
While obtaining the history, the nurse learns the client's mother's was treated with diethylstilbestrol (DES) during her pregnancy. The nurse determines that this client is at risk for which of the following?
- A. Vulvar cancer
- B. Breast cancer
- C. Vaginal cancer
- D. Endometrial cancer
Correct Answer: C
Rationale: Vaginal cancer is associated with the risk factor of being born to mothers treated with DES during their pregnancy. The upper posterior third of the vagina is the most common site of vaginal cancer. Metastatic lesions may occur in the cervix or adjacent areas such as the vulva, uterus, or rectum. DES is not a risk factor associated with vulvar or breast cancers. Endometrial cancer occurs in women who take estrogens without the addition of progesterone for 5 or more years during and after menopause.
A client reports loss of interest in sexual relations and discomfort during intercourse. Which is the best response by the nurse?
- A. Don't worry, every woman goes through this.
- B. These are normal, manageable symptoms of menopause.
- C. You need to discuss this with your spouse.
- D. Hormome replacement therapy can resolve your symptoms.
Correct Answer: B
Rationale: Diminished libido and/or dyspareunia are common symptoms associated with perimenopause. Explaining that this can be a normal finding may help to alleviate worries for the client and provide hope for management of the symptoms. The nurse should avoid telling a client 'not to worry' or 'talk to someone else' because these can negate client feelings and shut down communication. HRT may not be recommended for this client.
The nurse is caring for a client hospitalized for pelvic inflammatory disease (PID) who is discovered to have a ruptured pelvic abscess. Which nursing action is the priority at this time?
- A. Prepare the client for surgery.
- B. Administer antibiotic therapy as prescribed.
- C. Provide intravenous fluid replacement.
- D. Encourage bed rest.
Correct Answer: A
Rationale: A ruptured pelvic abscess requires emergency surgery. Administering antibiotic therapy as prescribed, providing intravenous fluid replacement, and encouraging bed rest are all appropriate actions, but they are lower priority for a client with a ruptured pelvic abscess.
Which risk factor(s) supports the need for ovarian cancer screening? Select all that apply.
- A. Carrying genetic mutation for the disease
- B. Being nulliparous
- C. Family history of lung cancer
- D. Breastfeeding
- E. Use of oral contraceptives for 5 years or more
- F. Multiple full-term pregnancies
Correct Answer: A,B
Rationale: Woman who are nulliparous, have a family history of ovarian cancer, and/or carry a genetic mutation for it tend to develop ovarian cancer more often than others. Preventive measures recommended to lower the risk of ovarian cancer include having at least 2 full-term pregnancies, breastfeeding after pregnancies, and using oral contraceptives for 3 years or more. History of lung cancer is not a risk factor.