Nokea
The nurse in the gynecology clinic is assessing a 14-year-old client who reports being sexually active. Which information should the nurse teach the client? Select all that apply.
- A. Inform the client that the nurse must tell the parents of her being sexually active.
- B. Teach the client about possible birth control options.
- C. Instruct the client regarding sexually transmitted disease.
- D. Demonstrate how a condom is applied correctly.
- E. Tell the client the importance of finishing all antibiotics.
- F. Discuss the importance of attending parenting classes.
Correct Answer: B,C,D
Rationale: Teaching birth control, STD prevention, and condom use empowers the sexually active teen. Parental notification depends on jurisdiction, antibiotics are irrelevant without infection, and parenting classes are premature.
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Which breast palpation technique is most correct?
- A. Examine the breast while using the heel of the hand.
- B. Examine the breast while using the index finger only.
- C. Examine the breast while using the index finger and thumb.
- D. Examine the breast while using the pads of the fingertips.
Correct Answer: D
Rationale: Using the pads of the fingertips allows for better sensitivity to detect lumps or changes in breast tissue during palpation, making it the most effective technique for BSE.
When the client asks how this condition will affect him sexually, which response by the nurse is most appropriate?
- A. It most likely will have little effect on your masculinity.
- B. It means that you will probably be impotent.
- C. You may notice that your breasts will enlarge later.
- D. Your sex drive will not be like that of other boys.
Correct Answer: A
Rationale: An undescended testicle, if corrected, typically has minimal impact on sexual function or masculinity, especially if addressed early.
The nurse is formulating a care plan for a client post-abdominal hysterectomy. Which nursing diagnosis is appropriate for the client who has developed a complication?
- A. Potential for urinary retention.
- B. Potential for nerve damage.
- C. Potential for intestinal obstruction.
- D. Potential for fluid imbalance.
Correct Answer: C
Rationale: Intestinal obstruction is a common complication post-abdominal hysterectomy due to adhesions or ileus. Urinary retention and fluid imbalance are risks but less specific, and nerve damage is rare.
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.
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.