Nokea
The nurse is caring for a patient who has undergone a radical vulvectomy for vulvar carcinoma. Which of the following nursing diagnoses is priority at this time?
- A. Bathing self-care deficit related to pain
- B. Risk for infection as evidenced by invasive procedure (contamination of the wound with urine and stool)
- C. Imbalanced nutrition: less than body requirements related to insufficient dietary intake
- D. Risk for ineffective sexual pattern as evidenced by impaired relationship with significant other (disfiguration caused by the surgery)
Correct Answer: B
Rationale: Complex and meticulous wound care is needed to prevent infection and delayed wound healing. The other nursing diagnoses may also be appropriate for the patient but are not the highest priority immediately after surgery.
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A patient who is 58-years-old calls the health clinic and tells the nurse that she has a moderate amount of vaginal bleeding after 6 years of menopause. Which of the following procedures should the nurse anticipate teaching the patient about?
- A. Endometrial biopsy
- B. Uterine balloon therapy
- C. Laser endometrial ablation
- D. Dilation and curettage (D&C)
Correct Answer: A
Rationale: A postmenopausal woman with vaginal bleeding should be evaluated for endometrial cancer, and endometrial biopsy is the primary test for endometrial cancer. D&C will be needed only if the biopsy does not provide sufficient information to make a diagnosis. Endometrial ablation and balloon therapy are used to treat menorrhagia, which is unlikely in this patient.
The nurse is caring for a patient who is diagnosed with stage 0 cervical cancer using a punch biopsy. Which of the following treatments should the nurse include in the teaching plan?
- A. Radiation
- B. Conization
- C. Chemotherapy
- D. Radical hysterectomy
Correct Answer: B
Rationale: Because the carcinoma is in situ, conization can be used for treatment. Radical hysterectomy, chemotherapy, or radiation will not be needed.
The nurse is caring for a patient who has been diagnosed with human papilloma virus (HPV) infection and who smokes cigarettes, uses oral contraceptives, and has a history of candidiasis. Which of the following topics should the nurse include in the teaching plan?
- A. Use of water-soluble lubricants
- B. Antifungal cream administration
- C. Importance of smoking cessation
- D. Possible difficulties with conception
Correct Answer: C
Rationale: Because smoking and HPV infection are both associated with increased cervical cancer risk, the nurse should emphasize the importance of avoiding smoking. An HPV infection does not decrease vaginal lubrication, decrease ability to conceive, or require the use of antifungal creams.
The nurse has just received change-of-shift report about the following four patients. Which of the following patients should be assessed first?
- A. A patient with a possible ectopic pregnancy who is complaining of severe shoulder pain
- B. A patient in the fifteenth week of gestation who is experiencing uterine cramping and spotting
- C. A patient who has a radium implant in place to treat cervical cancer and is crying in her room
- D. A patient with ovarian cancer who is complaining of 8/10 pain after an abdominal hysterectomy
Correct Answer: A
Rationale: The patient with the ectopic pregnancy has symptoms consistent with rupture and needs immediate assessment for signs of hemorrhage and possible transfer to surgery. The other patients should also be assessed as quickly as possible but do not have symptoms of life-threatening complications.
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.