Chapter 40 My Nursing Test Banks

Kozier & Erbs Fundamentals of Nursing, 10/E
Chapter 40

Question 1

Type: MCSA

A client speaks about an adult son who is a practicing homosexual and expresses concern by stating: I am so worried about him and I know he is going to hell. What is the most important fact for the nurse to consider in formulating a response to this clients concern?

1. Normal sexuality is described as whatever behaviors give pleasure and satisfaction to those adults involved.

2. Because alternative lifestyles are now so well accepted in society, this parent should not feel so much concern.

3. What constitutes normal sexual expression varies among cultures and religions.

4. Sexual development is genetically determined and not affected by environment.

Correct Answer: 3

Rationale 1: Even though many consider whatever activity gives pleasure and satisfaction to the involved adults to be normal, some cultures and religions do not hold that belief.

Rationale 2: Although alternative lifestyles are well accepted in some cultures, apparently that is not true in this parents belief patterns.

Rationale 3: This nurse should remember that culture and religion have a big impact upon what a person believes to be normal sexual behavior.

Rationale 4: Sexual development has both genetic and environmental components.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values

AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences

NLN Competencies: Relationship-centered care; Knowledge; The role of family, culture, and community in a persons development

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 4. Give examples of how the family, culture, religion, and personal expectations and ethics influence ones sexuality.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 934

Question 2

Type: MCSA

The parent of a 20-month-old is very concerned because the baby touches the genital area during diaper changes. How should the nurse respond to this concern?

1. At 20 months this touching is not a sexual experience.

2. Masturbation to orgasm is common and normal at this age.

3. Genital stimulation should not be occurring until the age of 2 1/2 or 3.

4. Babies are sexual beings, but this activity should be discouraged.

Correct Answer: 1

Rationale 1: At 20 months, exploration and touching of the genital area is no different than exploration and touching of fingers and toes. This touching is not considered a sexual experience.

Rationale 2: Masturbation to orgasm can occur as early as age 3, although males do not ejaculate until after puberty.

Rationale 3: At around age 21/2 or 3 the child begins to differentiate between genital differences and to identify as a male or female.

Rationale 4: There is no need to discourage genital exploration at 20 months.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values

AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences

NLN Competencies: Relationship-centered care; Knowledge; The role of family, culture, and community in a persons development

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1. Describe sexual development and concerns across the life span.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 935

Question 3

Type: MCSA

The nurse is teaching a class on body development to a group of middle school girls. One of the girls asks about using tampons for sanitary protection during menstruation. What advice should the nurse include?

1. Tampons should not be used until the menstrual cycle is well established, usually 2 to 3 years after the first period occurs.

2. Superabsorbent tampons should be used at night to protect from overflow accidents.

3. Tampons should be alternated with sanitary pads to help decrease risk for infection.

4. Tampons should be changed at least every 8 hours.

Correct Answer: 3

Rationale 1: There is no evidence of need to delay tampon use.

Rationale 2: Sanitary pads, not tampons, should be used at night.

Rationale 3: The nurse should teach these girls to alternate tampons with sanitary pads to decrease risk for infection.

Rationale 4: Tampons should be changed more frequently than every 8 hours to prevent infection and odor.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 936

Question 4

Type: MCSA

The nurse is developing strategies for the relief of menstrual cramping to teach a group of young clients. What should be the focus of these strategies?

1. Increase of blood flow to the uterine muscle

2. Avoidance of uterine contraction

3. Minimization of menstrual flow

4. Decrease in estrogen production

Correct Answer: 1

Rationale 1: Menstrual cramping is a result of the muscle ischemia that occurs when the client experiences powerful uterine contractions. Increase of blood flow to the uterine muscle through rest, some exercises, application of heat to the abdomen, and presence of milder uterine contractions (such as those associated with orgasm) can decrease pain and cramping.

Rationale 2: Increase of blood flow to the uterine muscle can decrease pain and cramping. There is no connection between the actual amount of flow and pain. Estrogen production should follow normal patterns and should not be altered.

Rationale 3: There is no connection between the actual amount of flow and pain.

Rationale 4: Estrogen production should follow normal patterns and should not be altered.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 936

Question 5

Type: MCSA

During a routine physical, an 11-year-old tells the nurse that many students in school are doing it. How should the nurse respond to this statement?

1. Tell the client to talk with parents about sexual matters.

2. Ask what doing it means to this client.

3. State that sexual activity is not appropriate at age 11.

4. Stay silent and wait for the client to continue the discussion.

Correct Answer: 2

Rationale 1: An 11-year-old may feel uneasy about discussing sexual matters with parents, so this statement to the nurse may be the only opportunity to discuss concerns.

Rationale 2: The nurse should ask what doing it means to this 11-year-old client. It is important that the nurse and the client are talking about the same thing before additional information is shared.

Rationale 3: This is not the time to tell the client about what is or is not appropriate; it is the time to make the client feel comfortable talking with the nurse.

Rationale 4: Staying silent may make the client feel as if the nurse is disapproving and would adversely affect the clients comfort level.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patients support network

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 936

Question 6

Type: MCSA

A young adult single mother of a second-grade child has to make a decision regarding the teacher her child will have in third grade and asks the nurse for advice. All other variables being equal, which choice is best?

1. A woman with 35 years of teaching experience

2. A man who is 40 years old

3. A newly graduated 22-year-old man

4. A 30-year-old woman

Correct Answer: 2

Rationale 1: Because the child needs role modeling from both males and females, this teacher is not the best choice.

Rationale 2: If all other variables are equal, the best choice is the 40-year-old male, as this child needs role modeling from both females (the mother) and males (this teacher).

Rationale 3: Even though the child needs role modeling from both males and females, this teacher is not the best choice because of the teachers age.

Rationale 4: Because the child needs role modeling from both males and females, this teacher is not the best choice.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Give examples of how the family, culture, religion, and personal expectations and ethics influence ones sexuality.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 940

Question 7

Type: MCSA

Which statement made by a postmenopausal client should the nurse evaluate as indicating the need for further assessment?

1. For some reason, I have more sexual desire than ever.

2. I use water-soluble lubricant to treat my vaginal dryness.

3. I am so glad that I dont need to worry about sex anymore.

4. Sex certainly takes longer than it used to, but Im getting used to that.

Correct Answer: 3

Rationale 1: This statement reflects normal changes associated with aging and healthy responses to those changes.

Rationale 2: This statement reflects normal changes associated with aging and healthy responses to those changes.

Rationale 3: The nurse would further assess the client who made the statement, I am so glad that I dont need to worry about sex anymore. This statement is unclear. Does it mean that the client is glad not to have to engage in sex anymore, or does it mean that she will not have to worry about getting pregnant anymore?

Rationale 4: This statement reflects normal changes associated with aging and healthy responses to those changes.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Describe sexual development and concerns across the life span.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 947

Question 8

Type: MCSA

A research article the nurse is reading discusses the prevalence of androgyny in persons 20 to 30 years old. What should the nurse keep in mind when caring for clients who are androgynous?

1. They do not limit behaviors to one gender over the other.

2. They are attracted to people of the same gender.

3. They often repress their sexual feelings.

4. They hold rigid stereotyped gender role expectations.

Correct Answer: 1

Rationale 1: Androgyny means flexibility in gender roles. Androgynous individuals do not limit behaviors to one gender over another.

Rationale 2: Androgyny has nothing to do with gender attraction.

Rationale 3: Androgyny has nothing to do repression of sexual feelings.

Rationale 4: Androgynous individuals do not hold rigid stereotyped gender role expectations; androgyny means flexibility in gender roles.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Discuss the varieties of sexuality.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 938

Question 9

Type: MCSA

A client experienced female circumcision as a puberty ritual while living in Africa as a child. For which health problem should the nurse monitor the client as an adult?

1. Early menopause

2. Increased menstrual flow

3. Chronic urinary tract infection

4. Tendency for postpartum hemorrhage

Correct Answer: 3

Rationale 1: There is no indication that early menopause is a result of female circumcision.

Rationale 2: There is no indication that increased menstrual flow is a result of female circumcision.

Rationale 3: Female circumcision increases the possibility that the client will suffer chronic urinary tract infection.

Rationale 4: There is no indication that female circumcision causes postpartum hemorrhage.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Give examples of how the family, culture, religion, and personal expectations and ethics influence ones sexuality.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 941

Question 10

Type: MCSA

The 45-year-old client reports that she has no interest in sex and that she and her husband have not had intercourse in 16 years. How should the nurse interpret this assessment data?

1. This couple is experiencing sexual dysfunction.

2. The womans lack of sexual desire has resulted in impotence in her husband.

3. If both partners share the same lack of desire, there is often not a problem.

4. This situation is so unnatural that some dysfunction is present.

Correct Answer: 3

Rationale 1: This situation is unnatural in the predominant North American culture, but if both members of the couple are comfortable with the relationship, no dysfunction is present.

Rationale 2: There is no evidence that the wifes lack of desire has resulted in sexual impotence in her husband, but further assessment might be in order.

Rationale 3: If both members of a couple have the same lack of desire and they are comfortable, there is likely no problem with the couples sexuality.

Rationale 4: This situation is unnatural in the predominant North American culture, but if both members of the couple are comfortable with the relationship, no dysfunction is present.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 6. Identify the forms of altered sexual function.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 943

Question 11

Type: MCSA

A client is concerned because he was unable to achieve an erection during his last sexual encounter with his wife. He tells the nurse that he has worried about becoming impotent because he had a sexually transmitted infection as a young adult. What is the nurses best response to this clients concerns?

1. Sexually transmitted infections may result in sexual problems in adults.

2. Erectile dysfunction is the correct term for the inability to achieve or sustain an erection.

3. An occasional incident like this is normal and common and there is no reason to be concerned.

4. The medical diagnosis of erectile dysfunction is not made until the man has erection difficulties in 25% or more of his interactions.

Correct Answer: 3

Rationale 1: Although this can occur, it does not address the clients concerns about impotence.

Rationale 2: Simply correcting the clients use of medical terminology does not address his concerns.

Rationale 3: This client is concerned about his masculinity and sexual abilities. The correct answer at this point is to tell him that it is common and normal for men to experience occasional erectile difficulties.

Rationale 4: Even though this is true, it is not the best response to address the clients concerns.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patients support network

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Describe sexual development and concerns across the life span.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 944

Question 12

Type: MCSA

The nurse is preparing for pelvic physical examination of a woman who has been medically diagnosed with vaginismus. What equipment should the nurse obtain for this examination?

1. Culture tubes to assess expected vaginal infection

2. Extra cleaning supplies to remove thick external secretions

3. Smaller-than-normal vaginal speculums

4. Equipment for preexamination douche

Correct Answer: 3

Rationale 1: The client does not have an infection.

Rationale 2: The client does not have thick external secretions.

Rationale 3: Clients with vaginismus experience involuntary spasm of the outer one-third of the vaginal muscles. This spasm makes internal examination, tampon use, and intercourse difficult. Use of smaller-than-normal vaginal speculums may make examination easier.

Rationale 4: This client does not need a preexamination douche.

Global Rationale:

Cognitive Level: Applying

Client Need: Safe and Effective Care Environment

Client Need Sub: Safety and Infection Control

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 8. Formulate nursing diagnoses and interventions for the client experiencing sexual problems.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 945

Question 13

Type: MCSA

There is disagreement among the nursing unit staff regarding how much sexual history should be included in adult admission assessments. What standard is generally the most applicable?

1. A complete sexual history must be included in the admission history and physicals.

2. Sexual information should be pursued only if the clients chief complaint indicates possible sexual dysfunction.

3. Sexual assessment should be done by the physician and not repeated by the nurse.

4. The amount of sexual information taken will vary on a case-by-case basis.

Correct Answer: 4

Rationale 1: A complete sexual history is not necessary for every client.

Rationale 2: This topic should be addressed only after rapport has been established.

Rationale 3: Although the nurse should be sensitive about repeating questions that have already been asked, the client may be more forthcoming with information with the nurse.

Rationale 4: The amount of sexual information taken will vary on a case-by-case basis. The nurse can open the conversation by asking open-ended questions.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 945

Question 14

Type: MCSA

The mother of a 5-year-old tells the nurse that her daughter has always been closer to her than to her husband. The mother expresses concern that, over the last 2 months, the little girl wants to spend all of her time with her father instead of with the mother. The nurse recognizes that this behavior

1. may indicate sexual abuse by the father and should be further investigated.

2. is a normal expectation of a preschooler developing sexuality.

3. indicates that the girl is overidentifying with the male gender.

4. can be a sign of precocious puberty and should be monitored.

Correct Answer: 2

Rationale 1: The nurse would be concerned if this attention to the father is accompanied by any manifestation of sexual abuse, but that is not indicated in this question.

Rationale 2: A part of the normal sexual development of a preschooler is a time in which the child focuses love on the parent of the other gender. The same-gender parent may feel excluded during this time, but can be assured that the behavior is normal.

Rationale 3: There is no indication of overidentification with the male gender.

Rationale 4: There is no indication of precocious puberty.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Describe sexual development and concerns across the life span.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 935

Question 15

Type: MCSA

A recently married couple is trying to conceive a child. The husband is a collegiate athlete and his coach forbids sexual activity for 2 days prior to a game. The wife asks the nurse if abstinence before the game is necessary. What is the best response?

1. As long as intercourse is not involved, there is no reason to avoid sexual activity.

2. Some residual physical weakness is common for up to 18 hours after sex.

3. This is a common myth among athletes, but there is no basis in fact.

4. In fact, sexual activity before intense physical exercise increases stamina and endurance.

Correct Answer: 3

Rationale 1: There is no evidence that avoiding intercourse is necessary.

Rationale 2: The idea that sexual activity weakens the person physically is a common misconception among athletes, but there is no evidence to support that idea.

Rationale 3: The idea that sexual activity weakens the person physically is a common misconception among athletes, but there is no evidence to support that idea.

Rationale 4: There is no evidence that sexual activity before intense exercise affects stamina or endurance.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 4. Communicate effectively with all members of the healthcare team, including the patient and the patients support network

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 4. Give examples of how the family, culture, religion, and personal expectations and ethics influence ones sexuality.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 936

Question 16

Type: MCSA

The 15-year-old female tells the nurse that she makes her boyfriend stop intercourse before she has an orgasm so she will not get pregnant. What teaching is necessary for this client?

1. Even though she doesnt get pregnant, she might still get a sexually transmitted infection.

2. Intercourse until orgasm may actually reduce conception because the vaginal contractions help to expel sperm.

3. Conceiving is not related to whether or not the female partner experiences an orgasm.

4. As long as her boyfriend does not ejaculate in her vagina, conception is unlikely.

Correct Answer: 3

Rationale 1: Conceiving is not related to experiencing orgasm. This client is very likely to conceive and is also at risk for getting any sexually transmitted infection her boyfriend might have.

Rationale 2: Conceiving is not related to experiencing orgasm.

Rationale 3: Conceiving is not related to experiencing orgasm.

Rationale 4: The seminal fluid expelled prior to ejaculation also contains sperm and can result in pregnancy even if the male ejaculates outside the vagina.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 936

Question 17

Type: MCSA

The high school student tells the school nurse that during biology the class learned that alcohol is associated with erectile dysfunction. The student wonders why so many girls get pregnant during evenings when alcohol is consumed. The nurse should plan a response based upon which concept?

1. Alcohol is a central nervous system depressant that affects judgment.

2. Erectile dysfunction only occurs after years of alcohol abuse.

3. Alcohol is a sexual stimulant.

4. Erectile dysfunction occurs only in men older than 50.

Correct Answer: 1

Rationale 1: Alcohol is implicated in behaviors leading to undesired pregnancy because it is a central nervous system depressant and affects judgment.

Rationale 2: Situational erectile dysfunction often occurs when the male partner is drunk. Chronic erectile dysfunction is more common in older men, and alcohol abuse is associated with this problem.

Rationale 3: Alcohol is implicated in behaviors leading to undesired pregnancy because it is a central nervous system depressant and affects judgment. It is not a sexual stimulant.

Rationale 4: Situational erectile dysfunction often occurs when the male partner is drunk. Chronic erectile dysfunction is more common in older men, and alcohol abuse is associated with this problem.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 944

Question 18

Type: MCSA

The female client has experienced recurrent candidiasis with intense vaginal itching and excoriation. After treatment the client is reexamined, and the nurse practitioner finds presence of a white, cheesy discharge. What recommendation is necessary?

1. Referral to a surgeon for excision of infected tissue

2. Examination and treatment of sexual partner

3. Treatment with a stronger oral antibiotic

4. Routine douches with a topical antibiotic solution

Correct Answer: 2

Rationale 1: There is no need for tissue excision.

Rationale 2: Candidiasis is a sexually transmitted infection. It may be that this womans sexual partner is also infected with candidiasis and that the couple is transmitting the infection between them.

Rationale 3: Antibiotic therapy is not indicated and may, in fact, complicate treatment.

Rationale 4: Antibiotic therapy is not indicated and may, in fact, complicate treatment.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8. Formulate nursing diagnoses and interventions for the client experiencing sexual problems.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 937

Question 19

Type: MCSA

The nurse enters the room and finds the adult client masturbating. What action should the nurse take?

1. Tell the client that masturbation is harmful to sexual well-being.

2. Say excuse me and leave the room.

3. Request that the client stop so that care can be provided.

4. Ask the client if there are any sexual concerns that should be discussed.

Correct Answer: 2

Rationale 1: Masturbation is not harmful to sexual well-being.

Rationale 2: In this situation, the nurse should quickly and politely leave the room.

Rationale 3: It is inappropriate to ask the client to stop so that care can be provided.

Rationale 4: Masturbation does not indicate sexual concerns that should be discussed.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Define sexual health.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 937

Question 20

Type: MCSA

A nurse colleague learns that a grandchilds day-care center is planning a class on sexuality for 3- and 4-year-olds. Discussion of this plan should include what concept?

1. At this age, education regarding sexuality should come from parents.

2. Children are sexual beings from before birth.

3. Understanding the body and sexuality are a part of growth and development.

4. Sexual activity is beginning at earlier and earlier ages.

Correct Answer: 1

Rationale 1: Although all of these statements are true, the primary consideration is that early childhood education on sex should come primarily from parents.

Rationale 2: Parents need to be the primary educators of children at an early age; however, peers, teachers, media, and toys also teach about sexual issues.

Rationale 3: Parents need to be the primary educators of children at an early age; however, peers, teachers, media, and toys also teach about sexual issues.

Rationale 4: Parents need to be the primary educators of children at an early age; however, peers, teachers, media, and toys also teach about sexual issues.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 4. Give examples of how the family, culture, religion, and personal expectations and ethics influence ones sexuality.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 947

Question 21

Type: MCSA

In discussion with teenagers, the nurse chooses to use the term sexually transmitted infection rather than sexually transmitted disease. What is the rationale for this choice?

1. Infection is a much more precise term for the transmission that occurs.

2. The word disease may elicit guilt, shame, and fear in the client.

3. Sexually transmitted disease does not receive as much third-party reimbursement as does sexually transmitted infection.

4. These terms can be used interchangeably and there is no good rationale for using one over the other.

Correct Answer: 2

Rationale 1: Substituting the term infection for disease makes the diagnosis less threatening and makes it sound more treatable.

Rationale 2: The term sexually transmitted disease can elicit guilt, shame, and fear in the client.

Rationale 3: Third-party reimbursement is not a reason for choice of terms in this instance.

Rationale 4: The preciseness of the term is not an issue.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 949

Question 22

Type: MCSA

The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the P section of this format?

1. Ask the physician for permission to discuss sexual topics with the client.

2. Obtain signed informed consent from both the client and the spouse or partner prior to providing them with sexual information.

3. Acknowledge the clients spoken and unspoken sexual concerns when providing care.

4. Document precertification for benefits from the clients insurance company regarding sexual teaching.

Correct Answer: 3

Rationale 1: There is no need to ask permission from the physician prior to discussing sexual topics.

Rationale 2: Obtaining signed informed consent from both the client and spouse or partner is not required.

Rationale 3: The P section of this format reflects permission giving. This giving of permission refers to acknowledging the clients spoken and unspoken sexual concerns and giving the client permission to be a sexual being.

Rationale 4: Documentation of precertification for benefits from the clients insurance company would be an issue only if the nurse is acting in the role as a sexual therapist for which insurance would reimburse.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 949

Question 23

Type: MCSA

The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the LI section of this format?

1. In order to avoid causing anxiety, limit the amount of information given to clients regarding adverse sexual side effects of treatments or medications.

2. Give the client accurate but concise information in regard to any sexual questions that might be asked.

3. State information using slang terms to refer to sexual body parts because the client is not likely to know the proper terms.

4. Review current research literature associated with the sexual concerns of the client and partner.

Correct Answer: 2

Rationale 1: Clients deserve information regarding sexual side effects, and the nurse is obligated to provide that information.

Rationale 2: LI represents limited information. The nurse should give accurate but concise information regarding sexual matters.

Rationale 3: Although the nurse should use terms the client understands, assuming that the client only understands slang terms could cause embarrassment for the client and the nurse. A better strategy is to use correct terms while assessing the clients understanding, changing to more common terms if necessary.

Rationale 4: Although reviewing current literature is always a good idea, it does not relate to the LI section of the PLISSIT format.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 950

Question 24

Type: MCSA

The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the SS section of this format?

1. Use the nurses knowledge about how disease affects sexuality to offer specific suggestions for the client.

2. Focus interventions on explaining the somatic sexual difficulties and their treatment.

3. Offer the client a list of expected sexual side effects of drugs or treatments.

4. Identify any concerns the client has regarding attraction to the same sex.

Correct Answer: 1

Rationale 1: SS represents specific suggestions. The nurse should use specialized knowledge and skill about how sexuality and functioning are affected by the disease process or therapy to offer specific suggestions for intervention.

Rationale 2: Although some therapy may have somatic effects, the nurse should not focus solely on those effects.

Rationale 3: Just giving the client a list of expected sexual side effects is not appropriate at this level of the format.

Rationale 4: SS does not stand for same sex.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 950

Question 25

Type: MCSA

The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse best reflects the IT section of this format?

1. Use information technology such as the Internet to obtain guidance suggestions for the client.

2. Use the technique of informal therapeutic groups to assist the client and partner.

3. Evaluate previous interventions and treatment for success.

4. Recommend intensive therapy with a qualified sex therapist.

Correct Answer: 4

Rationale 1: Using information technology does not reflect this need for more intensive therapy.

Rationale 2: Using informal therapeutic groups does not reflect this need for more intensive therapy.

Rationale 3: Evaluation of previous interventions and treatments is not a part of the format.

Rationale 4: IT represents intensive therapy. At this point in intervention, the nurse recognizes that the client requires therapy with a nurse who has specialized preparation and knowledge of sexual and gender identity disorders. Referral or recommendation for intensive therapy is required.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 950

Question 26

Type: MCSA

The daughters of an 80-year-old man who is aphasic after suffering a cerebrovascular accident (stroke) express concern that their father is always exposing and playing with himself and his catheter while they are in the room. Upon assessment, the nurse finds the client pulling on and rubbing his penis. What is the nurses priority action?

1. Tell the client to keep his hands away from his penis.

2. Assess the clients penis for irritation from the catheter.

3. Ask the client to keep his linens at waist level when he has visitors.

4. Collaborate with the physician regarding medications to control this behavior.

Correct Answer: 2

Rationale 1: Telling the client to keep his hands away from his penis is inappropriate and assumes the client is masturbating.

Rationale 2: The nurse should assess whether this client has irritation of the penis that is causing his actions. The nurse needs to determine if there is a physical reason such as irritation that the client is trying to communicate.

Rationale 3: Telling the client to keep his linens pulled up is inappropriate and assumes the client is masturbating.

Rationale 4: Medicating the client to control the behavior is inappropriate and assumes that the client is doing something wrong.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 8. Formulate nursing diagnoses and interventions for the client experiencing sexual problems.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 951

Question 27

Type: MCMA

After an assessment, the nurse determines that a client has strong sexual health. What did the nurse assess in the client?

Standard Text: Select all that apply.

1. Knowledge about sexual behavior

2. Reluctance to discuss sexual history

3. Utilization of birth control method that fits lifestyle

4. Statement that there are no issues with sexuality

5. Discussing sexual problems with healthcare provider

Correct Answer: 1, 3, 5

Rationale 1: Characteristics of sexual health include knowledge about sexuality and sexual behavior.

Rationale 2: Reluctance to discuss sexual history is not a characteristic of sexual health.

Rationale 3: Characteristics of sexual health include the right to make free and responsible reproductive choices.

Rationale 4: Making a statement that there are no issues with sexuality is not a characteristic of sexual health.

Rationale 5: Characteristics of sexual health include the ability to access sexual health care for sexual concerns, problems, and disorders.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. Define sexual health.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 938

Question 28

Type: MCMA

The nurse is preparing to assess a clients sexual health. What will the nurse include in this assessment?

Standard Text: Select all that apply.

1. Sexual self-concept

2. Body image

3. Gender identity

4. Contraceptive choices

5. Employment

Correct Answer: 1, 2, 3

Rationale 1: Sexual self-concept is a component of sexual health.

Rationale 2: Body image is a component of sexual health.

Rationale 3: Gender identity is a component of sexual health.

Rationale 4: Contraceptive choices are not a component of sexual health.

Rationale 5: Employment is not a component of sexual health.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 938

Question 29

Type: MCSA

During an assessment, a client tells the nurse of a desire to wear clothing that is typically associated with the opposite sex. The nurse realizes this client is describing which gender identity?

1. Intersex

2. Transgenderism

3. Homosexuality

4. Cross-dressing

Correct Answer: 4

Rationale 1: Intersex is a condition in which there are contradictions among chromosomal sex, gonadal sex, internal organs, and external genital appearance.

Rationale 2: Transgender individuals have a condition called gender dysphoria, or gender identity disorder: a strong and persistent feeling of discomfort with ones assigned gender. For the transgendered person, sexual anatomy is not consistent with gender identity.

Rationale 3: Homosexuality is not characterized by wearing clothing associated with the opposite sex.

Rationale 4: Cross-dressing makes ones outward appearance consistent with their inner identity and gender role, and increases their comfort with themselves.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Discuss the varieties of sexuality.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 939

Question 30

Type: MCSA

During a sexual assessment, a client tells the nurse about a preference for oralgenital sex. How should the nurse instruct this client?

1. Explain the need to follow safe sex practices.

2. Explain the need to use contraception.

3. Explain the importance of having an annual HIV test.

4. Explain thy routine gynecologic examinations are not necessary.

Correct Answer: 1

Rationale 1: Oralgenital sex is not completely free of the potential for sexually transmitted illness transmission, and safe sex practices must be used.

Rationale 2: Contraception is not necessary for oralgenital sex.

Rationale 3: An annual HIV test is not necessary for oralgenital sex.

Rationale 4: The nurse should instruct the client on the importance of having routine gynecologic examinations.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Discuss the varieties of sexuality.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 940

Question 31

Type: MCMA

The nurse is preparing an educational session on the sexual response cycle. What should be included when discussing the physiological changes in females during the excitement phase?

Standard Text: Select all that apply.

1. The vagina dries.

2. The length of the vagina narrows and swells.

3. Erection of the clitoris occurs.

4. The breasts enlarge.

5. The uterus elevates.

Correct Answer: 3, 4, 5

Rationale 1: During the excitement phase of the sexual response cycle in females, there is vaginal lubrication.

Rationale 2: During the excitement phase of the sexual response cycle in females, the inner two-thirds of the vagina widens and lengthens, and the outer third swells and narrows.

Rationale 3: Physiological changes in females during the excitement phase of the sexual response cycle include erection of the clitoris.

Rationale 4: Physiological changes in females during the excitement phase of the sexual response cycle include enlargement of the breasts.

Rationale 5: Physiological changes in females during the excitement phase of the sexual response cycle include elevation of the uterus.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Describe physiological changes during the sexual response cycle.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 942

Question 32

Type: MCMA

When discussing the orgasmic phase of the sexual response cycle, what should the nurse include as physiological changes that affect both sexes?

Standard Text: Select all that apply.

1. The respiratory rate can increase up to 40 breaths per minute.

2. Involuntary muscle spasms occur throughout the body.

3. The heart rate decreases to 20 beats below normal.

4. Systolic blood pressure can increase 2030 mm Hg above normal.

5. Diastolic blood pressure can decrease 2050 mm Hg below normal.

Correct Answer: 1, 2, 4

Rationale 1: Physiological changes that affect both sexes during the orgasmic phase of the sexual response cycle include an increase in respiratory rate of up to 40 breaths per minute.

Rationale 2: Physiological changes that affect both sexes during the orgasmic phase of the sexual response cycle include involuntary muscle spasms throughout the body.

Rationale 3: Physiological changes that affect both sexes during the orgasmic phase of the sexual response cycle include an increase in heart rate, not a decrease.

Rationale 4: Physiological changes that affect both sexes during the orgasmic phase of the sexual response cycle include an increase of systolic blood pressure of 2030 mm Hg above normal.

Rationale 5: Physiological changes that affect both sexes during the orgasmic phase of the sexual response cycle include an increase in diastolic blood pressure, not a decrease.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Describe physiological changes during the sexual response cycle.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 942

Question 33

Type: MCSA

The nurse is discussing the resolution phase of the sexual response cycle with a group of students in a health education class. What should be included as a physiological change that affects males only?

1. Genitalia and breasts return to pre-excitement states.

2. There is a refractory period during which the body will not respond to sexual stimulation.

3. The heart rate returns to normal.

4. Possible sleepiness or intense relaxation may occur.

Correct Answer: 2

Rationale 1: This is a physiological change that affects both sexes.

Rationale 2: During the resolution phase of the sexual response cycle, the physiological change that affects males only is a refractory period during which the body will not respond to sexual stimulation.

Rationale 3: This is a physiological change that affects both sexes.

Rationale 4: This is a physiological change that affects both sexes.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Describe physiological changes during the sexual response cycle.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 942

Question 34

Type: MCMA

The nurse is conducting a sexual health history with a client. What questions should the nurse ask during this history?

Standard Text: Select all that apply.

1. What are your erotic fantasies?

2. Are you currently sexually active?

3. Do you experience any pain with sexual interaction?

4. Do you have difficulty with sexual desire?

5. What do you like the best about having sex?

Correct Answer: 2, 3, 4

Rationale 1: Asking the client to describe erotic fantasies is not appropriate.

Rationale 2: Asking whether the client is sexually active is appropriate for the nurse.

Rationale 3: Asking whether the client has any pain with sexual interaction is appropriate.

Rationale 4: Asking whether the client has any difficulty with sexual desire is appropriate.

Rationale 5: Asking what the client likes the best about having sex is not appropriate.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 946

Question 35

Type: MCSA

The nurse is conducting a health history with an older client with arthritis and heart disease. When gathering the sexual history for this client, what question should the nurse ask?

1. Do you have any difficulty with sexual desire and orgasm?

2. How often do you have sexual relations?

3. What type of contraception do you use?

4. Have there been any changes in your sexual functioning that might be related to your illness or the medications you take?

Correct Answer: 4

Rationale 1: This question is not necessarily appropriate for an older client.

Rationale 2: This question is not appropriate for the nurse to ask any client.

Rationale 3: This question is not appropriate for an older client.

Rationale 4: All nursing histories should at least include a question such as Have there been any changes in your sexual functioning that might be related to your illness or the medications you take?

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 7. Identify basic sexual questions the nurse should ask during client assessment.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 946

Question 36

Type: MCSA

The nurse is preparing educational materials to be used when instructing clients on testicular and breast self-examination. What would be applicable for both sets of instructions?

1. Perform palpation in the shower.

2. Perform the examination lying down.

3. Perform the examination once each week.

4. Perform the examination bimonthly.

Correct Answer: 1

Rationale 1: One optional method to palpate the breasts is to perform the self-examination in the shower. For the testicular self-examination, the examination should be done in the bath or the shower.

Rationale 2: The testicular examination is not performed lying down.

Rationale 3: The testicular and breast self-examinations should be done monthly.

Rationale 4: The testicular and breast self-examinations should be done monthly.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 948

Question 37

Type: MCMA

The nurse who is teaching a client breast self-examination describes inspection of the breasts before a mirror. Which findings should the nurse tell the client should be evaluated by a health care provider?

Standard Text: Select all that apply.

1. Puckering of the skin

2. Flattening of the breast from the side view

3. Free movement of the breast over the chest wall

4. Symmetry of the nipples

5. Change in shape

Correct Answer: 1, 2, 5

Rationale 1: The client should be instructed to observe for puckering of the skin.

Rationale 2: The client should be instructed to observe for changes in the size or shape of the breasts.

Rationale 3: The breasts should have free movement over the chest wall.

Rationale 4: Nipple symmetry is a normal assessment finding.

Rationale 5: The client should be instructed to observe for changes in the size or shape of the breasts.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 948

Question 38

Type: MCMA

The nurse is teaching a class of young adult men and women. What self-examination schedules should the nurse instruct these participants to follow?

Standard Text: Select all that apply.

1. Monthly breast self-exams for women

2. Yearly breast self-exams for men

3. Weekly testicular self-exams for men

4. Monthly breast self-exams for men

5. Yearly vulvar self-exams for women

Correct Answer: 1, 4

Rationale 1: Women should be instructed to examine their breasts on a monthly schedule.

Rationale 2: Men should be instructed to examine their breasts on a monthly schedule.

Rationale 3: Men should be instructed to examine their testicles monthly.

Rationale 4: Men should be instructed to examine their breasts on a monthly schedule.

Rationale 5: There is no need for a yearly scheduled vulvar self-exam for women, as any abnormalities noticed should be examined by the woman or her health care provider immediately.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care

NLN Competencies: Context and Environment; Practice; apply health promotion/disease prevention strategies; apply health policy

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 9. Recognize health promotion teaching related to reproductive structures.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 948

Question 39

Type: MCMA

While the nurse is measuring blood pressure, the client lifts his hand and fondles the nurses breast. What should the nurse do about this behavior?

Standard Text: Select all that apply.

1. Ignore the fondling.

2. Move the clients hand away.

3. Refocus the client on appropriate behavior.

4. Tell the client to stop performing the behavior.

5. Communicate that the behavior is not acceptable.

Correct Answer: 2, 3, 4, 5

Rationale 1: The nurse needs to set limits with the client, and ignoring the behavior would communicate that it is acceptable.

Rationale 2: The nurse needs to set firm limits and take the clients hand and move it away.

Rationale 3: The nurse needs to try to refocus the client from the inappropriate behavior to appropriate behavior.

Rationale 4: The nurse needs to set firm limits and tell the client to stop the behavior.

Rationale 5: The nurse needs to communicate that the behavior is not acceptable. This will set limits as to what is appropriate and not appropriate behavior with the client.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Formulate nursing diagnoses and interventions for the client experiencing sexual problems.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 951


Question 40

Type: MCMA

After reviewing a list of prescribed medications, the nurse plans to complete a sexual history with the client. Which medications in the clients list caused the nurse to make this clinical decision?

Standard Text: Select all that apply.

1. Antibiotics

2. Antipyretics

3. Cardiotonics

4. Beta-blockers

5. Anticoagulants

Correct Answer: 3, 4

Rationale 1: Antibiotics are not identified as altering sexual response or desire.

Rationale 2: Antipyretics are not identified as altering sexual response or desire.

Rationale 3: Cardiotonics decrease sexual desire

Rationale 4: Beta-blockers decrease sexual desire.

Rationale 5: Anticoagulants are not identified as altering sexual response or desire.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care

AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches

NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 8. Formulate nursing diagnoses and interventions for the client experiencing sexual problems.

MNL Learning Outcome: 2.2.3. Examine the components of sexuality and the associated nursing care.

Page Number: 944

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