An adult client was born as a female gender but has a male gender identity. Which statement by the nurse demonstrates a therapeutic approach of respecting the client's gender identity?

"Do you go by he, she, or they?"

"What pronouns do you go by?""

"What led to this hospital admission?"

"What brings you in today?"

Answer and Explanation

The Correct Answer is B

A. "Do you go by he, she, or they?" This question is direct and acknowledges the importance of pronouns, but it might be better phrased to be more open-ended and respectful.

B. "What pronouns do you go by?" This is the most respectful and open-ended approach, allowing the client to express their preferred pronouns without making assumptions. It demonstrates a clear understanding of the importance of gender identity and respects the client's autonomy.

C. "What led to this hospital admission?" While this question is relevant to the client’s care, it does not address the client's gender identity directly, which is crucial in this context.

D. "What brings you in today?" Similar to option C, this question focuses on the reason for the hospital visit but does not address the client's gender identity, missing an opportunity to show respect for their identity.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. Administer a saline enema for constipation. Administering a saline enema may be necessary for constipation, but it is not directly related to managing bone marrow suppression.

B. Initiate contact precautions. Contact precautions are typically used for infectious diseases. In clients with bone marrow suppression, neutropenic precautions are more appropriate to prevent infections.

C. Encourage independence in the completion of ADLs. While promoting independence is important, clients with bone marrow suppression may be fatigued or immunocompromised, requiring assistance to reduce infection risk and conserve energy.

D. Monitor oral mucosa daily. Monitoring oral mucosa daily is crucial because clients with bone marrow suppression are at risk for mucositis, which can lead to infection and impact nutrition and hydration.

A. Risk for aspiration B. Risk for falls C. Risk for impaired skin integrity D. Decreased intracranial adaptive capacity

Correct Answer is A

Explanation

A. Risk for aspiration: The gag reflex is crucial for preventing aspiration. An absent gag reflex significantly increases the risk of food or fluids entering the airway, leading to aspiration pneumonia or choking.

B. Risk for falls: While risk for falls is a concern in stroke patients, the immediate risk related to the absence of the gag reflex is more directly associated with aspiration.

C. Risk for impaired skin integrity: Impaired skin integrity is important but is a secondary concern compared to the risk of aspiration due to the absence of the gag reflex.

D. Decreased intracranial adaptive capacity: This diagnosis relates to the brain's ability to adapt to changes. While important, it is less immediately relevant compared to the risk of aspiration from the loss of the gag reflex.

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An adult client was born as a female gender but has a male gender identity. Which statement by the nurse demonstrates a therapeutic approach of respecting the client's gender identity?

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Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has bone marrow suppression related to chemotherapy treatments. Which of the following interventions should the nurse include in the plan?

Correct Answer is D

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Correct Answer is A

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