Chapter 40 My Nursing Test Banks

 

Kozier & Erbs Fundamentals of Nursing, 9/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. Since 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: While 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: Page Reference: 1036

Cognitive Level: Analyzing

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Give examples of how the family, culture, religion, and personal expectations and ethics influence ones sexuality.

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 2-1/2 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: Page Reference: 1037

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Describe sexual development and concerns across the life span.

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. Super absorbent tampons should be used at night to protect from overflow accidents.

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

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

Global Rationale: Page Reference: 1036

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Recognize health promotion teaching related to reproductive structures.

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: Page Reference: 1036

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 09 Recognize health promotion teaching related to reproductive structures.

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: Page Reference: 1036

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 07 Identify basic sexual questions the nurse should ask during client assessment.

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: Since the child needs role models 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 models from both males and females, this teacher is not the best choice because of the teachers age.

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

Global Rationale: Page Reference: 1037

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Give examples of how the family, culture, religion, and personal expectations and ethics influence ones sexuality.

Question 7

Type: MCSA

Which statement, made by a postmenopausal client, would 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: Page Reference: 1037

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 09 Recognize health promotion teaching related to reproductive structures.

Question 8

Type: MCSA

A research article the nurse is reading discusses the prevalence of androgyny in persons 20 to 30 years old. The nurse understands which of the following about androgynous persons?

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 since androgyny means flexibility in gender roles.

Global Rationale: Page Reference: 1040

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Discuss the varieties of sexuality.

Question 9

Type: MCSA

The client experienced female circumcision as a puberty ritual while living in Africa as a child. What condition should the nurse monitor the client for 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: Page Reference: 1043

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 04 Give examples of how the family, culture, religion, and personal expectations and ethics influence ones sexuality.

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 does the nurse interpret these 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: Page Reference: 1045

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 06 Identify the forms of male and female altered sexual function.

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 since 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: Page Reference: 1045

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 01 Describe sexual development and concerns across the life span.

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 pre-examination douche.

Global Rationale: Page Reference: 1047

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 08 Formulate nursing diagnoses and interventions for the client experiencing sexual problems.

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: While 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: Page Reference: 1048

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 07 Identify basic sexual questions the nurse should ask during client assessment.

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: Page Reference: 1037

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 01 Describe sexual development and concerns across the life span.

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: Page Reference: 1038

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 04 Give examples of how the family, culture, religion, and personal expectations and ethics influence ones sexuality.

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: Page Reference: 1038

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 09 Recognize health promotion teaching related to reproductive structures.

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 plans a response based upon which concept?

1. Alcohol is a central nervous system depressant which 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: Page Reference: 1038

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 09 Recognize health promotion teaching related to reproductive structures.

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: Page Reference: 1038

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 08 Formulate nursing diagnoses and interventions for the client experiencing sexual problems.

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: Page Reference: 1047

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 05 Describe physiological changes in males and females during the sexual response cycle.

Question 20

Type: MCSA

A nurse colleague is outraged 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: While all of these statements are true, the primary consideration is that early childhood education on sex should come primarily from parents.

Rationale 2: While all of these statements are true, the primary consideration is that early childhood education on sex should come primarily from parents.

Rationale 3: While all of these statements are true, the primary consideration is that early childhood education on sex should come primarily from parents.

Rationale 4: While all of these statements are true, the primary consideration is that early childhood education on sex should come primarily from parents.

Global Rationale: Page Reference: 1050

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 04 Give examples of how the family, culture, religion, and personal expectations and ethics influence ones sexuality.

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: The term sexually transmitted disease can elicit guilt, shame, and fear in the client. Substituting the term infection for disease makes the diagnosis less threatening and makes it sound more treatable. Third-party reimbursement is not a reason for choice of terms in this instance. The preciseness of the term is not an issue.

Rationale 2: The term sexually transmitted disease can elicit guilt, shame, and fear in the client. Substituting the term infection for disease makes the diagnosis less threatening and makes it sound more treatable. Third-party reimbursement is not a reason for choice of terms in this instance. The preciseness of the term is not an issue.

Rationale 3: The term sexually transmitted disease can elicit guilt, shame, and fear in the client. Substituting the term infection for disease makes the diagnosis less threatening and makes it sound more treatable. Third-party reimbursement is not a reason for choice of terms in this instance. The preciseness of the term is not an issue.

Rationale 4: The term sexually transmitted disease can elicit guilt, shame, and fear in the client. Substituting the term infection for disease makes the diagnosis less threatening and makes it sound more treatable. Third-party reimbursement is not a reason for choice of terms in this instance. The preciseness of the term is not an issue.

Global Rationale: Page Reference: 1051

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 09 Recognize health promotion teaching related to reproductive structures.

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: Page Reference: 1053

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 07 Identify basic sexual questions the nurse should ask during client assessment.

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

Global Rationale: Page Reference: 1053

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 07 Identify basic sexual questions the nurse should ask during client assessment.

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 is affected by disease process or therapy to offer specific suggestions for intervention.

Rationale 2: While 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: Page Reference: 1053

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts:

Learning Outcome: 07 Identify basic sexual questions the nurse should ask during client assessment.

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: 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. Using information technology or informal therapeutic groups does not reflect this need for more intensive therapy. Evaluation of previous interventions and treatments is not a part of the format.

Rationale 2: 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. Using information technology or informal therapeutic groups does not reflect this need for more intensive therapy. Evaluation of previous interventions and treatments is not a part of the format.

Rationale 3: 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. Using information technology or informal therapeutic groups does not reflect this need for more intensive therapy. 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. Using information technology or informal therapeutic groups does not reflect this need for more intensive therapy. Evaluation of previous interventions and treatments is not a part of the format.

Global Rationale: Page Reference: 1054

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts:

Learning Outcome: 07 Identify basic sexual questions the nurse should ask during client assessment.

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: The nurse should assess whether this client has irritation of the penis that is causing his actions. Telling the client to keep his hands away from his penis or to keep his linens pulled up is inappropriate and assumes the client is masturbating. Medicating the client to control the behavior is also inappropriate and assumes that the client is doing something wrong. All three incorrect options overlook the possibility of a physical reason such as irritation that the client is trying to communicate.

Rationale 2: The nurse should assess whether this client has irritation of the penis that is causing his actions. Telling the client to keep his hands away from his penis or to keep his linens pulled up is inappropriate and assumes the client is masturbating. Medicating the client to control the behavior is also inappropriate and assumes that the client is doing something wrong. All three incorrect options overlook the possibility of a physical reason such as irritation that the client is trying to communicate.

Rationale 3: The nurse should assess whether this client has irritation of the penis that is causing his actions. Telling the client to keep his hands away from his penis or to keep his linens pulled up is inappropriate and assumes the client is masturbating. Medicating the client to control the behavior is also inappropriate and assumes that the client is doing something wrong. All three incorrect options overlook the possibility of a physical reason such as irritation that the client is trying to communicate.

Rationale 4: The nurse should assess whether this client has irritation of the penis that is causing his actions. Telling the client to keep his hands away from his penis or to keep his linens pulled up is inappropriate and assumes the client is masturbating. Medicating the client to control the behavior is also inappropriate and assumes that the client is doing something wrong. All three incorrect options overlook the possibility of a physical reason such as irritation that the client is trying to communicate.

Global Rationale: Page Reference: 1054

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 08 Formulate nursing diagnoses and interventions for the client experiencing sexual problems.

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: Page Reference: 1039

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 02 Define sexual health.

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: Page Reference: 1040

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 07 Identify basic sexual questions the nurse should ask during client assessment.

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: Page Reference: 1041

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 03 Discuss the varieties of sexuality.

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. The need to follow safe sex practices.

2. The need to use contraception.

3. The importance of having an annual HIV test.

4. Why 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: Page Reference: 1041

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 03 Discuss the varieties of sexuality.

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.

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 breasts.

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

Global Rationale: Page Reference: 1043

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 05 Describe physiological changes in males and females during the sexual response cycle.

Question 32

Type: MCMA

When discussing the orgasmic phase of the sexual response cycle, which of the following will 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 throughout the body.

3. The heart rate decreases 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 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 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: Page Reference: 1044

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 05 Describe physiological changes in males and females during the sexual response cycle.

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.

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: Page Reference: 1044

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 05 Describe physiological changes in males and females during the sexual response cycle.

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: Page Reference: 1048

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 07 Identify basic sexual questions the nurse should ask during client assessment.

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: Page Reference: 1048

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 07 Identify basic sexual questions the nurse should ask during client assessment.

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: Page Reference: 1051-1052

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 09 Recognize health promotion teaching related to reproductive structures.

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 healthcare 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 size or shape of the breasts.

Global Rationale: Page Reference: 1052

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 09 Recognize health promotion teaching related to reproductive structures.

Question 38

Type: MCMA

What self-examination schedules should the nurse teach a class of young adult men and women?

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 healthcare provider immediately.

Global Rationale: Page Reference: 1052

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 09 Recognize health promotion teaching related to reproductive structures.

Kozier & Erbs Fundamentals of Nursing, 9/E Test Bank

Copyright 2012 by Pearson Education, Inc.

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