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 D
Explanation
A. Responsibility: Responsibility refers to the duty or obligation to fulfill one's role or tasks appropriately. While advocating for the client may be considered a responsibility of the nurse, the specific action described in the scenario—calling the insurance company to strongly explain the client's need for rehabilitation—is more accurately categorized as advocacy.
B. Confidentiality: Confidentiality pertains to protecting the privacy and confidentiality of patient information. The scenario does not involve the disclosure of confidential information but rather advocating for the client's needs regarding their rehabilitation placement.
C. Social justice: Social justice involves promoting fairness, equality, and equitable access to resources and opportunities for all members of society. While advocating for the client may align with principles of social justice, the specific action described in the scenario—calling the insurance company to argue for the client's rehabilitation placement—is more directly related to individual advocacy rather than addressing broader societal inequalities.
D. Advocacy: Advocacy refers to actively supporting and speaking up for the rights, needs, and interests of others. In this scenario, the nurse advocates for the elderly client by calling the insurance company to strongly explain why the client needs to go to a rehabilitation facility despite the facility's refusal. This action demonstrates the nurse's commitment to ensuring the client receives appropriate care and support.
Correct Answer is ["B","E"]
Explanation
A. Diarrhea: Diarrhea results in fluid loss from the body and is considered an insensible fluid loss rather than sensible fluid loss. Sensible fluid loss refers to measurable fluid losses such as urine output and sweating.
B. Urinary output: Urinary output represents sensible fluid loss as it is measurable and reflects the volume of fluid excreted by the kidneys. Monitoring urinary output is essential for assessing fluid balance in clients.
C. Profuse sweating: Profuse sweating results in sensible fluid loss as it is measurable and can lead to significant fluid depletion if not adequately replaced. Sweating is the body's mechanism for thermoregulation, and excessive sweating, such as during strenuous exercise or in hot environments, can result in notable fluid loss.
D. Vomiting: Vomiting results in fluid loss from the body and is considered an insensible fluid loss rather than sensible fluid loss. While vomiting leads to the expulsion of gastric contents and fluids, the volume of fluid loss is not easily measurable compared to urine output or sweating.
E. Increased respiratory effort: Increased respiratory effort, such as during heavy breathing or respiratory distress, can result in sensible fluid loss through exhalation. This loss occurs as water vapor is expelled from the lungs during respiration. Monitoring respiratory rate and effort can provide insights into fluid balance in clients, particularly in conditions such as respiratory infections or heart failure.
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