The nurse is evaluating a transgender female client in the emergency department who is taking estrogen therapy. Which of the following assessment findings would be of priority concern for the nurse?

Client reports having intermittent mild headaches.

Client reports some erectile dysfunction.

Client reports having dyspnea and chest pain.

Client reports having elevated liver function tests.

Answer and Explanation

The Correct Answer is C

Choice A reason: Intermittent mild headaches can be a side effect of estrogen therapy, but they are generally not life-threatening. While they should be monitored and managed, they do not constitute an immediate priority compared to more severe symptoms.

Choice B reason: Erectile dysfunction is a common side effect of estrogen therapy in transgender females. Although it can affect quality of life, it is not an urgent medical concern and does not require immediate intervention.

Choice C reason: Dyspnea (difficulty breathing) and chest pain are potentially serious symptoms that could indicate cardiovascular issues, including pulmonary embolism, which is a known risk associated with estrogen therapy. These symptoms require immediate attention and intervention to rule out life-threatening conditions.

Choice D reason: Elevated liver function tests can occur with estrogen therapy and should be monitored over time. However, while they indicate a need for further investigation and possible adjustment of therapy, they are not as immediately critical as symptoms of dyspnea and chest pain.

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Correct Answer is D

Explanation

Choice A reason: While evaluating what went wrong and developing policies for future incidents is important, this statement is more suited for an after-action review or a quality improvement session. A critical incident stress debriefing focuses on the emotional and psychological support for staff rather than policy evaluation.

Choice B reason: Excluding ancillary personnel from the debriefing session is inappropriate. All staff involved in the incident, including ancillary personnel, should be included in the debriefing to address their emotional and psychological needs. This statement does not support the inclusive nature of debriefing sessions.

Choice C reason: Passing around the disaster written policy for review is not appropriate for a stress debriefing session. The purpose of a debriefing is to provide a safe space for staff to express their emotions and experiences rather than reviewing policies.

Choice D reason: This statement is appropriate for a critical incident stress debriefing as it encourages staff to express their feelings openly and assures them of confidentiality. Creating a safe and supportive environment is essential for addressing the emotional and psychological impact of the incident on staff.

A. Arrange for the client to remain on bedrest. B. Tell the client to remain calm. C. Encourage the client to share their feelings. D. Give the client time to rest and return later for your assessment.

Correct Answer is C

Explanation

Choice A reason: Arranging for the client to remain on bedrest may not address the underlying reasons for the client's upset and agitation. While physical rest can be beneficial, it is more important to address the client's emotional and psychological needs through communication and support.

Choice B reason: Telling the client to remain calm can be perceived as dismissive and may not effectively alleviate their distress. It is important for the nurse to acknowledge the client's feelings and provide a supportive environment for them to express themselves.

Choice C reason: Encouraging the client to share their feelings is the best action to assist the client. By providing a supportive and empathetic environment, the nurse can help the client express their emotions, identify the cause of their distress, and work together to find appropriate solutions. This approach promotes therapeutic communication and can lead to a more accurate assessment and effective care plan.

Choice D reason: Giving the client time to rest and returning later for the assessment may delay addressing the client's immediate emotional needs. It is important for the nurse to engage with the client promptly to understand their concerns and provide support.

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The nurse is evaluating a transgender female client in the emergency department who is taking estrogen therapy. Which of the following assessment findings would be of priority concern for the nurse?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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