Preview Extract
Chapter 48
1. The nurse is instructing a client about the timing of ovulation during the menstrual cycle.
While reviewing the laboratory analysis of the client’s hormones, the nurse would examine
for increases in which of following levels?
1. Luteinizing hormone
2. Progesterone
3. Estrogen
4. Gonadotropin-releasing hormone
Answer: Luteinizing hormone
Rationale:
When the luteinizing hormone peaks, ovulation occurs. Increases in the progesterone level
would occur after ovulation. Estrogen levels will peak prior to the luteinizing hormone
release, which is necessary for ovulation. The gonadotropin-releasing hormone stimulates the
anterior pituitary to release the follicle-stimulating hormone, which occurs prior to ovulation.
2. A client with a menstrual cycle of 28 days asks about the timing of ovulation. The nurse
would respond by stating that ovulation would most likely occur on day:
1. 14 to 16.
2. 12 to 14.
3. 10 to 12.
4. 20 to 22.
Answer: 14 to 16.
Rationale:
Ovulation will occur at midcycle. Because there are 28 days in the client’s menstrual cycle,
ovulation would occur on day 14 to. The other answers are not considered midcycle for the
client.
3. A client is having a routine prostate examination. An important question that the nurse
would ask at this time is:
1. “Do you have difficulty with urination?”
2. “Do you experience constipation?”
3. “Do you have polyuria in the morning?”
4. “Do you take laxatives or stool softeners?”
Answer: “Do you have difficulty with urination?”
Rationale:
When the prostate is enlarged, it disrupts urinary flow and causes several urinary symptoms.
Experiencing constipation is not associated with the prostate gland. Polyuria in the morning
does not indicate any signs of prostate disease. Taking laxatives or stool softeners does not
affect the function of the prostate.
4. During the assessment of the medication history for a client with an enlarged prostate, the
nurse would inquire about the use of:
1. Saw palmetto.
2. Fish oil.
3. Ginko.
4. Green tea.
Answer: Saw palmetto.
Rationale:
Saw palmetto is the herbal supplement used to treat clients with an enlarged prostate gland.
The other herbal remedies are not indicated for clients with prostate enlargement.
5. During a physical examination, a male client reports discharge from the urinary meatus.
The discharge is not visible to the nurse. The nurse would first instruct the client to:
1. Strip the penis to bring discharge to the meatus for culture.
2. Return to the clinic when the discharge occurs.
3. Go to the emergency department for further testing.
4. Continue to watch for other signs of sexually transmitted diseases.
Answer: Strip the penis to bring discharge to the meatus for culture.
Rationale:
The client should strip the penis to bring discharge to the meatus so that testing can be
performed. Returning to the clinic when the discharge occurs is appropriate, but the initial
action would be to attempt to obtain a culture of the fluid. Going to the emergency
department is unnecessary because the client can be treated and further tested during the time
of the examination. Watching for other signs of sexually transmitted diseases is premature
because the nurse does not know if the discharge is related to a sexually transmitted disease.
6. The nurse is assisting the health care provider with a routine prostate examination. The
nurse would position the client:
Select all that apply.
1. Leaning over the examination table.
2. On the left side with right knee drawn up.
3. On the edge of the table with the rectum exposed.
4. On the right side with both knees flexed.
5. Standing in the most comfortable position.
Answer: 1. Leaning over the examination table.
2. On the left side with right knee drawn up.
Rationale:
Leaning over the examination table. This is a correct anatomical position for a routine
prostate examination. On the left side with right knee drawn up. This is a correct anatomical
position for a routine prostate examination. On the edge of the table with the rectum exposed.
This is not the recommended position to facilitate examination of the prostate. On the right
side with both knees flexed. This is not the recommended position to facilitate examination of
the prostate. Standing in the most comfortable position. This is not the recommended position
to facilitate examination of the prostate.
7. A male client states that he is having problems with impotence. Which of the following
diseases should the nurse question as part of the client’s past medical history?
Select all that apply.
1. Hypertension
2. Diabetes
3. Alcoholism
4. Herpes
5. HIV
Answer: 1. Hypertension
2. Diabetes
3. Alcoholism
Rationale:
Hypertension. Hypertension clients may be taking antihypertensive medication, which may
affect the erection of male clients. Diabetes. Diabetes will impair the circulation to the penis,
thus creating difficulty with obtaining an erection. Alcoholism. Alcoholism has been shown
to affect the ability for the male client to achieve an erection. Herpes. Herpes will not impair
the male client’s ability to achieve an erection. HIV. HIV will not impair the male client’s
ability to achieve an erection.
8. During a routine physical examination, a nurse instructs a client about safe sex practices.
Which of the following should the nurse include in her teaching?
Select all that apply.
1. Sexually active individuals should be tested for HIV.
2. Condoms provide a means of safer sex.
3. Limit sexual partners.
4. Use lubricants such as oils and creams during sex.
5. Oral sex will prevent sexually transmitted diseases.
Answer: 1. Sexually active individuals should be tested for HIV.
2. Condoms provide a means of safer sex.
3. Limit sexual partners.
Rationale:
Sexually active individuals should be tested for HIV. All sexually active individuals should
get tested for HIV. The reason HIV has become so widespread is because individuals do not
know they have the disease. Condoms provide a means of safer sex. Condoms do provide a
means of safer sex, but they do not guarantee safe sex. Limit sexual partners. Limiting sex
partners is correct, but optimally clients should have a monogamous partner. Use lubricants
such as oils and creams during sex. Individuals should not use oils and creams; a better
choice is to use water-soluble lubricants such as KY jelly. Oral sex will prevent sexually
transmitted diseases. Oral sex is not safe for the transmission of sexually transmitted diseases.
9. While obtaining a social history on a male client regarding his patterns of alcohol use, the
nurse becomes suspicious of a problem with drinking. The nurse continues assessing the
client using the CAGE questionnaire. The nurse would ask, “Have you ever:
Select all that apply.
1. Felt the need to cut down on drinking?”
2. Felt annoyed by criticism of your drinking?”
3. Felt guilty about drinking?”
4. Taken a drink first thing in the morning?”
5. Felt the desire to stop drinking?”
Answer: 1. Felt the need to cut down on drinking?”
2. Felt annoyed by criticism of your drinking?”
3. Felt guilty about drinking?”
4. Taken a drink first thing in the morning?”
Rationale:
Felt the need to cut down on drinking?” This question is one of the first four answers because
these are considered part of the CAGE questionnaire, which stands for cutting down,
annoyance if criticized, guilty feelings, eye-openers. These screening questions are used to
help identify alcohol abuse. Felt annoyed by criticism of your drinking?” This question is one
of the first four answers because these are considered part of the CAGE questionnaire, which
stands for cutting down, annoyance if criticized, guilty feelings, eye-openers. These screening
questions are used to help identify alcohol abuse. Felt guilty about drinking?” This question
is one of the first four answers because these are considered part of the CAGE questionnaire,
which stands for cutting down, annoyance if criticized, guilty feelings, eye-openers. These
screening questions are used to help identify alcohol abuse. Taken a drink first thing in the
morning?” This question is one of the first four answers because these are considered part of
the CAGE questionnaire, which stands for cutting down, annoyance if criticized, guilty
feelings, eye-openers. These screening questions are used to help identify alcohol abuse. Felt
the desire to stop drinking?” This question is not part of the CAGE questionnaire.
10. A client is having a breast examination and is asked by the nurse to position her arms at
her side and then press her hands to her hips. The client asks why she has to perform so many
different positions for the examination. The nurse would respond by stating that several
positions:
1. Pull ligaments, causing dimpling if a tumor is present.
2. Help test motor strength.
3. Help to determine state of balance.
4. Provide a neurological assessment along with the breast examination.
Answer: Pull ligaments, causing dimpling if a tumor is present.
Rationale:
Several maneuvers will move the breast and pull the suspensory ligaments in such a way that
a tumor would cause dimpling or a bulge. Testing motor strength or state of balance is not
done during a breast examination and is not the reason for the client’s maneuvering.
Neurological assessments are not the reason for maneuvering the extremities during a breast
examination.
11. During a routine breast examination of a client, the nurse notes a small amount of nipple
discharge. The nurse would:
Select all that apply.
1. Collect a specimen on slide.
2. Document the finding.
3. Ask the client if this has occurred before.
4. Send the specimen to the lab.
5. Tell the client she may have cancer.
Answer: 1. Collect a specimen on slide.
2. Document the finding.
3. Ask the client if this has occurred before.
4. Send the specimen to the lab.
Rationale:
Collect a specimen on slide. The drainage should be collected on a specimen slide. Document
the finding. The nurse would document the finding so that future comparisons can be made if
the drainage would continue. Ask the client if this has occurred before. The nurse would
question if this has occurred before and when the drainage began. Send the specimen to the
lab. The nipple drainage would be sent to the lab for analysis. Tell the client she may have
cancer. Telling the client she has cancer is inappropriate; discharge does not always indicate a
sign of cancer.
12. During a routine pelvic examination the nurse instructs the client to bear down. The nurse
understands that the reason for this is to assess for:
Select all that apply.
1. Cystoceles.
2. Rectoceles.
3. Prolapsed uterus.
4. Ovarian cysts.
5. Vaginal tumors.
Answer: 1. Cystoceles.
2. Rectoceles.
3. Prolapsed uterus.
Rationale:
Cystoceles. Cystoceles, or relaxation of the anterior vagina wall under the urinary bladder, is
assessed by asking the client to bear down so that the health care provider can determine the
presence of the structures through the vagina. Rectoceles. Rectoceles, or relaxation of the
posterior vaginal wall over the rectum, is assessed by asking the client to bear down so that
the health care provider can determine the presence of the structures through the vagina.
Prolapsed uterus. Prolapsed uterus, or the protrusion of the uterus into the vaginal wall, is
assessed by asking the client to bear down so that the health care provider can determine the
presence of the structures through the vagina. Ovarian cysts. Ovarian cysts are palpated
manually and the client does not have to bear down to determine their presence. Vaginal
tumors. Vaginal tumors may be detected by visual inspection of the pelvis thorough a
speculum device.
13. The nurse is instructing a female client about sexual functioning changes that may result
from the aging process. Which of the following nursing diagnoses would the nurse
incorporate in the plan of care for this client regarding sexual intercourse?
Select all that apply.
1. Alteration in Comfort
2. Impaired Skin Integrity
3. Impaired Physical Mobility
4. Risk for Infection
5. Risk for Injury
Answer: 1. Alteration in Comfort
2. Impaired Skin Integrity
3. Impaired Physical Mobility
4. Risk for Infection
Rationale:
Rationale:
Alteration in Comfort. Intercourse may be painful because of the estrogen loss and drying of
the vaginal mucosa. Impaired Skin Integrity. Impaired skin integrity may result because of
the thinning of the vaginal mucosa and loss of adipose tissue. Impaired Physical Mobility.
The elderly population may have impaired mobility, which will decrease the libido of the
client. Risk for Infection. With intercourse, the vaginal tissue may tear and could result in
infection of the disrupted tissue. Risk for Injury. The client is not at risk for injury during
sexual intercourse.
14. A female client is experiencing hot flashes. The client asks the nurse how long will these
last. The nurse would respond by stating that hot flashes:
1. May last up to 5 years.
2. Usually occur once a month.
3. Will occur for 2 years.
4. Will not occur after the first year.
Answer: May last up to 5 years.
Rationale:
Hot flashes are unpredictable and may last up to 5 years, especially if the client is not taking
hormone replacement therapy.
15. Which of the following nursing diagnoses would the nurse include in the plan of care
with an older client experiencing urinary incontinence?
Select all that apply.
1. Risk for Social Isolation
2. Anxiety
3. Altered Comfort; pain
4. Activity Intolerance
5. Risk for Injury
Answer: 1. Risk for Social Isolation
2. Anxiety
Rationale:
Risk for Social Isolation. The client with urinary incontinence may experience social isolation
because of the embarrassment of the episodes and the potential odor for the client. Anxiety.
The client with urinary incontinence may experience anxiety because of the frequency of
incontinence episodes. The client may wear a protective undergarment to avoid having to
quickly empty the bladder or to control the incontinence episode. Altered Comfort; pain.
Urinary incontinence is not associated with pain. Activity Intolerance. Urinary incontinence
will not impair the client’s ability to perform activities of daily living. Risk for Injury. Risk
for injury is incorrect because the client is not prone to injury with episodes of incontinence.
16. A young adult male asks the nurse about the frequency of performing self-testicular
exams. The nurse would respond by stating that testicular self-exams:
1. Have shown to cause more harm than benefit.
2. Are unnecessary for the client’s age.
3. Should be performed once a month.
4. Are very beneficial the more they are performed.
Answer: Have shown to cause more harm than benefit.
Rationale:
Testicular self-exams have been shown to cause more harm than benefit, according to the
United States Preventative Service task Force (USPSTF). The guidelines of the USPSTF state
that routine exams should not be performed. The guidelines do not indicate that self-testicular
exams are beneficial the more they are performed.
17. A 20-year-old female asks the nurse when she should begin having pelvic examinations.
The nurse would respond by asking:
1. “Are you sexually active?”
2. “Are you on any medications?”
3. “Do you have a boyfriend?”
4. “Are you pregnant?”
Answer: “Are you sexually active?”
Rationale:
The United States Preventive Task Force (USPSTF) recommends that sexually active females
have pelvic examinations when they are sexually active. Asking about medications is too
broad of a question and does not give the nurse information on the client’s sexual practices.
Having a boyfriend does not always indicate that the client is sexually active. Pregnancy is a
reason for a pelvic examination, but the nurse should not assume that the client may be
pregnant.
18. A female client states the she has a strong family history of ovarian cancer. The nurse
recommends screening for this disease by obtaining a(n):
Select all that apply.
1. Transvaginal ultrasound.
2. Serum-CA-125 level.
3. Record of menstrual cycles.
4. Abdominal x-ray.
5. CT scan.
Answer: 1. Transvaginal ultrasound.
2. Serum-CA-125 level.
Rationale:
Transvaginal ultrasound. Transvaginal ultrasound is a recommended practice for females with
strong family histories of ovarian cancer, according to the American Cancer Society. SerumCA-125 level. Obtaining serum CA-125 levels is a recommended practice for females with
strong family histories of ovarian cancer, according to the American Cancer Society. Record
of menstrual cycles. Obtaining records of menstrual cycles is not a recommended screening
practice for ovarian cancer. Abdominal x-ray. Abdominal x-rays are not a recommended
screening practice for ovarian cancer. CT scan. CT scans are not a recommended screening
practice for ovarian cancer.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
