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A patient has been diagnosed with endometriosis. When planning this patients care, the nurse should prioritize what nursing diagnosis?
- A. Anxiety related to risk of transmission
- B. Acute pain related to misplaced endometrial tissue
- C. Ineffective tissue perfusion related to hemorrhage
- D. Excess fluid volume related to abdominal distention
Correct Answer: B
Rationale: Endometriosis causes pain due to misplaced endometrial tissue, making acute pain a priority nursing diagnosis. It is not transmissible, so anxiety about transmission is irrelevant. Hemorrhage and fluid volume excess are not typical.
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When reviewing the electronic health record of a female patient, the nurse reads that the patient has a history of adenomyosis. The nurse should be aware that this patient experiences symptoms resulting from what pathophysiologic process?
- A. Loss of muscle tone in the vaginal wall
- B. Excessive synthesis and release of unopposed estrogen
- C. Invasion of the uterine wall by endometrial tissue
- D. Proliferation of tumors in the uterine wall
Correct Answer: C
Rationale: Adenomyosis involves the invasion of endometrial tissue into the uterine wall, causing symptoms. It is not related to vaginal muscle tone, unopposed estrogen, or tumor proliferation.
A patient has returned to the post-surgical unit after vulvar surgery. What intervention should the nurse prioritize during the initial postoperative period?
- A. Placing the patient in high Fowlers position
- B. Administering sitz baths every 4 hours
- C. Monitoring the integrity of the surgical site
- D. Avoiding analgesics unless the patients pain is unbearable
Correct Answer: C
Rationale: An important intervention for the patient who has undergone vulvar surgery is to monitor closely for signs of infection in the surgical site, such as redness, purulent drainage, and fever. The patient should be placed in low Fowlers position to reduce pain by relieving tension on the incision. Sitz baths are discouraged after wide excision of the vulva because of the risk of infection. Analgesics should be administered preventively on a scheduled basis to relieve pain and increase the patients comfort level.
A 14-year-old is brought to the clinic by her mother. The mother explains to the nurse that her daughter has just started using tampons, but is not yet sexually active. The mother states I am very concerned because my daughter is having a lot of stabbing pain and burning. What might the nurse suspect is the problem with the 14-year-old?
- A. Vulvitis
- B. Vulvodynia
- C. Vaginitis
- D. Bartholins cyst
Correct Answer: B
Rationale: Vulvodynia is a chronic vulvar pain syndrome with symptoms like burning and stabbing pain, often triggered by initial tampon use. Vulvitis is typically infectious. Vaginitis involves vaginal inflammation, and Bartholins cyst involves a blocked gland.
A 30-year-old patient has come to the clinic for her yearly examination. The patient asks the nurse about ovarian cancer. What should the nurse state when describing risk factors for ovarian cancer?
- A. Use of oral contraceptives increases the risk of ovarian cancer.
- B. Most cases of ovarian cancer are attributed to tobacco use.
- C. Most cases of ovarian cancer are considered to be random, with no obvious causation.
- D. The majority of women who get ovarian cancer have a family history of the disease.
Correct Answer: C
Rationale: Most cases of ovarian cancer are random, with only 5% to 10% having a familial connection. Oral contraceptives are associated with a reduced risk, and tobacco is not a major risk factor.
A patient is post-operative day 1 following a vaginal hysterectomy. The nurse has notes an increase in the patient's abdominal girth and the patient complains of bloating. What is not the nurses most appropriate action?
- A. Provide the patient an with an unsweetened, carbonated beverage.
- B. Apply a warm compress to the patient's lower abdomen.
- C. Provide an ice pack to apply to the patient's perineum and suprapubic region.
- D. Assist the patient into a prone position.
Correct Answer: B
Rationale: Applying a warm compress to the abdomen can relieve bloating and flatus post-hysterectomy. Carbonated beverages and ice packs are not recommended, and prone positioning may be uncomfortable.