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A nursing student is learning how to perform sexual assessments using the PLISSIT model. According to this model, the student should begin an assessment by doing which of the following?
- A. Briefly teaching the patient about normal sexual physiology
- B. Assuring the patient that what he says will be confidential
- C. Asking the patient if he is willing to discuss sexual functioning
- D. Ensuring patient privacy
Correct Answer: D
Rationale: The correct answer is D: Ensuring patient privacy. In the PLISSIT model, ensuring patient privacy is crucial as it creates a safe and confidential environment for discussing sensitive topics like sexual health. This step helps build trust and allows the patient to feel comfortable sharing intimate details. Briefly teaching about normal sexual physiology (A) may come later in the assessment process. Assuring confidentiality (B) is important but doesn't address the immediate need for privacy. Asking if the patient is willing to discuss sexual functioning (C) assumes patient readiness without first establishing a private setting.
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A patient in her 30s has two young children and has just had a modified radical mastectomy with immediate reconstruction. The patient shares with the nurse that she is somewhat worried about her future, but she appears to be adjusting well to her diagnosis and surgery. What nursing intervention is most appropriate to support this patients coping?
- A. Encourage the patients spouse or partner to be supportive while she recovers.
- B. Encourage the patient to proceed with the next phase of treatment.
- C. Recommend that the patient remain optimistic for the sake of her children.
- D. Arrange a referral to a community-based support program.
Correct Answer: D
Rationale: The correct answer is D, which is to arrange a referral to a community-based support program. This option is the most appropriate because it offers the patient ongoing support from individuals who understand what she is going through. Community-based support programs can provide a safe space for the patient to share her feelings, connect with others in similar situations, and access additional resources for coping. This intervention focuses on providing the patient with adequate support beyond the immediate recovery period, which is crucial for long-term coping and adjustment.
Option A is incorrect as it may not consider the patient's individual needs for support beyond her spouse or partner. Option B may be premature as the patient might need time to process her diagnosis and surgery before moving on to the next phase of treatment. Option C may put undue pressure on the patient to maintain a specific emotional state for the sake of others, which may not be beneficial for her own coping and healing process.
A patient who has AIDS has been admitted for the treatment of Kaposis sarcoma. What nursing diagnosis should the nurse associate with this complication of AIDS?
- A. Risk for Disuse Syndrome Related to Kaposis Sarcoma B)Impaired Skin Integrity Related to Kaposis Sarcoma C)Diarrhea Related to Kaposis Sarcoma
- B. Impaired Swallowing Related to Kaposis Sarcoma
Correct Answer: B
Rationale: The correct answer is B) Impaired Skin Integrity Related to Kaposis Sarcoma. Kaposis sarcoma can cause skin lesions that may lead to impaired skin integrity due to tissue breakdown. The nurse should prioritize interventions to prevent infection and promote wound healing.
Choice A is incorrect because Disuse Syndrome is not directly related to Kaposis Sarcoma. Choice C, Diarrhea, is not a common complication of Kaposis Sarcoma. Choice D, Impaired Swallowing, is not typically associated with Kaposis Sarcoma.
The nurse is caring for a patient diagnosed with Parkinsons disease. The patient is having increasing problems with rising from the sitting to the standing position. What should the nurse suggest to the patient to use that will aid in getting from the sitting to the standing position as well as aid in improving bowel elimination?
- A. Use of a bedpan
- B. Use of a raised toilet seat
- C. Sitting quietly on the toilet every 2 hours
- D. Following the outlined bowel program
Correct Answer: B
Rationale: Correct Answer: B - Use of a raised toilet seat
Rationale: A raised toilet seat helps the patient with Parkinson's disease by providing additional height, making it easier for them to transition from sitting to standing. This aids in improving mobility and reducing the risk of falls. Furthermore, the raised seat can also promote proper positioning for bowel elimination, making the process more comfortable and effective.
Incorrect Choices:
A: Using a bedpan does not address the issue of transitioning from sitting to standing, nor does it aid in improving bowel elimination for the patient.
C: Sitting quietly on the toilet every 2 hours may not directly address the physical challenges the patient is facing in transitioning from sitting to standing.
D: Following the outlined bowel program is important, but it does not specifically address the physical support needed to transition from sitting to standing for a patient with Parkinson's disease.
A nurse providing prenatal care to a pregnant woman is addressing measures to reduce her postpartum risk of cystocele, rectocele, and uterine prolapse. What action should the nurse recommend?
- A. Maintenance of good perineal hygiene
- B. Prevention of constipation
- C. Increased fluid intake for 2 weeks postpartum
- D. Performance of pelvic muscle exercises Chapter 58: Breast Cancer: Breast cancer – risks factors, Diagnostic tests and management, Self Breast Exam, Perioperative care: Complications, Rehab, Discharge teaching
Correct Answer: D
Rationale: The correct answer is D, performance of pelvic muscle exercises. Pelvic muscle exercises, also known as Kegel exercises, help strengthen the pelvic floor muscles which support the bladder, uterus, and bowel. By strengthening these muscles, the risk of developing cystocele, rectocele, and uterine prolapse postpartum is reduced. It is a proactive approach to prevent these conditions.
Choice A, maintenance of good perineal hygiene, is important for preventing infections but does not specifically address the risk of pelvic organ prolapse. Choice B, prevention of constipation, is also important but does not directly target the muscle weakness that contributes to prolapse. Choice C, increased fluid intake for 2 weeks postpartum, is not as effective in preventing prolapse as pelvic muscle exercises.
In summary, pelvic muscle exercises are the most appropriate recommendation as they directly address strengthening the muscles that support the pelvic organs, reducing the risk of prolapse postpartum.
An oncology patient has begun to experience skin reactions to radiation therapy, prompting the nurse to make the diagnosis Impaired Skin Integrity: erythematous reaction to radiation therapy. What intervention best addresses this nursing diagnosis?
- A. Apply an ice pack or heating pad PRN to relieve pain and pruritis
- B. Avoid skin contact with water whenever possible
- C. Apply phototherapy PRN
- D. Avoid rubbing or scratching the affected area
Correct Answer: D
Rationale: Correct Answer: D - Avoid rubbing or scratching the affected area
Rationale:
1. Rubbing or scratching can further damage the already compromised skin integrity.
2. By avoiding rubbing or scratching, the patient reduces the risk of infection and delayed healing.
3. This intervention promotes skin healing and prevents worsening of the condition.
Summary:
A: Applying ice pack or heating pad may provide temporary relief but does not address the root cause of impaired skin integrity.
B: Avoiding skin contact with water is not necessary and may not directly improve skin integrity.
C: Phototherapy is not indicated for erythematous reactions to radiation therapy and may not address the issue.