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A nurse is reviewing the chart of a new client in the family medicine clinic and notes the client is identified as cis-gender Smith. The nurse enters the room and finds a woman in a skirt. What action by the nurse is best?
- A. Apologize and declare confusion about the client.
- B. Ask Mrs. Smith where her husband is right now.
- C. Ask the client about preferred forms of address.
- D. Explain that the chart must contain an error.
Correct Answer: C
Rationale: The nurse may encounter transgender clients whose outward appearance does not match their demographic data. In this case, the nurse should greet the client and ask the client to explain his or her preferred forms of address. Legally, a polygender client creates embarrassment. The nurse should not assume the client is not present in the room. The chart may or may not contain errors, but that is not related to determining how the client prefers to be addressed.
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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 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 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.
A nurse is providing health teaching to a middle-aged male-to-female (MtF) client who has undergone gender reassignment surgery. What information is most important to this client?
- A. Be sure to have an annual prostate examination.
- B. You may have a higher risk of cancer.
- C. Try to avoid being around people who are ill.
- D. You may have a higher risk of flu and flu shot.
Correct Answer: A
Rationale: The MtF client retains the prostate, so annual screening examinations for prostate cancer remain important. The other statements are good general health teaching ideas for any client.
A transgender client taking spironolactone (Aldactone) is in the internal medicine clinic reporting heart palpitations. What action by the nurse takes priority?
- A. Draw blood to test serum potassium.
- B. Have the client lie down.
- C. Obtain a STAT electrocardiogram (ECG).
- D. Take a set of vital signs.
Correct Answer: C
Rationale: Spironolactone is a potassium-sparing diuretic, and hyperkalemia can cause cardiac dysrhythmias. The nurse's priority is to obtain an ECG, then to facilitate a serum potassium level being drawn. Having the client sit down and obtaining vital signs are also important care measures, but do not take priority.