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 B

Explanation

Choice A reason: Fidelity refers to the ethical principle of keeping promises and maintaining trust. In nursing, this principle involves being loyal to the client and upholding commitments made to them. While important, fidelity does not directly address the nurse's concern about the potential harm caused by administering the opioid medication.

Choice B reason: Nonmaleficence is the ethical principle of "do no harm." This principle is directly applicable in this scenario, as the nurse's concern is about potentially hastening the client's death by administering the opioid medication. By choosing not to administer the medication, the nurse is acting to avoid causing harm, aligning with the principle of nonmaleficence.

Choice C reason: Veracity is the principle of truthfulness and honesty. It involves providing accurate information to clients and being truthful in communication. Although important in healthcare, veracity does not specifically address the nurse's concern about the potential harm of administering the opioid medication.

Choice D reason: Utilitarianism is an ethical theory that focuses on the consequences of actions and aims to achieve the greatest good for the greatest number of people. While utilitarianism can guide decision-making in healthcare, it is not the most relevant principle in this scenario where the primary concern is avoiding harm to the individual client.

A. Assign the tasks that were not completed to the next nursing shift. B. Allow each staff member to judge if the task needs to be completed. C. Perform follow-up with each staff member regarding the performance and outcome of each task. D. Document that the task was completed.

Correct Answer is C

Explanation

Choice A reason: Assigning tasks that were not completed to the next nursing shift is a part of shift change protocols but is not the primary responsibility after delegating tasks. Follow-up is crucial to ensure that all tasks are completed correctly and on time.

Choice B reason: Allowing each staff member to judge if the task needs to be completed undermines the importance of the tasks and could lead to inconsistencies in patient care. It is essential to follow up and ensure that the tasks are completed as delegated.

Choice C reason: Following up with each staff member regarding the performance and outcome of each task is critical. This ensures that the tasks are completed correctly, provides an opportunity to address any issues, and reinforces accountability in the team.

Choice D reason: Documenting that the task was completed is important, but it should occur after the nurse has confirmed that the task was performed correctly. Follow-up is essential to verify the accuracy and completeness of the delegated tasks before documentation.

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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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Correct Answer is B

Explanation

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Explanation

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