Chapter 41 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 41

Question 1

Type: MCSA

A 56-year-old female patient thinks shes losing her mind because of constant anxiety, flushing, inability to sleep, and headaches. The nurse would ask assessment questions based on which condition being the most likely cause of these symptoms?

1. Premenstrual syndrome

2. Menopause

3. Postmenopause

4. Dysmenorrhea

Correct Answer: 2

Rationale 1: Manifestations of premenstrual syndrome occur 7 to 10 days prior to the start of the menstrual flow. In the United States, most women stop menstruating between 48 and 55 years of age. No information is given in the question to suggest that the woman is still menstruating.

Rationale 2: Vasomotor instability in menopause often results in hot flashes, palpitations, dizziness, and headaches. Other problems that result from vasomotor instability include insomnia, frequent awakening, and night sweats. The woman may experience irritability, anxiety, and depression as a result of these events.

Rationale 3: Postmenopause starts one year after the menstrual flow ceases. No information is given in the question about menstrual flow.

Rationale 4: These symptoms are not consistent with dysmenorrhea.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 41-1

Question 2

Type: MCSA

A female patient who is experiencing menopause is tired of the night sweats. Which activity can the nurse suggest to help this patient?

1. Ensure that the bedroom temperature is cool and limit sleeping attire.

2. Reduce intake of milk and milk products.

3. Suggest talking with the physician about a hysterectomy.

4. Exercise 1 hour before going to sleep.

Correct Answer: 1

Rationale 1: The underlying cause of hot flashes is not known; however, many physiologic effects of menopause are responsive to nonpharmacologic methods of relief, such as lifestyle changes and control of the environment.

Rationale 2: The recommended daily intake of calcium for women over 50 is 1,200 mg.

Rationale 3: Encouraging the patient to look into surgical intervention is outside the scope of nursing practice. A hysterectomy will further reduce the patients natural estrogen levels and could make night sweats worse.

Rationale 4: Exercise immediately before bedtime can interrupt sleep.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 41-5

Question 3

Type: MCMA

The nurse is assisting a patient with ways to reduce the severity of the monthly menstrual discomforts associated with premenstrual syndrome. Which information should the nurse review with this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Avoid exercise during the days immediately before menstruation.

2. Investigate the use of alternative therapies such as black cohosh root.

3. Follow a low-carbohydrate diet

4. Increase sodium intake.

5. Restrict caffeine intake.

Correct Answer: 2,5

Rationale 1: Regular exercise may provide some relief from symptoms.

Rationale 2: Alternative and complementary therapies such as black cohosh root, chasteberry, evening primrose oil, wild yam root, and dong quai may help to relieve anxiety and depression.

Rationale 3: The diet should be high in complex carbohydrates.

Rationale 4: Sodium should be restricted to minimize fluid retention.

Rationale 5: Caffeine restriction reduces irritability.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 41-5

Question 4

Type: MCSA

The mother of a 16-year-old female reports that the teen began menstruating at age 14 but has stopped for about 5 months. Which response would be the highest priority for the nurse to make to this mother?

1. Thats normal for a 16-year-old. That happened to me when I was 16.

2. Does she have a boyfriend?

3. Its probably psychological.

4. Have you noticed any other changes in diet, activity, or weight loss?

Correct Answer: 4

Rationale 1: The condition reported by the parent is not normal.

Rationale 2: It is not appropriate for the nurse to assume that the girl is sexually active. Having a boyfriend does not necessarily indicate sexual activity.

Rationale 3: The nurse has no basis for this statement without further assessment.

Rationale 4: Secondary amenorrhea, which is the absence of menses for at least 3 months in a previously menstruating female, may be caused by anorexia nervosa, excessive athletic activity or training, or a large weight loss. Other causes include hormonal imbalances and ovarian tumors. Pregnancy is also a cause of secondary amenorrhea but should not be the first assumption.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 41-1

Question 5

Type: MCSA

A patient is diagnosed with uterine prolapse into the vagina. Which factor most likely contributed to this patients disorder?

1. Multiple pregnancies

2. Endometriosis

3. Pelvic inflammatory disease

4. Cervical tumor

Correct Answer: 1

Rationale 1: Downward displacement of the pelvic organs into the vagina results from weakened pelvic musculature, usually attributed to stretching of the supporting ligaments and muscles during pregnancy and childbirth. Multiple pregnancies may contribute to this disorder.

Rationale 2: Endometriosis is not a typical cause of uterine prolapse.

Rationale 3: Pelvic inflammatory disease is not associated with uterine prolapse.

Rationale 4: Cervical tumors are not associated with uterine prolapse.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 41-1

Question 6

Type: MCSA

A female patient is diagnosed with chocolate cysts. The nurse would teach the patient that these cysts occur in association with which condition?

1. Pelvic inflammatory disease

2. Use of oral contraceptives

3. Endometrial overgrowth

4. Hormone imbalance

Correct Answer: 3

Rationale 1: These cysts are not associated with pelvic inflammatory disease.

Rationale 2: These cysts are not associated with use of oral contraceptives.

Rationale 3: Endometrial cysts are caused by endometrial overgrowth and are often filled with old blood; hence the name chocolate cysts. Endometrial cysts are the result of endometrial implants on the ovary and are associated with endometriosis.

Rationale 4: These cysts are not associated with hormone imbalance.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 41-1

Question 7

Type: MCMA

A 25-year-old female is diagnosed with endometriosis. The nurse works with the patient to achieve which desired outcomes?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patient reports no further nausea or vomiting.

2. The patients menstrual cycle extends to 28 days.

3. Menstrual discomfort does not interfere with activities of daily living.

4. The patient agrees to early hysterectomy for definitive treatment.

5. The patient reports fewer incidents of bladder incontinence.

Correct Answer: 2,3

Rationale 1: Nausea and vomiting are not common manifestations of endometriosis.

Rationale 2: Patients with endometriosis often have menstrual cycles shorter than the normal 28 days, leading to greater blood loss over time. A therapeutic goal is to lengthen this cycle.

Rationale 3: Patients with endometriosis often experience severe menstrual discomfort that can be debilitating. A goal is to reduce this discomfort to a manageable level.

Rationale 4: Hysterectomy is reserved for extreme cases.

Rationale 5: Bladder incontinence is not a manifestation of endometriosis.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 41-2

Question 8

Type: MCSA

The nurse is collecting data during a routine patient admission history and physical. The patient reports she has experienced bleeding between her menstrual periods. What initial action by the nurse is most appropriate?

1. Determine the timing of the bleeding episodes.

2. Determine the amount of bleeding.

3. Assess for the presence of sexually transmitted infections.

4. Review the length of the patients normal menstrual cycles.

Correct Answer: 1

Rationale 1: Bleeding between menstrual cycles could have several causes. It can be a result of mid-cycle ovulation and normal. It is most important to identify the timing of the bleeding to determine the underlying cause.

Rationale 2: Assessment of the amount of bleeding is second in importance.

Rationale 3: There is no indication the patient has sexually transmitted infections.

Rationale 4: The length of the patients menstrual cycle is a part of the data collection process, but it is not of the greatest importance.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 41-1

Question 9

Type: MCSA

A 41-year-old patient reports that her menstrual periods have become irregular, with the last period occurring approximately 4 months ago. What information should be provided to the patient concerning the use of contraceptives during the perimenopausal period?

1. Contraceptive use should continue.

2. Contraceptives are no longer needed.

3. Contraceptives will be needed only if menstruation occurs.

4. Contraceptive use will be needed for only another 2 months.

Correct Answer: 1

Rationale 1: After 1 year of amenorrhea, a woman is considered to be in menopause. It is still possible for the woman to become pregnant during this period.

Rationale 2: It is still possible for the woman to become pregnant during this period.

Rationale 3: It is possible for the woman to become pregnant for a year after menstruation ceases.

Rationale 4: It is possible for the woman to become pregnant for longer than 6 months after menstruation ceases.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 41-5

Question 10

Type: MCSA

A patient who has been experiencing the clinical manifestations associated with menopause voices an interest in using alternative and complementary therapies to manage them. What is the best initial response by the nurse?

1. Alternative and complementary therapies seldom work.

2. Many women report success with those measures.

3. What types of therapies are of interest to you?

4. Have you discussed this with the health care provider?

Correct Answer: 3

Rationale 1: The success of these remedies varies by user. It is inappropriate for the nurse to meet the patients request with negativity. Patients using alternative therapies are asked to report them to their health care providers.

Rationale 2: This is not the best initial step for this scenario.

Rationale 3: Alternative and complementary therapies are used by many women to manage the manifestations associated with menopause. The nurse has a responsibility to collect data from the patient and determine which therapies are of interest to her.

Rationale 4: This would not be the initial step for this scenario. Patients using alternative therapies are asked to report them to their health care providers.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 41-5

Question 11

Type: MCSA

A patient who recently had a hysterectomy states that she is nervous about taking the estrogen replacement therapy prescribed by her health care provider. She states that she is worried about developing breast cancer later in life. Which statement by the nurse is most appropriate?

1. The risk of breast cancer is somewhat increased for women who opt to take estrogen replacement therapy.

2. The risk of breast cancer is not increased for women who have had a hysterectomy and take estrogen replacement medications.

3. Has your gynecologist discussed estrogenprogestin combination therapy with you?

4. Has your gynecologist shared that it is not necessary to take estrogen drugs after a hysterectomy?

Correct Answer: 1

Rationale 1: Although research on the subject continues, current findings suggest the risk for the development of breast cancer is slightly greater for women who take estrogen replacement therapy after undergoing a hysterectomy.

Rationale 2: Although research on the subject continues, current findings do not support this statement.

Rationale 3: Progestin therapies are not used for women who are in surgical menopause.

Rationale 4: While it is not mandatory to take estrogen replacement therapy after surgery, the nurse should clarify and correct any misconceptions of the patient.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 41-4

Question 12

Type: MCMA

A 30-year-old patient reports increased irritability during the days preceding the onset of her menstrual cycle. Which measures might assist in the management of her irritability?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Increase dietary sugar intake to promote energy.

2. Increase intake of simple carbohydrates.

3. Reduce caffeine.

4. Utilize guided imagery.

5. Drink one glass of red wine each evening.

Correct Answer: 3,4

Rationale 1: The diet can be modified to aid in the management of premenstrual syndrome. Reducing sugar intake is one modification.

Rationale 2: The diet can be modified to aid in the management of premenstrual syndrome. Reducing the intake of simple carbohydrates is one modification.

Rationale 3: A reduction in caffeine intake is indicated to reduce irritability.

Rationale 4: Guided imagery can be used to reduce stress and promote relaxation.

Rationale 5: The health benefits of red wine have been reported relating to cancer prevention, protection of the heart and brain, and reducing inflammation. Although the patient may find drinking wine relaxing, this course is not a priority in nursing care.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 41-4

Question 13

Type: MCSA

A patient who has been experiencing premenstrual syndrome (PMS) reports to the clinic with a diet diary she has kept over the past several weeks. The nurse should suggest the patient make a dietary modification based on which entry in this diary?

1. Daily intake of caffeine-free soda

2. Daily intake of low-fat yogurt

3. Daily intake of foods rich in magnesium

4. Daily intake of white bread

Correct Answer: 4

Rationale 1: Reducing caffeine is beneficial in the management of premenstrual syndrome.

Rationale 2: Increasing the intake of calcium-rich foods is beneficial in the management of premenstrual syndrome.

Rationale 3: Increasing the intake of magnesium-rich foods is beneficial in the management of premenstrual syndrome.

Rationale 4: The dietary intake of simple carbohydrates should be reduced. White bread should be traded for whole-grain bread if possible.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 41-4

Question 14

Type: MCSA

A patient is scheduled to undergo a laparoscopic gynecologic procedure. Which statement by the patient indicates to the nurse a need for further education about the procedure?

1. I can expect to go home a few hours after the procedure.

2. I might experience some abdominal pain after the procedure.

3. Walking may help reduce my postprocedure pain.

4. I should report shoulder pain, as it might signal a complication.

Correct Answer: 4

Rationale 1: Laparoscopic procedures are often completed on an outpatient basis unless complications arise.

Rationale 2: Abdominal pain will be present due to the invasiveness of the surgical procedure.

Rationale 3: The greatest amount of postprocedure pain is often associated with the carbon dioxide gas instilled into the abdomen. Walking helps to dissipate this gas.

Rationale 4: The presence of shoulder pain is anticipated after laparoscopic procedures. The discomfort is a result of the carbon dioxide injected into the abdominal cavity to promote visualization during the procedure.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 41-4

Question 15

Type: MCMA

A patient is preparing to be discharged to home after a total hysterectomy. Which statements by the patient indicate to the nurse that the teaching session has been successful?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. I will need to report a temperature greater than 101 degrees.

2. I will experience vaginal bleeding after the surgery.

3. I will need to report any hot flashes and night sweats.

4. I will still need to see my physician for gynecological examinations.

5. I can resume sexual intercourse as soon as I desire.

Correct Answer: 2,4

Rationale 1: The patient should be advised to seek medical advice if the temperature rises over 100F.

Rationale 2: Vaginal bleeding after hysterectomy can last up to 4 weeks.

Rationale 3: The patient who has a hysterectomy with the loss of the ovaries will immediately begin surgical menopause. The loss of estrogen is immediate. It will take time for the hormone replacement therapy to manage the clinical manifestations associated with menopause.

Rationale 4: The patient who has had a hysterectomy still will need gynecological examinations.

Rationale 5: The patient should not have intercourse or place anything in the vagina until released by the health care provider in 6 to 8 weeks.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 41-4

Question 16

Type: MCMA

A patient shares with a nurse that she has pain during intercourse. The nurse asks questions to determine if the patient has which problems?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Perforated hymen

2. Vaginal scarring

3. Fear of sexual abuse

4. Vaginismus

5. Perimenopause

Correct Answer: 2,3,4,5

Rationale 1: A physical condition that may result in pain during intercourse is an imperforate hymen.

Rationale 2: Vaginal scarring can cause the vaginal muscles at the introitus to contract so tightly that an erect penis cannot be inserted.

Rationale 3: Fear of sexual abuse is a psychological cause of painful intercourse.

Rationale 4: Vaginismus occurs when the vaginal muscles at the introitus contract so tightly that an erect penis cannot be inserted.

Rationale 5: Falling levels of estrogen in perimenopause and menopause may result in vaginal dryness and painful intercourse.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 41-1

Question 17

Type: MCMA

A patient tells the nurse she thinks she is in menopause. The nurse would assess the patient for which common manifestations of menopause?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Increased body hair

2. Vaginal dryness

3. Hot flashes

4. Sleep disturbance

5. Vaginitis

Correct Answer: 2,3,4,5

Rationale 1: As estrogen levels decline, decreasing body hair may be noted.

Rationale 2: As estrogen levels decline, vaginal dryness is noted.

Rationale 3: As estrogen levels decline, hot flashes are noted.

Rationale 4: As estrogen levels decline, sleep disturbance may occur.

Rationale 5: As estrogen levels decline, vaginitis may be noted.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 41-1

Question 18

Type: MCMA

Hormone replacement therapy (HRT) is being discussed with a patient who is scheduled for a total hysterectomy. The patient should be informed she will be at an increased risk for which disorders as a result of HRT?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Breast cancer

2. Strokes

3. Venous thrombosis

4. Colon cancer

5. Heart attack

Correct Answer: 1,2,3,5

Rationale 1: Long-term HRT increases the risk for breast cancer.

Rationale 2: Long-term HRT increases the risk for stroke.

Rationale 3: Long-term HRT increases the risk for thrombosis.

Rationale 4: There is no correlation between HRT and an increased risk for colon cancer.

Rationale 5: Long-term HRT increases the risk for heart attack.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 41-4

Question 19

Type: MCMA

The nurse is planning care for a woman with premenstrual syndrome (PMS). Which nursing diagnoses would be most applicable to the care of this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Activity Intolerance

2. Acute Pain

3. Ineffective Coping

4. Ineffective Thermoregulation

5. Sexual Dysfunction

Correct Answer: 2,3

Rationale 1: The woman with PMS has discomfort but does not meet the criteria for Activity Intolerance.

Rationale 2: In PMS, women may have pain from headaches (migraines), menstrual cramps, excessive fluid retention, breast swelling, joint/muscle pain, and backache.

Rationale 3: Ineffective Coping is associated with the wide mood swings that occur during PMS.

Rationale 4: The woman with PMS may experience flushing but does not meet the criteria for Ineffective Thermoregulation.

Rationale 5: PMS symptoms do not directly cause Sexual Dysfunction.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 41-3

Question 20

Type: MCMA

The nurse is providing care for a patient with dysfunctional uterine bleeding (DUB). The nurse would reinforce teaching about which procedures as options for managing DUB?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Hysterectomy

2. Watchful waiting

3. Colposcopy

4. Hormonal agents

5. Dilatation and curettage

Correct Answer: 1,4,5

Rationale 1: Hysterectomy may be necessary, although it is generally the least desirable course of action.

Rationale 2: True dysfunctional uterine bleeding is a serious condition that may result in anemia. It may also be symptomatic of other disorders. Watchful waiting is not a primary treatment modality.

Rationale 3: Colposcopy is a test to evaluate the cells of the cervix. It would not be useful in the treatment of DUB.

Rationale 4: The patient may be given agents to correct hormonal imbalance.

Rationale 5: Intervention in dysfunctional uterine bleeding is focused on using the least invasive method that proves effective in relieving the symptoms. Dilatation and curettage is one common procedure used.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 41-4

Question 21

Type: MCMA

The nurse is developing a teaching plan for a postmenopausal woman who has stress incontinence secondary to a prolapsed uterus. The nurse would include which interventions in the teaching plan?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Kegel exercises

2. Increased caffeine intake

3. Use of progesterone supplements

4. Proper perineal care

5. Use of perineal pads

Correct Answer: 1,4,5

Rationale 1: Kegel exercises can strengthen perineal muscle tone, reduce urinary leakage, and minimize uterine prolapse.

Rationale 2: Reducing or eliminating caffeine can reduce urinary frequency and urgency.

Rationale 3: Estrogen, not progesterone, supplements can improve perineal muscle tone in postmenopausal women.

Rationale 4: Proper perineal care is essential with stress incontinence to minimize skin irritation and the potential for infection.

Rationale 5: Use of perineal pads allows the patient to return to her normal daily activities.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 41-4

Question 22

Type: MCMA

A patient is concerned about her risk of cervical cancer because her sister was just diagnosed with the disease. The nurse would discuss which common risk factors?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. History of human papillomavirus (HPV) infections

2. First intercourse before the age of 20

3. Multiple sex partners

4. Long-term use of birth control pills

5. Alcohol abuse

Correct Answer: 1,3,4

Rationale 1: HPV infection is a strong risk factor for development of cervical cancer.

Rationale 2: First pregnancy, not first intercourse, at a young age is a risk factor.

Rationale 3: Having multiple sex partners puts the woman at a higher risk of infections that in turn increase the risk of cervical cancer.

Rationale 4: Use of birth control pills for over 5 years increases the risk of cervical cancer.

Rationale 5: Alcohol abuse has not been shown to be a risk factor for cervical cancer.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 41-5

Question 23

Type: MCSA

A 32-year-old African American woman has just been diagnosed with uterine fibroid tumors. Which statement would the nurse evaluate as indicating further education is necessary to meet the patient goal of understanding this diagnosis?

1. These tumors are frequently seen in African American women.

2. The growth of my tumors is directly linked to my progesterone levels.

3. The tumors tend to develop slowly.

4. These tumors are benign.

Correct Answer: 2

Rationale 1: African American women are most often affected by fibroid tumors.

Rationale 2: Fibroid tumor growth is linked to estrogen production. Progesterone levels are not tied to fibroid tumor growth.

Rationale 3: Fibroid tumors tend to grow slowly.

Rationale 4: Fibroid tumors are benign.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 41-2

Question 24

Type: MCSA

A patient who has been experiencing dysmenorrhea has been diagnosed with endometriosis. The patient asks how this condition is responsible for her pain. What information should the nurse include when teaching the patient about the disorder?

1. The endometrial tissue located outside of the uterus responds to the hormones responsible for menstruation.

2. Elevated levels of follicle-stimulating hormone (FSH) during menstruation are causing the endometrial tissue to contract, resulting in pain.

3. The shedding of the endometrial lining during menstruation is the cause of the cramping.

4. The loss of blood during the menstrual period is causing a hormonal imbalance that is the underlying cause of the pain.

Correct Answer: 1

Rationale 1: Endometriosis is the presence of endometrial tissue outside of the uterus. This tissue is responsive to the hormones that control menstruation. The hormonal changes during menstruation are responsible for the inflammation and pain.

Rationale 2: FSH plays a role in the females reproductive physiology only prior to menstruation.

Rationale 3: Shedding of the endometrial tissue is normal and is not directly responsible for the pain being experienced.

Rationale 4: The blood loss does not cause a hormonal imbalance.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 41-4

Question 25

Type: MCSA

A woman is diagnosed with a cystocele. She states she is relieved the condition is only the result of weakening of the structures that support her uterus. What response by the nurse is indicated?

1. I am glad you have been able to receive some background information about your condition.

2. A cystocele is actually the result of the rectum pushing forward into the vagina.

3. The cystocele has occurred because the bladder is pressing downward on the vagina.

4. This condition is actually caused by a weakening of the uterus itself.

Correct Answer: 3

Rationale 1: The patients information is not correct.

Rationale 2: A protrusion of the rectum is known as a rectocele.

Rationale 3: The cystocele is the result of a weakening of the wall between the vagina and the bladder. This causes the bladder to protrude into the vaginal vault.

Rationale 4: The uterus is not weakened in this condition.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 41-4

Question 26

Type: MCSA

The health care provider has fit an older adult with a pessary to manage her cystocele. What information should the nurse provide for this patient?

1. There is no risk of allergy to this device.

2. The pessary provides only minimal contraceptive protection.

3. The pessary must be removed before sexual intercourse.

4. The pessary may increase the risk for pelvic infections.

Correct Answer: 4

Rationale 1: There is a risk for allergy to the components of the pessary.

Rationale 2: A pessary provides no contraceptive protection.

Rationale 3: A pessary may be worn during sexual intercourse.

Rationale 4: The insertion of a foreign, nonsterile body into the vagina can increase the risk for infections.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 41-4

Question 27

Type: MCSA

A couple has come to the health care providers office with concerns about infertility. While collecting data, the woman questions the nurse about who is at fault for the inability to conceive. Which statement by the nurse is most appropriate at this time?

1. As long as you get pregnant, there is no need to place blame.

2. The causes of infertility are varied. Determining the cause in each case requires further investigation.

3. Unfortunately, infertility is usually the fault of the woman.

4. Most causes of infertility are never explained.

Correct Answer: 2

Rationale 1: It is too premature to discuss pregnancy, and this particular response belittles the couples concerns.

Rationale 2: Infertility is the inability to conceive after 12 months of appropriately timed intercourse. Diagnostic testing and a review of the medication history will be needed to determine the underlying cause.

Rationale 3: The cause of infertility is described as 1/3 female related, 1/3 male related, and 1/3 a combination or unexplained.

Rationale 4: In many cases, the cause of infertility is discovered and can be corrected.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 41-5

Question 28

Type: MCSA

A couple has been experiencing infertility for 4 years. After becoming pregnant using the zygote intrafallopian transfer (ZIFT) procedure, the woman is diagnosed with an ectopic pregnancy. The health care provider opts to manage the condition with methotrexate. Which nursing diagnosis will the nurse include in this patients plan of care?

1. Parenting, Readiness for Enhanced

2. Grieving, Risk for Complicated

3. Maternal/Fetal Dyad, Risk for Disturbed

4. Fluid Volume Excess

Correct Answer: 2

Rationale 1: Readiness for Enhanced Parenting is not an appropriate nursing diagnosis for this couple.

Rationale 2: Methotrexate will kill the cells growing ectopically, which will end the pregnancy. This couple is likely to experience complicated grief.

Rationale 3: The maternal/fetal dyad will cease to exist with this therapy.

Rationale 4: Fluid Volume Excess is not a complication of this therapy.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 41-3

Question 29

Type: MCSA

A colposcopy has been ordered for a patient. What should be included in the education provided to the patient?

1. Sexual intercourse is restricted for 2 days before the procedure.

2. The patient may expect to feel referred shoulder pain in the first few days after the procedure.

3. Heavy vaginal bleeding is likely after the procedure.

4. The procedure will likely require the patient to stay overnight at the hospital.

Correct Answer: 1

Rationale 1: Semen can interfere with the test results.

Rationale 2: Referred shoulder pain may be seen with a laparoscopic procedure, not with colposcopy.

Rationale 3: Bleeding after the procedure is not unusual, but it should not be heavy.

Rationale 4: The procedure is normally performed in the health care providers office; hospitalization is not indicated.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 41-4

Question 30

Type: MCSA

The nurse is providing care to a 20-year-old woman who has come to the emergency department with reports of having been sexually assaulted a few hours ago. The victim expresses concerns about contact with the authorities. What information should the nurse provide?

1. You must agree to notification of law enforcement in order to receive referrals to support services.

2. You are the victim of a crime and will need to make the report.

3. The police will be able to protect you from further violence.

4. Before any information can be disclosed, you will have to give consent.

Correct Answer: 4

Rationale 1: The refusal to participate in a legal investigation does not limit the victims access to supportive or medical services.

Rationale 2: The patient does not have to make a report.

Rationale 3: Law enforcement is not always able to protect individuals from violence.

Rationale 4: Seeking treatment does not automatically allow law enforcement authorities access to the patient and her medical information.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 41-6

Question 31

Type: MCSA

A 25-year-old woman reports to her health care providers office with reports of having been sexually assaulted by an acquaintance 4 days ago. The woman is concerned about pregnancy. What action is indicated by the nurse?

1. Inform the woman she likely is already pregnant and will not benefit from emergency contraception.

2. Assess the womans financial resources to obtain the emergency contraception preparation.

3. Determine any potential allergies to the components of the emergency contraception pills.

4. Advise the woman that emergency contraception is administered only in the first 72 hours after the attack.

Correct Answer: 4

Rationale 1: Advising the woman she is already pregnant may not be correct. In addition, offering this medical counseling is beyond the nurses scope of practice.

Rationale 2: There is no need to assess for financial resources to obtain the medication.

Rationale 3: There is no need to assess for allergies to obtain the medication.

Rationale 4: Emergency contraception is provided in the first 72 hours after a sexual assault; the patient has passed the window of eligibility.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 41-6

Question 32

Type: MCSA

A woman is being treated in the emergency department after being sexually assaulted. During the gathering of evidence, the nurse collects samples for toxicology. The patient questions why this is being done, as she has been the victim of an attack. What information can the nurse provide?

1. The toxicology report will provide the police with information about the victims potential exposure to sexually transmitted infections.

2. The toxicology report can provide information as to whether the woman was drunk at the time of the assault.

3. The toxicology report will enable the authorities to determine if the womans recall of the events is credible.

4. The use of toxicology can assess if the woman was under the influence of drugs at the time of the assault.

Correct Answer: 4

Rationale 1: Toxicology reports do not provide information about sexually transmitted infections.

Rationale 2: The presence of alcohol is determined by blood alcohol testing.

Rationale 3: The establishment of credibility is not the motivating force behind the collection of toxicology samples.

Rationale 4: The use of toxicology can determine if the woman was under the influence of drugs at the time of the assault; drugs may have hindered her ability to divert or fight off an attack.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 41-6

Question 33

Type: MCSA

A 40-year-old patient undergoes a total abdominal hysterectomy. After the procedure, the patient expresses an interest in hormone replacement therapy. What information should the nurse provide?

1. The underlying reason for the hysterectomy will be the primary determinant of the type of hormone replacement therapy selected.

2. This patient may be managed by an estrogen/progestin compound.

3. Hormone replacement therapy is not indicated after this particular procedure.

4. The patient is close enough to menopause not to be a candidate for hormone replacement therapy.

Correct Answer: 3

Rationale 1: The reason for the hysterectomy does not direct hormone replacement therapy.

Rationale 2: This patient will not require hormone replacement therapy, as the ovaries are still in place.

Rationale 3: A total abdominal hysterectomy is the removal of the uterus and cervix. The fallopian tubes are not removed during this procedure. As the woman has her own ovaries, hormone replacement therapy is not indicated.

Rationale 4: The patients age is not the criterion for hormone replacement therapy.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 41-4

Question 34

Type: MCSA

A patient has been diagnosed with vulvovaginal candidiasis (VCC). The nurse would evaluate the teaching goal for this patient as successful if the patient makes which statement?

1. I will take the entire 28-day course of antibiotics.

2. I will douche each evening to cleanse my vaginal area.

3. Now that I know the symptoms, if I get another infection I can use over-the-counter medications.

4. I will start wearing cotton underwear.

Correct Answer: 4

Rationale 1: Antibiotics for VCC are given in 1-, 3-, or 7-day courses.

Rationale 2: Douching should be avoided.

Rationale 3: Recurrent vaginitis requires further consultation with the health care provider.

Rationale 4: Cotton underwear allows for better absorption of moisture.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 41-2

Question 35

Type: MCMA

The school nurse is providing health promotion information regarding menstruation to a group of girls in middle school. Which strategies should the nurse suggest to avoid toxic shock syndrome (TSS)?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Use superabsorbent tampons.

2. Change tampons at least every 4 hours.

3. Alternate the use of tampons and sanitary napkins.

4. Drink additional fluids while menstruating.

5. Take anti-inflammatory medications daily while wearing tampons.

Correct Answer: 2,3

Rationale 1: The use of superabsorbent tampons increases the risk that they are not changed frequently enough. This in turn increases the risk for TSS.

Rationale 2: Primary prevention includes changing tampons every 2 to 4 hours.

Rationale 3: Alternating tampons and sanitary napkins reduces the risk of TSS.

Rationale 4: There is no connection between fluid intake and the risk of TSS.

Rationale 5: There is no connection between the use of anti-inflammatory medications and reduction of TSS.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 41-4

 

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