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During the nurses assessment of a female patient, the patient reveals that she experienced sexual abuse when she was a young woman. What is the nurses most appropriate response to this disclosure?
- A. Reassure her that this information will be kept a secret.
- B. Begin the process of intensive psychotherapy.
- C. Encourage the patient to phone 911.
- D. Facilitate appropriate resources and referrals.
Correct Answer: D
Rationale: The nurse's primary roles in response to a disclosure of past sexual abuse are to provide empathy and arrange for appropriate resources and referrals, such as counseling or support services. Promising secrecy is inappropriate as confidentiality has limits, psychotherapy is beyond the nurse's scope, and calling 911 is unnecessary for a past event.
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The nurse is taking the sexual history of an adolescent who has come into the free clinic. What question best assesses the patients need for further information?
- A. Are you involved in an intimate relationship at this time?
- B. How many patients are you asking this of?
- C. What questions or concerns do you have about your sexual health?
- D. Have you ever been diagnosed with a sexually transmitted infection?
Correct Answer: C
Rationale: An open-ended question related to the patient's need for further information should be included while obtaining a sexual history. This approach encourages the patient to express specific concerns or areas of uncertainty, facilitating targeted education. The other listed questions are not open-ended and do not directly assess the need for further information.
A premenopausal patient is complaining of vaginal spotting and sharp, colicky lower abdominal pain. She informs the nurse that her period is 2 weeks late. The nurse should recognize a need for this patient to be investigated for what health problem?
- A. Trichomonas vaginalis
- B. Ectopic pregnancy
- C. Cervical cancer
- D. Fibromyalgia
Correct Answer: B
Rationale: Clinical symptoms of an ectopic pregnancy include delay in menstruation of 1 to 2 weeks, vaginal spotting, and sharp, colicky pain. These symptoms align with the patient's presentation, warranting investigation for this condition. Trichomonas vaginalis causes vaginal infection, typically with discharge, not typically associated with delayed menstruation or colicky pain. Cervical cancer may cause abnormal bleeding but is less likely to present with acute colicky pain and delayed menstruation. Fibromyalgia is unrelated to menstrual irregularities or vaginal spotting.
A 21-year-old woman has sought care because of heavy periods and has subsequently been diagnosed with menorrhagia. The nurse should recognize which of the following as the most likely cause of the patients health problem?
- A. Hormonal disturbances
- B. Cervical or uterine cancer
- C. Pelvic inflammatory disease
- D. A sexually transmitted infection (STI)
Correct Answer: A
Rationale: Menorrhagia in young women is most commonly caused by hormonal disturbances, which disrupt normal menstrual regulation. Cervical or uterine cancer, pelvic inflammatory disease, and STIs are less likely causes in this age group.
A community health nurse is leading a health education session addressing menopause and other aspects of womens health. What dietary supplements should the nurse recommend to prevent morbidity associated with osteoporotic fractures?
- A. Vitamin B12 and vitamin C
- B. Vitamin A and potassium
- C. Vitamin B6 and phosphorus
- D. Calcium and vitamin D
Correct Answer: D
Rationale: Calcium and vitamin D supplementation are recommended to reduce bone loss and prevent osteoporotic fractures, a key concern in menopause. Other listed supplements do not address bone health effectively.
A newly pregnant patient is being assessed in an obstetric clinic. The patient states that she has been experiencing intense abdominal pain and the nurse anticipates that the patient will be assessed for ectopic pregnancy. In addition to ultrasonography, what diagnostic test should the nurse anticipate?
- A. Computed tomography
- B. Human chorionic gonadotropin (hCG) testing
- C. Estrogen and progesterone testing
- D. Abdominal x-ray
Correct Answer: B
Rationale: If an ectopic pregnancy is suspected, the patient is assessed using ultrasound and hCG testing, which can confirm pregnancy location and viability. CT and x-rays are contraindicated during pregnancy due to radiation risks, and estrogen/progesterone levels are not diagnostic for ectopic pregnancy.