A nurse is assessing an older adult client's perception of sexuality. Which of the following statements made by the client indicates a need for intervention?

"I do not have to worry about using protection now that I am in menopause."

use lubricants to help prevent pain during sex."

1 feel more self-conscious with how I look now that I am older."

"I still think about having sex at my age?

Answer and Explanation

The Correct Answer is A

A.   This statement reflects a misconception about menopause and sexual health, indicating a need for education on safe sex practices.
B.   This statement indicates the client is taking steps to address discomfort during sexual activity, which is appropriate.
C.   This statement reflects body image concerns commonly experienced by older adults and may warrant further exploration but does not necessarily indicate a need for immediate intervention.
D.   This statement indicates a normal interest in sexual activity and does not necessarily indicate a need for intervention.

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Correct Answer is C

Explanation

A. This response is associated with cranial nerve II, the optic nerve.

B. Tongue position is associated with cranial nerve XII, the hypoglossal nerve.

C. A symmetrical smile is indicative of cranial nerve VII, the facial nerve.

D. This action is associated with cranial nerve XI, the accessory nerve.

A. Dietary intake B. Oxygen saturation C. Pain level D. Blood pressure E. Allergies F. Informed consent

Correct Answer is ["A","C","E","F"]

Explanation

A. The nurse asks the client when was the last time they ate or drank anything, and verifies that they are fasting according to the preoperative instructions. Dietary intake is important because the client should have an empty stomach to prevent aspiration during anesthesia.

B. The oxygen saturation remains at 96% on room air, which is within the normal range. No immediate follow-up is needed based on this parameter.
C. The client's pain level has increased from 6 to 8 on a scale of 0 to 10. This increase in pain intensity requires further assessment and intervention to ensure adequate pain management before surgery.
D. The client's blood pressure remains relatively stable within normal limits.

However, the increase in pain intensity may impact blood pressure, and it's essential to monitor for any significant changes.
E. The allergies are important to identify because the client is allergic to shellfish, latex, and penicillin, which could cause anaphylaxis or other adverse reactions during surgery or anesthesia. The nurse should ensure that the client is wearing an allergy bracelet and that the surgical team is aware of the allergies.
F. The informed consent is essential to obtain before any invasive procedure. The nurse should verify that the client understands the risks, benefits, and alternatives of the surgery and that the consent form is signed and witnessed.

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A nurse is assessing an older adult client's perception of sexuality. Which of the following statements made by the client indicates a need for intervention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's cranial nerve VII. Which of the following responses should the nurse expect?

Correct Answer is C

Explanation

Correct Answer is ["A","C","E","F"]

Explanation

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