Nokea
A patient calls the clinic because of an unusually heavy menstrual flow. She tells the nurse that she has saturated two tampons in the past 2 hours. Which of the following amounts of blood loss should the nurse estimate from the patient's information?
- A. 10-20 mL
- B. 20-30 mL
- C. 30-40 mL
- D. 40-60 mL
Correct Answer: D
Rationale: The average tampon absorbs 20-30 mL. Since the patient saturated two tampons in 2 hours, the estimated blood loss is 40-60 mL.
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Which of the following questions should the nurse ask when assessing a patient who has a history of benign prostatic hyperplasia (BPH)?
- A. Have you noticed any unusual discharge from your penis?
- B. Has there been any change in your sex life in the last year?
- C. Do you find it hard to initiate your urinary stream?
- D. Have you been experiencing any difficulty in achieving an erection?
Correct Answer: C
Rationale: Enlargement of the prostate blocks the urethra, leading to urinary changes. Benign prostatic hyperplasia is a common problem of older men. It can alter normal urination, causing retention and difficulty in initiating the urinary stream. The other questions address possible problems with infection or sexual difficulties but would not be helpful in determining whether there were functional changes caused by BPH.
The nurse is assessing the sexual-reproductive functional health pattern for a patient. Which of the following questions is most useful in determining the patient's sexual orientation and risk factors?
- A. Do you have sex with men, women, or both?
- B. Which gender do you prefer to have sex with?
- C. What types of sexual activities do you prefer?
- D. Are you heterosexual, homosexual, or bisexual?
Correct Answer: A
Rationale: This question is the most simply stated and will increase the likelihood of obtaining the relevant information about sexual orientation and possible risk factors associated with sexual activity. A patient who prefers intercourse with women may also have intercourse at times with men. The types of sexual activities engaged in may not indicate sexual orientation. Many patients who have intercourse with both men and women do not identify themselves as homosexual or bisexual.
The nurse is assessing an older-adult male patient and the patient says that he does not respond to sexual stimulation the way he did when he was younger. Which of the following responses to the patient's comment is best?
- A. Many men need more sexual stimulation with aging.
- B. Interest in sex frequently decreases as men get older.
- C. Erectile dysfunction is a common problem with older men.
- D. Tell me more about how your sexual response has changed.
Correct Answer: D
Rationale: The initial response by the nurse should be further assessment of the problem. The other statements by the nurse are accurate but might not respond to the patient's concerns.
The nurse is assessing a patient who has amenorrhea with a weight of 41 kg. The patient makes all of the following statements. Which one indicates a need for immediate teaching by the nurse?
- A. I have not been able to eat much at all for the past three months.
- B. I drink at least three glasses of nonfat milk daily.
- C. I am not sexually active but currently have a boyfriend.
- D. I was recently treated for a sexually transmitted infection.
Correct Answer: A
Rationale: Not being able to eat much at all for the past three months indicates that the patient may be experiencing anorexia. Anorexia can cause amenorrhea. The other statements by the patient do not suggest any urgent teaching needs.
The nurse is providing teaching to a patient who is having an endometrial biopsy. Which of the following instructions should the nurse include?
- A. Plan to have someone drive you home after the procedure.
- B. Receive IV contrast solution during the procedure.
- C. Expect mild abdominal cramps after the procedure.
- D. Drink several glasses of fluids before the procedure.
Correct Answer: C
Rationale: An endometrial biopsy may cause mild abdominal cramping after the procedure due to uterine manipulation. IV contrast is not used, and there is no need for a driver or to drink fluids beforehand.