Nursing Chapter 40 Rationale During The Excitement Phase The Sexual

Question 22

Type: MCSA

The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse

best reflects the P section of this format?

1. Ask the physician for permission to discuss sexual topics with the client.

2. Obtain signed informed consent from both the client and the spouse or partner prior to providing them with

sexual information.

3. Acknowledge the client’s spoken and unspoken sexual concerns when providing care.

4. Document precertification for benefits from the client’s insurance company regarding sexual teaching.

Question 23

Type: MCSA

The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse

best reflects the LI section of this format?

1. In order to avoid causing anxiety, limit the amount of information given to clients regarding adverse sexual side

effects of treatments or medications.

2. Give the client accurate but concise information in regard to any sexual questions that might be asked.

3. State information using slang terms to refer to sexual body parts because the client is not likely to know the

proper terms.

4. Review current research literature associated with the sexual concerns of the client and partner.

Question 24

Type: MCSA

The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse

best reflects the SS section of this format?

1. Use the nurse’s knowledge about how disease affects sexuality to offer specific suggestions for the client.

2. Focus interventions on explaining the somatic sexual difficulties and their treatment.

3. Offer the client a list of expected sexual side effects of drugs or treatments.

4. Identify any concerns the client has regarding attraction to the same sex.

Question 25

Type: MCSA

The nurse uses the PLISSIT format in helping clients who have sexual dysfunction. Which action by the nurse

best reflects the IT section of this format?

1. Use information technology such as the Internet to obtain guidance suggestions for the client.

2. Use the technique of informal therapeutic groups to assist the client and partner.

3. Evaluate previous interventions and treatment for success.

4. Recommend intensive therapy with a qualified sex therapist.

Question 26

Type: MCSA

The daughters of an 80-year-old man who is aphasic after suffering a cerebrovascular accident (stroke) express

concern that their father is “always exposing and playing with himself and his catheter” while they are in the room.

Upon assessment, the nurse finds the client pulling on and rubbing his penis. What is the nurse’s priority action?

1. Tell the client to keep his hands away from his penis.

2. Assess the client’s penis for irritation from the catheter.

3. Ask the client to keep his linens at waist level when he has visitors.

4. Collaborate with the physician regarding medications to control this behavior.

Question 27

Type: MCMA

After an assessment, the nurse determines that a client has strong sexual health. What did the nurse assess in the

client?

Standard Text: Select all that apply.

1. Knowledge about sexual behavior

2. Reluctance to discuss sexual history

3. Utilization of birth control method that fits lifestyle

4. Statement that there are no issues with sexuality

5. Discussing sexual problems with healthcare provider

Question 28

Type: MCMA

The nurse is preparing to assess a client’s sexual health. What will the nurse include in this assessment?

Standard Text: Select all that apply.

1. Sexual self-concept

2. Body image

3. Gender identity

4. Contraceptive choices

5. Employment

Question 29

Type: MCSA

During an assessment, a client tells the nurse of a desire to wear clothing that is typically associated with the

opposite sex. The nurse realizes this client is describing which gender identity?

1. Intersex

2. Transgenderism

3. Homosexuality

4. Cross-dressing

Question 30

Type: MCSA

During a sexual assessment, a client tells the nurse about a preference for oral–genital sex. How should the nurse

instruct this client?

1. Explain the need to follow safe sex practices.

2. Explain the need to use contraception.

3. Explain the importance of having an annual HIV test.

4. Explain thy routine gynecologic examinations are not necessary.

Question 31

Type: MCMA

The nurse is preparing an educational session on the sexual response cycle. What should be included when

discussing the physiological changes in females during the excitement phase?

Standard Text: Select all that apply.

1. The vagina dries.

2. The length of the vagina narrows and swells.

3. Erection of the clitoris occurs.

4. The breasts enlarge.

5. The uterus elevates.

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Question 32

Type: MCMA

When discussing the orgasmic phase of the sexual response cycle, what should the nurse include as physiological

changes that affect both sexes?

Standard Text: Select all that apply.

1. The respiratory rate can increase up to 40 breaths per minute.

2. Involuntary muscle spasms occur throughout the body.

3. The heart rate decreases to 20 beats below normal.

4. Systolic blood pressure can increase 20–30 mm Hg above normal.

5. Diastolic blood pressure can decrease 20–50 mm Hg below normal.

Question 33

Type: MCSA

The nurse is discussing the resolution phase of the sexual response cycle with a group of students in a health

education class. What should be included as a physiological change that affects males only?

1. Genitalia and breasts return to pre-excitement states.

2. There is a refractory period during which the body will not respond to sexual stimulation.

3. The heart rate returns to normal.

4. Possible sleepiness or intense relaxation may occur.

Question 34

Type: MCMA

The nurse is conducting a sexual health history with a client. What questions should the nurse ask during this

history?

Standard Text: Select all that apply.

1. “What are your erotic fantasies?”

2. “Are you currently sexually active?”

3. “Do you experience any pain with sexual interaction?”

4. “Do you have difficulty with sexual desire?”

5. “What do you like the best about having sex?”

Question 35

Type: MCSA

The nurse is conducting a health history with an older client with arthritis and heart disease. When gathering the

sexual history for this client, what question should the nurse ask?

1. “Do you have any difficulty with sexual desire and orgasm?”

2. “How often do you have sexual relations?”

3. “What type of contraception do you use?”

4. “Have there been any changes in your sexual functioning that might be related to your illness or the

medications you take?”

Question 36

Type: MCSA

The nurse is preparing educational materials to be used when instructing clients on testicular and breast self-

examination. What would be applicable for both sets of instructions?

1. Perform palpation in the shower.

2. Perform the examination lying down.

3. Perform the examination once each week.

4. Perform the examination bimonthly.

Question 37

Type: MCMA

The nurse who is teaching a client breast self-examination describes inspection of the breasts before a mirror.

Which findings should the nurse tell the client should be evaluated by a health care provider?

Standard Text: Select all that apply.

1. Puckering of the skin

2. Flattening of the breast from the side view

3. Free movement of the breast over the chest wall

4. Symmetry of the nipples

5. Change in shape

Question 38

Type: MCMA

The nurse is teaching a class of young adult men and women. What self-examination schedules should the nurse

instruct these participants to follow?

Standard Text: Select all that apply.

1. Monthly breast self-exams for women

2. Yearly breast self-exams for men

3. Weekly testicular self-exams for men

4. Monthly breast self-exams for men

5. Yearly vulvar self-exams for women

Question 39

Type: MCMA

While the nurse is measuring blood pressure, the client lifts his hand and fondles the nurse’s breast. What should

the nurse do about this behavior?

Standard Text: Select all that apply.

1. Ignore the fondling.

2. Move the client’s hand away.

3. Refocus the client on appropriate behavior.

4. Tell the client to stop performing the behavior.

5. Communicate that the behavior is not acceptable.

Question 40

Type: MCMA

After reviewing a list of prescribed medications, the nurse plans to complete a sexual history with the client.

Which medications in the client’s list caused the nurse to make this clinical decision?

Standard Text: Select all that apply.

1. Antibiotics

2. Antipyretics

3. Cardiotonics

4. Beta-blockers

5. Anticoagulants