Nokea
On the basis of this client's age, which statement by the nurse is the best explanation for the client's discomfort?
- A. The pelvic muscles are more sensitive to pressure after menopause.
- B. The clitoris is unable to respond to sexual foreplay as women age.
- C. The vagina hypertrophies if intercourse is infrequent.
- D. The mucus-producing glands decrease with aging.
Correct Answer: D
Rationale: Postmenopausal vaginal dryness due to decreased mucus production is a common cause of painful intercourse in older women.
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The office manager schedules a mandatory staff meeting for all nursing personnel. As the nurse enters the room, several documents containing the client's name, medical records number, mammogram results, and diagnosis are found unattended on the table. Which nursing actions are appropriate in this situation? Select all that apply.
- A. Notify housekeeping to come and dispose of the papers.
- B. Toss the papers in the trash.
- C. Put the papers into the shredder bin.
- D. Try to determine who left the papers unattended.
- E. State the papers neatly, placing them off to the side.
- F. Notify the office manager of the breach in confidentiality.
Correct Answer: C,F
Rationale: Shredding the papers ensures secure disposal of protected health information (PHI), and notifying the office manager addresses the confidentiality breach, as required by HIPAA regulations.
The nurse correctly teaches a couple that immediately after a vasectomy, it is best to continue using an alternative birth control method for which time period?
- A. 1 month
- B. 6 weeks
- C. 12 weeks
- D. 6 months
Correct Answer: C
Rationale: Sperm may remain in the vas deferens for up to 12 weeks post-vasectomy, requiring alternative contraception until azoospermia is confirmed.
The client is eight (8) hours post-transurethral prostatectomy for cancer of the prostate. Which nursing intervention is priority at this time?
- A. Control postoperative pain.
- B. Assess abdominal dressing.
- C. Encourage early ambulation to prevent DVT.
- D. Monitor fluid and electrolyte balance.
Correct Answer: D
Rationale: Fluid and electrolyte balance is critical post-TURP due to irrigation and bleeding risks (e.g., hyponatremia). Pain, dressings, and ambulation are important but secondary.
Unless the physician specifies otherwise, what is the maximum volume of urine the nurse should remove with the catheter at this time?
- A. 500 mL
- B. 1,000 mL
- C. 1,500 mL
- D. 2,000 mL
Correct Answer: B
Rationale: Removing up to 1,000 mL prevents bladder decompression injury, balancing the need to relieve retention with the risk of hypotension or hematuria.
Which question is most important for the nurse to ask next?
- A. Have you ever had any menstrual periods?
- B. Do you have any pubic hair growth?
- C. Have you ever been sexually attracted to males?
- D. Are there any siblings with a similar problem?
Correct Answer: A
Rationale: Determining if the client has ever menstruated is critical to differentiate between primary amenorrhea (never menstruated) and secondary amenorrhea (cessation of periods), guiding further assessment.