The nurse is talking with a 14-year-old female client who has just had her first sexual experience with a boy. At this time, the nurse should assess the client's knowledge of: (SELECT ALL THAT APPLY)
sexually transmitted infections.
the need for contraception.
facts vs. myths about sex.
hormonally-induced decrease in vaginal lubrication.
erectile dysfunction.
Correct Answer : A,B,C
A. Sexually transmitted infections (STIs): Assessing the client's knowledge of STIs is crucial following the initiation of sexual activity to ensure understanding of risks and preventive measures. It enables the nurse to provide education on STI transmission, symptoms, prevention methods (such as condom use), and the importance of regular STI screening.
B. The need for contraception: Assessing the client's understanding of contraception is essential to prevent unintended pregnancies. The nurse can explore the client's knowledge of contraceptive methods, their effectiveness, correct usage, and availability. Providing education on contraceptive options empowers the client to make informed decisions about protecting their sexual health.
C. Facts vs. myths about sex: Assessing the client's understanding of facts and myths surrounding sex helps identify any misconceptions or gaps in knowledge. This allows the nurse to provide accurate information about sexual anatomy, physiology, reproductive health, and healthy sexual practices. Addressing myths promotes sexual health literacy and reduces the risk of misinformation influencing behavior.
D. Hormonally-induced decrease in vaginal lubrication: Assessing hormonal changes affecting vaginal lubrication is less relevant in this context, as it primarily applies to physiological changes in older individuals or those experiencing hormonal fluctuations due to menopause or medical conditions. It is not typically a concern immediately following a first sexual experience in adolescence.
E. Erectile dysfunction: Assessing knowledge of erectile dysfunction is more pertinent in males and is typically not a primary concern immediately following a first sexual experience for a female client. While it is valuable to address sexual health comprehensively, focusing on topics directly relevant to the client's situation is paramount for effective assessment and education.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. A document that the client signs indicating they wish to be an organ donor: This describes an organ donor card or organ donation consent form, not a living will. An organ donor card is a document indicating the individual's wish to donate organs after death to benefit others in need of organ transplants.
B. A medical order that outlines the client's wishes if cardiac or respiratory arrest occurs: This describes a do-not-resuscitate (DNR) order, which is a medical order indicating that the individual does not wish to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or respiratory arrest. It is specific to resuscitation preferences and is different from a living will.
C. A witnessed legal document that describes the client's wishes regarding medical care if unable to speak: This is the correct description of a living will. A living will is a legal document that outlines a person's preferences regarding medical treatment and interventions in the event they become incapacitated and unable to communicate their wishes. It typically addresses preferences for life-sustaining treatments, such as mechanical ventilation, artificial nutrition and hydration, and other medical interventions.
D. A legal document that lists who gets the client's property & belongings before if they cannot communicate: This describes a last will and testament, which is a legal document that outlines how a person's property and assets should be distributed after their death. It does not address medical care preferences or interventions during the person's lifetime.
Correct Answer is B
Explanation
A. Asking the client to bear down as if urinating: This action is not appropriate in this situation because the lack of urine output may not necessarily be due to the client's inability to void. Checking for other potential issues, such as kinks in the tubing, is more appropriate as a first step.
B. Check for kinks in the tubing: This is the most appropriate first action. Kinks in the tubing can obstruct urine flow from the bladder to the drainage bag, leading to decreased or no urine output. By checking for kinks, the nurse can quickly identify and correct any obstructions, potentially resolving the issue without further intervention.
C. Increasing fluid intake: While maintaining adequate hydration is important for overall urinary function, it is not the most immediate action needed when there is no urine output in the catheter bag. Addressing potential mechanical issues, such as kinks in the tubing, takes precedence.
D. Inserting a new indwelling urinary catheter: Inserting a new catheter should not be the first action taken without investigating other potential causes for the lack of urine output. It is important to troubleshoot and address possible issues with the current catheter and drainage system before considering catheter replacement.
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