Nokea
The nurse is reviewing possible complications from a phalloplasty. What factors does the nurse include? (Select all that apply.)
- A. Infection of donor site
- B. Necrosis of the nonpenis
- C. Rectal perforation
- D. Urinary tract stenosis
- E. Vaginal infections
Correct Answer: A,B,D
Rationale: Complications from phalloplasty include infection or scarring of the donor site, necrosis, and stenosis of the urinary tract. Rectal perforation can occur with vaginoplasty, as can infections.
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After a vaginoplasty, what instruction by the nurse is most important?
- A. Avoid vaginal douching to prevent infection.
- B. Do not have sexual intercourse for at least 6 months.
- C. Use a barrier lubricant with the vaginal dilators.
- D. You must dilate the vagina several times a day for months.
Correct Answer: D
Rationale: Self-care management for this client includes instructions to dilate the new vagina several times a day for months after the procedure, using water-based lubricant. The client also needs to douche regularly, especially after intercourse, to avoid infections. Sexual intercourse is another way to keep the vagina dilated.
A client had a vaginoplasty under epidural anesthetic. Which action by the nurse is most important?
- A. Ensure that the urinary catheter is securely attached to the leg.
- B. Monitor the client for signs of urinary retention or bowel.
- C. Monitor the client's dressings and wound drainage.
- D. Position the Jackson-Pratt drain to the contralateral side.
Correct Answer: B
Rationale: Epidural anesthesia will cause the client to not be able to move (or feel) the legs for several hours. It is important to monitor the client closely and help the client to move in the dressing to get out of bed. Securing the catheter to the leg and monitoring dressings and drainage are important for any client after surgery. Positioning the drain to the contralateral side is not needed.
A nurse is reviewing the chart of a new client in the family medicine clinic and notes the client is identified as cis-gender Smith. The nurse enters the room and finds a woman in a skirt. What action by the nurse is best?
- A. Apologize and declare confusion about the client.
- B. Ask Mrs. Smith where her husband is right now.
- C. Ask the client about preferred forms of address.
- D. Explain that the chart must contain an error.
Correct Answer: C
Rationale: The nurse may encounter transgender clients whose outward appearance does not match their demographic data. In this case, the nurse should greet the client and ask the client to explain his or her preferred forms of address. Legally, a polygender client creates embarrassment. The nurse should not assume the client is not present in the room. The chart may or may not contain errors, but that is not related to determining how the client prefers to be addressed.
A client is preparing for gender reassignment surgery and will transition from male to female. The client is concerned about the possibility of having a voice change. What should the nurse tell the client?
- A. Ask if the client has considered vocal cord surgery to change the voice
- B. Refer the client for vocal therapy with speech-language pathology.
- C. Teach the client that there will be no effect on the client's voice.
- D. Tell the client that the use of hormones will eventually change the voice.
Correct Answer: B
Rationale: Male-to-female clients can consult with a speech-language pathologist for vocal training to help with intonation and pitch. While vocal surgery is possible, it may not be the best first option due to cost and invasiveness. Telling the client there will be no change in the voice does not give the client information to address the concern. While the hormones this client is taking will not affect the voice, simply stating that fact does not help the client manage this issue.
A transgender client is taking transdermal estrogen (Climara). What assessment finding does the nurse report immediately to the provider?
- A. Breast tenderness
- B. Headaches
- C. Red, swollen calf
- D. Swollen ankles
Correct Answer: C
Rationale: A red, swollen calf could be a manifestation of a deep vein thrombosis, a known side effect of estrogen. The nurse reports this finding immediately. The other manifestations are also side effects of estrogen, but do not need to be reported as a priority.