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The nurse writes a client problem of 'anxiety related to potential sexual dysfunction' for a client diagnosed with cancer of the prostate. Which intervention should the nurse implement?
- A. Tell the client to discuss his fears with the HCP.
- B. Talk to the wife about the client’s concerns.
- C. Inform the client sexual functioning will not be altered.
- D. Provide a private area for the client to discuss his concerns.
Correct Answer: D
Rationale: A private area facilitates open discussion of sexual dysfunction fears, reducing anxiety. HCP referral, spousal discussion, or false reassurance are less therapeutic.
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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.
The male client presents to the public health clinic complaining of joint pain and malaise. On assessment, the nurse notes a rash on the trunk, palms of the hands, and soles of the feet. Which action should the nurse implement next?
- A. Determine if the client has had a chancre sore within the last two (2) months.
- B. Ask the client how many sexual partners he has had in the past year.
- C. Refer the client to a dermatologist for a diagnostic work-up.
- D. Have the client provide a clean voided midstream urine specimen.
Correct Answer: A
Rationale: Joint pain, malaise, and a rash on palms/soles suggest secondary syphilis; confirming a prior chancre sore supports this diagnosis. Partner history, dermatology referral, and urine tests are less urgent.
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.
The client has failed to conceive after many attempts over a three (3)-year time period and asks the nurse, 'I have tried everything. What should I do now?' Which statement is the nurse’s best response?
- A. By “everything” do you mean you have consulted an infertility specialist?'
- B. You have tried everything. This must be hard for you. Would you like to talk?'
- C. You should get on an adoption list because it can take a long time.'
- D. You need to relax and not try so hard. It is your nerves preventing conception.'
Correct Answer: A
Rationale: Referring to an infertility specialist is proactive, addressing potential medical causes. Emotional support is secondary, adoption is premature, and blaming nerves is unhelpful.
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.