Question 1

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

Accepted Answer

Masturbation is a normal sexual activity, and if a nurse encounters a client masturbating, the appropriate action is to respect the client's privacy. Saying "excuse me" and leaving the room allows the client to have their privacy and dignity.

Question 2

A 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 should the nurse do first?

Accepted Answer

The nurse should first advise the young woman that she can still get pregnant before an orgasm occurs. This will address the immediate concern the young woman has about preventing pregnancy during sexual intercourse. After this immediate concern is addressed, the nurse can then provide education about sexually transmitted infections with unprotected sex and explore any sexual myths the young woman might believe. It is also important to provide information about contraceptive options, including the proper use of condoms to prevent both pregnancy and sexually transmitted infections.

Question 3

During discussion of family,the client speaks about an adult son who is a homosexual.The client expresses concern about his son,stating: "I am so worried about him.I know he is going to hell." What is the most important fact for the nurse to consider in formulating a response to this client's concern?

Accepted Answer

It is important for the nurse to recognize that the client's beliefs about sexuality are likely influenced by their culture and religion. By acknowledging this, the nurse can have a more respectful and empathetic response to the client's concerns. It is not appropriate or helpful to dismiss the client's concerns or make assumptions about what is "normal" or "acceptable" in society.

Question 4

After client teaching on testicular self-exam,Mr.Williams is restating to the nurse the steps of the procedure.What facts stated by Mr.Williams indicate a need for clarification of information? (Select all that apply.)

Accepted Answer

A) Testicular self-exams should be done monthly, not daily, to detect changes over time without causing unnecessary anxiety or false positives.D) The epididymis is located on the top and back of the testicle, not the bottom and front. Misunderstanding its location could lead to confusion during the exam.E) The epididymis has a different texture compared to the testicle; it is softer and may feel slightly bumpy, not as smooth as the testicle. Misunderstanding this could lead to unnecessary concern or missing important findings.

Question 5

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?

Accepted Answer

The P in PLISSIT stands for permission and involves giving the client permission to talk about sexual concerns. Acknowledging the client's spoken and unspoken sexual concerns when providing care is the best action that reflects this component. A is incorrect because the nurse should have the training and expertise to discuss sexual topics without needing permission from the physician. B is incorrect because informed consent is not required for providing sexual information. D is incorrect because arranging for peer counseling sessions falls under the S (specific suggestions) component of the PLISSIT format.

Question 6

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

Accepted Answer

The "IT" section of the PLISSIT model stands for "Intensive Therapy." This involves referring the client to a qualified sex therapist for specialized treatment. Therefore, the best choice is D. A is not directly related to intensive therapy and may not always provide reliable information. B may be helpful, but it is not considered intensive therapy. C does not involve further treatment and is only an evaluation of previous interventions.

Question 7

A 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?

Accepted Answer

Alcohol is a central nervous system depressant which affects judgment, leading to impaired decision-making and increased risk-taking behavior, including unprotected sex which can result in unintended pregnancies. The student's understanding of the link between alcohol and erectile dysfunction may not be entirely accurate, but the nurse's response should address the underlying issue of alcohol's effect on behavior and decision-making. Option B is incorrect as erectile dysfunction can occur even after occasional alcohol consumption. Option C is also incorrect as alcohol is known to impair sexual function. Finally, Option D is incorrect as erectile dysfunction can occur in younger men as well.

Question 8

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?

Accepted Answer

LI stands for "Limited Information" and refers to providing accurate but concise information in response to any sexual questions that may come up during the assessment. The PLISSIT format (Permission, Limited Information, Specific Suggestions, and Intensive Therapy) is a model used by nurses to help clients with sexual dysfunction. Option A is incorrect because limiting all information related to sexual side effects of treatments and medications can result in the client not understanding the potential risks and complications. Option C is incorrect because using slang terms can confuse or offend the client, and the nurse should always use proper terminology. Option D refers to the "SS" section of the PLISSIT model (Specific Suggestions) and is not relevant to the question asking about the "LI" section.

Question 9

A 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?

Accepted Answer

If both partners in a relationship share the same level of sexual desire, whether high or low, it may not be considered a problem for them. The key issue is the compatibility of sexual desires and needs between partners, not the level of desire in isolation.

Question 10

Mrs.Cape is a 56-year-old woman who had a right-sided mastectomy last year for breast cancer.She is currently cancer free,and is in the health clinic to speak with the nurse about her sexual relationship with her husband of 30 years.She tells the nurse that while she still has sexual desires,her body does not respond the same way it used to.She notes that she does not get the same level of excitement that she used to.In developing a plan of care,what nursing diagnosis is appropriate for Mrs.Cape?

Accepted Answer

Mrs. Cape's statement about her body not responding the same way and not experiencing the same level of excitement indicates an ineffective sexuality pattern. While anxiety, deficient knowledge and disturbed body image may also be appropriate nursing diagnoses, they do not fully encompass Mrs. Cape's concerns about her sexual relationship.

Question 11

The daughters of an 80-year-old man who is aphasic after suffering a cerebrovascular accident 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 nurse's priority action?

Accepted Answer

The nurse's priority action should be to assess the client's penis for irritation from the catheter. This behavior could be a sign of discomfort or irritation rather than inappropriate behavior, especially considering the client's condition (aphasia following a cerebrovascular accident). Addressing potential physical causes is a fundamental nursing responsibility.

Question 12

The nurse who is teaching a client about breast awareness describes inspection of the breasts before a mirror.Which findings should the nurse tell the client should be evaluated by a health care provider? (Select all that apply.)

Accepted Answer

Puckering of the skin, scaling on a nipple, and a change in shape are all potential signs of breast cancer and should be evaluated by a healthcare provider. Free movement of the breast over the chest wall and symmetry of the nipples are normal findings.

Question 13

A nurse colleague is outraged that a grandchild's daycare centre is planning a class on sexuality for 3- and 4-year-olds.She is intending on speaking to the daycare about their plans.What key concept should be included in this conversation?

Accepted Answer

The answer of A nurse colleague is outraged that a...

Question 14

The parents of a 17-month-old boy are very concerned because the baby touches his genital area during diaper changes.What information should the nurse share with the parents?

Accepted Answer

At 17 months, the child is not engaging in sexual behavior but rather exploring his body, which is a normal developmental milestone. It is important for the parents to acknowledge and accept this behavior as a normal part of their child's development. Discouraging or shaming the child for engaging in this behavior can lead to negative attitudes about sexuality later in life.

Question 15

A 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?

Accepted Answer

The presence of a white, cheesy discharge after treatment for recurrent candidiasis indicates that the infection may still be present or that a secondary infection may have occurred. Examination and treatment of the sexual partner is necessary to prevent reinfection and ongoing symptoms. Referral for excision surgery, stronger antibiotics or routine douching are not indicated in this scenario.

Question 16

Ms.Jenner is a community health nurse teaching sexual health to teenagers in the local high school.Which of the following conversations heard in the hallway following her lesson indicates the need for follow-up teaching?

Accepted Answer

While preventing pregnancies can be one way to reduce the risk of sexually transmitted infections, it is not a foolproof method. It is important for Ms. Jenner to follow-up with more comprehensive information on how to prevent sexually transmitted infections such as using condoms, getting tested regularly, and practicing abstinence. The other conversations in the hallway - A, C, and D - do not necessarily indicate a need for immediate follow-up teaching as they are accurate statements about sexual health.

Question 17

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

Accepted Answer

The SS in the PLISSIT model stands for "Specific Suggestions," where the healthcare provider offers targeted advice based on their knowledge and the client's specific situation, including how diseases or conditions affect sexuality.

Question 18

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

Accepted Answer

There is no scientific evidence to support the idea that sexual activity weakens individuals before physical activity. The coach's belief is a common myth among athletes that is not supported by facts.

Question 19

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?

Accepted Answer

The woman with vaginismus experiences involuntary muscle spasms in the pelvic floor muscles, making any penetration uncomfortable or even impossible. Therefore, the nurse should obtain smaller than normal vaginal speculums that will fit comfortably into the patient's vagina without causing undue pressure or pain. The culture swabs and equipment for pre-examination douche are not necessary for this examination, and the use of a vaginal suppository would not be appropriate for the assessment of vaginismus.

Question 20

Which statement,made by a postmenopausal woman may indicate the need for further assessment by the nurse?

Accepted Answer

This statement may indicate a lack of interest or concern about sexual health, which could be due to underlying issues such as depression, relationship problems, or misconceptions about postmenopausal sexuality that may need further assessment.

Quiz 45: Sexuality