Nokea
The nurse is assessing the client diagnosed with a rectocele. Which signs and symptoms should the nurse expect? Select all that apply.
- A. Rectal pressure.
- B. Flatus.
- C. Fecal incontinence.
- D. Constipation.
- E. Urinary frequency.
Correct Answer: A,B,C,D
Rationale: Rectocele causes rectal pressure, flatus, fecal incontinence, and constipation due to posterior vaginal wall protrusion. Urinary frequency is more associated with cystocele.
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The client is diagnosed with a rectovaginal fistula which is to be managed medically. Which information should the nurse teach the client prior to discharge?
- A. Douche with normal saline.
- B. Eat a low-residue diet.
- C. Keep ice packs to the area.
- D. Use an abdominal binder.
Correct Answer: B
Rationale: A low-residue diet reduces fecal output, aiding healing of a rectovaginal fistula. Douching risks infection, ice packs are ineffective, and binders are unrelated.
Which health practice is most appropriate for the nurse to teach this client?
- A. Take showers rather than tub baths if possible.
- B. Wipe away from the vagina after a bowel movement.
- C. The client's sexual experience with members of both sexes
- D. Avoid having sexual intercourse more than once a week.
Correct Answer: B
Rationale: Wiping away from the vagina prevents fecal bacteria from entering the vaginal area, reducing the risk of infections like candidiasis.
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 female client has a mother who died from ovarian cancer and a sister diagnosed with ovarian cancer. Which recommendations should the nurse make regarding early detection of ovarian cancer?
- A. The client should consider having a prophylactic bilateral oophorectomy.
- B. The client should have a transvaginal ultrasound and a CA-125 laboratory test every six (6) months.
- C. The client should have yearly magnetic resonance imaging (MRI) scans.
- D. The client should have a biannual gynecological examination with flexible sigmoidoscopy.
Correct Answer: B
Rationale: High familial risk warrants transvaginal ultrasound and CA-125 every 6 months for early detection. Prophylactic oophorectomy is a personal choice, MRI is not standard, and sigmoidoscopy is unrelated.
To accurately determine the dosage of antineoplastic drugs, which information is essential to obtain from the client's chart?
- A. Urine output for the past 24 hours
- B. Body weight and height
- C. Date of surgery
- D. Drug allergies
Correct Answer: B
Rationale: Body weight and height are used to calculate body surface area, which determines accurate dosing of antineoplastic drugs.