Nokea
The nurse is assessing a patient who is on the surgical unit after a radical abdominal hysterectomy. Which of the following findings is most important to report to the health care provider?
- A. Decreased bowel sounds in all four abdominal quadrants.
- B. Urine output of 100 mL in the first 8 hours after surgery.
- C. Symptom of pain at the incision site with coughing
- D. One inch increased abdominal girth
Correct Answer: B
Rationale: The decreased urine output indicates possible low blood volume and further assessment is needed to assess for possible internal bleeding. The other findings are not unusual after this surgery.
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The nurse is counselling a healthy perimenopausal woman who prefers not to use hormone therapy (HT). Which of the following treatment options should the nurse discuss with the patient? (Select all that apply.)
- A. Reduce coffee intake.
- B. Exercise several times a week.
- C. Take black cohosh supplements.
- D. Have a glass of wine in the evening.
- E. Increase intake of dietary soy products.
Correct Answer: A,B,C,E
Rationale: Reduction in caffeine intake, use of black cohosh, increasing dietary soy intake, and exercising three to four times weekly are recommended to reduce symptoms associated with menopause. Alcohol intake in the evening may increase the sleep problems associated with menopause.
A patient who is 45 years of age tells the nurse that she has not had a menstrual period for 3 months and asks whether she is going into menopause. Which of the following responses is best by the nurse?
- A. Have you thought about using hormone therapy?
- B. Most women feel a little depressed about entering menopause
- C. What was your menstrual pattern before your periods stopped?
- D. Since you are in your mid-40s, it is likely that you are menopausal.
Correct Answer: C
Rationale: The initial response by the nurse should be to assess the patient's baseline menstrual pattern. Although many women do enter menopause in the mid-40s, more information about this patient is needed before telling her that it is likely she is menopausal. Although hormone therapy (HT) may be prescribed, further assessment of the patient is needed before discussing therapies for menopause. Because the response to menopause is very individual, the nurse should not assume that the patient is experiencing any adverse emotional reactions.
The nurse is caring for a female patient in the health clinic who is diagnosed with genital warts. Which of the following information should the nurse include in the teaching plan?
- A. The need for regular Pap tests
- B. Increased risk for endometrial cancer
- C. Appropriate use of oral contraceptives
- D. Symptoms of pelvic inflammatory disease
Correct Answer: A
Rationale: Genital warts are caused by the human papilloma virus (HPV) and increase the risk for cervical cancer. There is no indication that the patient needs teaching about PID, oral contraceptives, or endometrial cancer.
The nurse is admitting a patient with increasing abdominal pain who is diagnosed with an ectopic pregnancy. The patient begins to cry and asks the nurse to leave her alone to grieve. Which of the following actions should the nurse take next?
- A. Stay with the patient and encourage her to discuss her feelings.
- B. Explain the reason for taking vital signs every 15-30 minutes.
- C. Close the door to the patient's room and minimize disturbances.
- D. Provide teaching about options for termination of the pregnancy.
Correct Answer: B
Rationale: Because the patient is at risk for rupture of the fallopian tube and hemorrhage, frequent monitoring of vital signs is needed. The patient has asked to be left alone, so staying with her and encouraging her to discuss her feelings are inappropriate actions. Minimizing contact with her and closing the door of the room is unsafe because of the risk for hemorrhage. Since the patient has requested time to grieve, it would be inappropriate to provide teaching about options for pregnancy termination.
A patient is diagnosed with vaginal candidiasis and an antifungal vaginal cream is prescribed. Which of the following patient statements indicate that the nurse's teaching about the treatment plan has been effective?
- A. I will tell my husband that we cannot have sex for the next month.
- B. I should clean carefully after each urination and bowel movement.
- C. I can douche daily with warm water if the itching continues to bother me.
- D. I will insert the cream using the applicator before I get up in the morning.
Correct Answer: B
Rationale: Cleaning of the perineal area will decrease itching caused by contact of the irritated tissues with urine and reduce the chance of further infection of irritated tissues by bacteria in the stool. Sexual intercourse should be avoided for 1 week. Douching will disrupt normal protective mechanisms in the vagina. The cream should be used at night so that it will remain in the vagina for longer.