Nursing Test Banks Sexuality Potter et al. Fundamentals of Nursing, 9th Edition
Chapter 35: Sexuality
Chapter 35: Sexuality
Potter et al.:
... [Show More] Fundamentals of Nursing, 9th Edition MULTIPLE CHOICE
1. A nurse is caring for a 15-year-old who in the past 6 months has had multiple male and female sexual part- ners. Which response by the nurse will be most effective?
a.
“Sexually transmitted infections and unwanted pregnancy are a real risk. Let’s discuss what you think is the best
method for protecting yourself.”
b. “Having sexual interaction with both males and females places you at higher risk for STIs. To protect yourself, you need to decide which orientation you are.”
c. “Your current friends are leading you to make poor choices. You should find new friends to hang out with.”
d. “I think it’s best to notify your parents. They know what’s best for you and can help make sure you practice safe sex.”
ANS: A
Some adolescents participate in risky behaviors. The nurse should acknowledge this feeling to the patient and offer education and alternatives, while giving the patient the autonomy to make his or her own decisions. Ado- lescents who engage in sexual risk behaviors experience negative health outcomes such as STIs and unintend- ed pregnancy. In addition, the pattern of risk-taking behavior tends to be established and continue throughout
life. The nurse should not force the patient to make a choice of orientation and should not pass judgment on a patient’s sexual orientation or social network; this would make the patient feel defensive and would eliminate the trust in the relationship. Involving parents is not the first line of action; parents should be notified only if the child is in a life or death situation.
DIF:Apply (application)REF:717 | 720 | 728
OBJ:Identify patient risk factors in the area of sexual health.
TOP: Communication and Documentation MSC: Psychosocial Integrity
2. A nurse is caring for a patient who expresses a desire to have an elective abortion. The nurse’s religious and ethical values are strongly opposed. How should the nurse best handle the situation?
a. Attempt to educate the patient about the consequences of abortion.
b. Refer the patient to a family planning center or another health professional.
c. Continue to care for the patient, and limit conversation as much as possible.
d. Inform the patient that, because of immoral issues, another nurse will have to care for her.
ANS: B
The nurse must be aware of personal beliefs and values and is not required to participate in counseling or pro- cedures that compromise those values. However, the patient is entitled to nonjudgmental care and should be referred to someone who can create a trusting environment. The nurse should not care for a patient if the quality of care could be jeopardized. The nurse should not attempt to push personal values onto a patient. The nurse also should not create tension by informing the patient that he or she does not have the same morals; this could cause the patient to feel guilty or defensive when receiving care from any health care professional.
DIF:Analyze (analysis)REF:720-721
OBJ:Identify personal attitudes, beliefs, and biases related to sexuality. TOP:ImplementationMSC:Management of Care
3. Which patient is most in need of a nurse’s referral to adoption services?
a. A woman considering abortion for an unwanted pregnancy
b. An infertile couple religiously opposed to artificial insemination
c. A woman who suffered miscarriage during her first pregnancy
d. An infertile couple who has been attempting conception for 3 months
ANS: B
Adoption is an option for someone with infertility, especially if infertility treatments are unavailable owing to re- ligious or financial constraints. A patient who wishes to have an elective abortion may be educated about all the possibilities, but the nurse should approach the patient in a nonjudgmental manner and should accept the patient’s decision. When a patient has recently miscarried, the nurse should assess the patient’s feelings about the loss and should address any concerns the patient may have about fertility. Infertility is the inability to con- ceive after 1 year of unprotected intercourse; therefore, talking about adoption after one miscarriage or after only 3 months of attempting conception would be too soon.
DIF:Analyze (analysis)REF:721
OBJ: Identify health care providers and community resources available to help patients resolve sexual concerns that are outside the nurse’s level of expertise. TOP: Assessment
MSC:Management of Care
4. The nurse is caring for a patient who recently had unprotected sex with a partner who has HIV. Which re- sponse by the nurse is best?
a. “You should have your blood drawn today to see if you were infected.”
b. “If you have the virus, you will have flu-like symptoms in 6 months.”
c. “Highly active antiretroviral therapy has been shown effective in slowing the disease process.”
d. “I will set you up with a support group to help you cope with dying within the next 10 years.”
ANS: C
Highly active retroviral therapy increases the survival time of a person with HIV or AIDS. HIV antibodies will not show up in blood work for 6 weeks to 3 months. The infection stage of HIV lasts for about a month after the virus is contracted; during that time, the patient may experience flu-like symptoms. A support group may be beneficial for a patient who contracts HIV; however, it is unknown whether the patient has contracted HIV, and antiretroviral therapy has helped people live beyond the 10 years expected if HIV goes untreated.
DIF:Apply (application)REF:719
OBJ: Identify and describe nursing interventions to promote sexual health. TOP: Communication and Documentation MSC: Physiological Adaptation
5. An 18-year-old male patient informs the nurse that he isn’t sure if he is homosexual because he is attracted to both genders. Which response by the nurse will help establish a trusting relationship?
a. “Don’t worry. It’s just a phase you will grow out of.”
b. “Those are abnormal impulses. You should seek therapy.”
c. “At your age, it is normal to be curious about both genders.”
d. “Having questions about sexuality is normal but if these sexual activities make you feel bad you should stop.”
ANS: C
Adolescents have questions about sexuality. The patient will feel most comfortable discussing his sexual con- cerns further if the nurse establishes that it is normal to ask questions about sexuality. The nurse can then dis- cuss in greater detail. Although it is normal for young adults to be curious about sexuality, the nurse should use caution in giving advice on taking sexual action. The nurse should promote safe sex practices. Telling the patient not to worry dismisses his concern. Telling the patient that he is abnormal might offend the patient and prevent him from establishing an open relationship.
DIF:Apply (application)REF:717 | 723
OBJ escribe key concepts of sexual development across the life span. TOP:Communication and Documentation
MSC:Health Promotion and Maintenance
6. A nurse is caring for a 35-year-old female patient who recently started taking antidepressants after repeated attempts at fertility treatment. The patient tells the nurse, “I feel happier, but my sex drive is gone.” Which nursing diagnosis has the highest priority?
a. Sexual dysfunction
b. Ineffective coping
c. Risk for self-directed violence
d. Deficient knowledge about contraception
ANS: A
Antidepressants have adverse effects on sexual desire and response. The nurse should be sure to educate the patient on the potential for these side effects and how to correct for them, for example, using lubricant to ease discomfort. The patient has taken steps toward effective coping by seeking therapy. The patient has not ex- pressed a reason for the nurse to be concerned about contraceptives. The nurse should always assess for con- cerns about violence in a patient’s life. Although some antidepressants have been related to self-directed vio- lence, this patient focus is on becoming pregnant (fertility treatments) but sex drive is gone.
DIF:Apply (application)REF:721 | 724 | 725
OBJ: Formulate appropriate nursing diagnoses for patients with alterations in sexuality. TOP lanningMSC:Management of Care
7. A nurse is using the PLISSIT model when caring for a patient with dyspareunia from diminished vaginal se- cretions. The nurse suggests using water-soluble lubricants. Which component of PLISSIT is the nurse using?
a. P
b. LI
c. SS
d. IT
ANS: C
The nurse is using the specific suggestions (SS). The PLISSIT model is as follows:
Permission to discuss sexuality issues
Limited Information related to sexual health problems being experienced Specific Suggestions—only when the nurse is clear about the problem Intensive Therapy—referral to professional with advanced training if necessary DIF:Apply (application)REF:723
OBJ: Identify and describe nursing interventions to promote sexual health. TOP: Implementation MSC: Health Promotion and Maintenance
8. A patient who has had several sexual partners in the past month expresses a desire to use a contraceptive. Which contraceptive method should the nurse recommend?
a. Condom
b. Diaphragm
c. Spermicide
d. Oral contraceptive
ANS: A
Condoms are both a contraceptive and a barrier against STIs and HIV; proper use will greatly reduce the risk. Spermicides, diaphragms, and oral contraceptives all protect against pregnancy; however, they are not a barri- er and do not prevent bodily fluids from coming in contact with the patient during sexual intercourse.
DIF:Apply (application)REF:718 | 728
OBJ: Use critical thinking skills when helping patients meet their sexual needs. TOP: Implementation MSC: Health Promotion and Maintenance
9. A woman who has been in a monogamous relationship for the past 6 months presents to clinic with herpes on her labia. The patient is distraught because her partner must have cheated on her. Which response by the nurse is most effective in establishing an open rapport with a patient?
a. Share a story.
b. Inform the patient that all encounters are confidential.
c. Encourage the patient to break up with her partner for cheating.
d. Tell the patient that she must be honest about every sexual experience she has had.
ANS: B
If open communication is to be established with the patient, the patient must know that she can trust health care team members. By telling the patient that all encounters are confidential, the nurse establishes trust.
Sharing a story brings the focus to the nurse, inhibiting open rapport. The nurse does not tell the patient what
to do, because that should be the patient’s decision. Forcing the patient to confide by sharing every sexual en- counter may hinder a trusting relationship.
DIF:Apply (application)REF:719 | 722 | 726
OBJ: Assess a patient’s sexuality. TOP: Communication and Documentation MSC:Management of Care
10. A nurse is preparing a community class about sexually transmitted infections. Which primary group will the nurse focus on for this class?
a. Bisexual women
b. Men who have sex with men
c. Youths between the ages of 24 and 27
d. Pregnant women and their partners
ANS: B
About 20 million people in the United States are diagnosed with an STI each year, with the highest incidence occurring in men who have sex with men, bisexual men, and youths between the ages of 15 and 24. While bi- sexual women, youths between the ages of 24 and 27, and pregnant women and their partners are important, they are not the primary groups affected by STIs.
DIF:Apply (application)REF:719
OBJ: Discuss the nurse’s role in maintaining or enhancing a patient’s sexual health. TOP: Teaching/Learning MSC: Health Promotion and Maintenance
11. The nurse is leading a seminar about menopause and age-related changes. Which response from a group member indicates the nurse needs to follow up?
a. “Hormones of sexual regulation decrease with aging.”
b. “Orgasms are no longer achievable after menopause.”
c. “The excitement phase is prolonged as we age.”
d. “As men age, their erection may be less firm.”
ANS: B
Believing that orgasms are no long achievable requires follow-up to correct this misconception. Orgasms are achievable at any age; however, it may take longer with aging. All other statements indicate that the patient does have an understanding of age-related changes and needs no follow-up. Both genders experience a re- duced availability of sex hormones. The excitement phase prolongs in both men and women. Men often have erections that are less firm and shorter acting.
DIF:Understand (comprehension)REF:717-718
OBJ: Evaluate patient outcomes related to sexual health needs. TOP: Evaluation MSC:Health Promotion and Maintenance
12. A patient who had a colostomy placed 1 month ago is feeling depressed and does not want to participate in sexual activities anymore. The patient is afraid that the partner does not want sex. The patient is afraid the os- tomy is physically unattractive. Which initial nursing intervention will be most effective in helping this patient resume sexual activity?
a. Inform the patient about a support group for people with colostomies.
b. Reassure the patient that lots of people resume sex the same week the colostomy is placed.
c. Teach the patient about intimate activities that can be done to incorporate the ostomy.
d. Discuss ways to adapt to new body image so the patient will be comfortable in resuming intimacy.
ANS: D
The nurse should first address the patient’s need to be comfortable with his or her own body image; once the patient’s issues related to body image are resolved, intimacy may follow. Reassuring the patient that others
manage to have sexual intercourse with an ostomy may help to decrease anxiety but may have the unintended effect of making the patient feel abnormal because he or she has not yet resumed sexual activity. Support groups may be helpful for the patient, but this is not the most effective initial intervention a nurse can provide; this may be helpful later. The patient is worried about the ostomy; incorporating it into intimate activities is in- sensitive and can even be damaging to the stoma.
DIF:Apply (application)REF:725
OBJ: Identify and describe nursing interventions to promote sexual health. TOP: Implementation MSC: Psychosocial Integrity
13. A mother brings her 12-year-old daughter into a clinic and inquires about getting a human papillomavirus (HPV) vaccine that day. Which information will the nurse share with the mother and daughter about the HPV vaccine?
a. Protects against human immunodeficiency virus (HIV)
b. Protects against cervical cancer
c. Protects against chlamydia
d. Protects against pregnancy
ANS: B
The HPV vaccine is effective against the four most common types of HPVs that can cause cervical cancer. It is not effective against HIV, chlamydia, or pregnancy.
DIF:Understand (comprehension)REF:719-720 | 728
OBJ: Discuss the nurse’s role in maintaining or enhancing a patient’s sexual health. TOP: Teaching/Learning MSC: Health Promotion and Maintenance
14. A parent asks about the human papillomavirus (HPV) vaccine. Which information will the nurse include in the teaching session?
a. It is recommended for girls 6 to 9 years old.
b. It is recommended for females ages 11 to 26.
c. It is recommended that booster injections be given.
d. It is recommended to receive four required injections.
ANS: B
The vaccine is safe for girls as young as 9 years old and is recommended for females ages 11 to 26 if they have not already completed the three required injections. Booster doses currently are not recommended. The vac- cine is most effective if administered before sexual activity or exposure.
DIF:Understand (comprehension)REF:720 | 728
OBJ: Identify and describe nursing interventions to promote sexual health. TOP: Teaching/Learning MSC: Health Promotion and Maintenance
15. A nursing student is providing education to a group of older adults who are in an independent living retire- ment village. Which statement made by the nursing student requires the nurse to intervene?
a. “Avoiding alcohol use will enhance your sexual functioning.”
b. “You need to tell your partner how you feel about sex and any fears you may have.”
c. “You do not need to worry about getting a sexually transmitted infection at this point in your life.”
d. “Using pillows and taking pain medication if needed before having sexual intercourse often help alleviate pain and improve sexual functioning.”
ANS: C
Research indicates many older adults are more sexuality active than previously thought and engage in high-risk sexual encounters, resulting in a steady increase HIV and STI rates over the past 12 years. Therefore, the nurse needs to intervene when the student tells the older adults that they are not at risk for developing an STI. Avoid- ing the use of alcohol; using pillows; taking pain medications before having intercourse if needed; and commu- nicating thoughts, fears, and feelings about sex all enhance sexual functioning.
DIF:Apply (application)REF:717 | 728
OBJ escribe key concepts of sexual development across the life span. TOP:EvaluationMSC:Management of Care
16. A nurse is interviewing a woman who uses a diaphragm. Which information from the patient will require the nurse to follow up?
a. “I have lost 12 pounds on this diet.”
b. “I use the diaphragm to prevent pregnancy.”
c. “I use a contraceptive cream with my diaphragm.”
d. “I know this provides a barrier over the cervical opening.”
ANS: A
The woman needs to be refitted after a significant change in weight (10-pound gain or loss) or pregnancy. The diaphragm is a round, rubber dome that has a flexible spring around the edge. It is used with a contraceptive cream or jelly and is inserted in the vagina so it provides a contraceptive barrier over the cervical opening.
DIF:Apply (application)REF:718
OBJ: Identify and describe nursing interventions to promote sexual health. TOP:EvaluationMSC:Health Promotion and Maintenance
17. A nurse is conducting a sexual assessment. Which question is appropriate for the nurse to ask?
a. Have you noticed any changes in the way you feel about yourself?
b. What is your favorite sex position with men and with women?
c. Do you think your partner is attractive?
d. Why do you like men over women?
ANS: A
Asking about any changes in the way you feel about yourself is an appropriate question to ask during a sexual assessment. Asking about favorite sex position with men and/or women is inappropriate and invasive. The as- sessment needs to focus on the patient, not the partner. Asking “why” questions is nontherapeutic and is judg- mental in this scenario.
DIF: Understand (comprehension) REF: 723 OBJ: Assess a patient’s sexuality. TOP:AssessmentMSC:Health Promotion and Maintenance
18. A 15-year-old patient is concerned because her mother wants her to receive the human papillomavirus (HPV) vaccination, but the patient is unsure if she wants it. Which response by the nurse is most therapeutic?
a. Ask the patient what concerns she may have about the vaccination.
b. Inquire about how many sexual partners she has had in the past year.
c. Remind her that her mother knows best and that she should respect her parents’ wishes.
d. Promote the importance of the vaccine, and recommend that the patient get the vaccine as soon as possible.
ANS: A
The nurse should encourage health promotion behaviors but first must consider the autonomy of the patient and assess the patient for more data. The nurse should value the input of the patient in making a decision and
assess what the patient is thinking to address any concerns the patient may have. The HPV vaccine is a preven- tative treatment; whether or not the patient is sexually active (asking about how many sexual partners) does not matter in this case. The nurse should not make assumptions about a patient’s home life (mother knows best); instead, the nurse should ask questions while establishing a therapeutic relationship. Recommending the patient get the vaccine as soon as possible is in violation of the patient’s rights.
DIF:Apply (application)REF:728
OBJ: Identify and describe nursing interventions to promote sexual health. TOP: Implementation MSC: Health Promotion and Maintenance
19. A nurse is reviewing a patient’s history. Which priority finding will alert the nurse to assess the patient for possible sexual dysfunction?
a. Takes vacations out of the country
b. Takes antianxiety medication
c. Takes exercise classes
d. Takes afternoon naps
ANS: B
Medications that can affect sexual functioning include antihypertensive, antipsychotics, antidepressants, and antianxiety. Taking vacations out of the country, exercise classes, and afternoon naps are not as priority for sex- ual functioning as medications.
DIF:Apply (application)REF:722
OBJ: Identify causes of sexual dysfunction. TOP: Assessment MSC:Health Promotion and Maintenance
20. A nurse is assessing a child for sexual abuse. Which assessment findings will the nurse expect?
a. Physical aggression and sleep disturbances
b. Many peers and no drug usage
c. Panic attacks and anorexia
d. Anxiety and depression
ANS: A
Behavioral signs of sexual abuse in a child include physical aggression, sleep disturbance, poor peer relation- ships, and substance abuse. Panic attacks, anorexia, anxiety, and depression are behavioral signs for adults.
DIF: Apply (application) REF: 724 OBJ: Assess a patient’s sexuality. TOP:AssessmentMSC:Health Promotion and Maintenance
21. The nurse is teaching a patient how to use a condom. Which instructions will the nurse provide?
a. Store in a warm lit space.
b. Use massage oils for lubrication.
c. Rinse and reuse the condom if needed.
d. Hold onto the condom when pulling out.
ANS: D
Teach patients to pull out right after ejaculating and to hold onto the condom when pulling out. Store condoms in a cool, dry place away from sunlight. Instruct patient to never reuse a condom or use a damaged condom.
Instruct patient to only use water-based lubricants (e.g., K-Y jelly) to prevent the condom from breaking; do not use petroleum jelly, massage oils, body lotions, or cooking oil.
DIF:Understand (comprehension)REF:728
OBJ: Discuss the nurse’s role in maintaining or enhancing a patient’s sexual health. TOP: Teaching/Learning MSC: Health Promotion and Maintenance
22. A nurse is caring for a patient with dyspareunia. In which order will the nurse provide care, starting with the
first step?
1. Determine which signs and symptoms of dyspareunia the patient has.
2. Mutually decide upon goals and objectives for dyspareunia.
3. Ask the patient if the dyspareunia is improving.
4. Develop a nursing diagnosis for the patient.
5. Use resources to help resolve the problem.
a. 5, 3, 1, 4, 2
b. 1, 4, 2, 5, 3
c. 3, 1, 4, 2, 5
d. 4, 2, 5, 3, 1
ANS: B
The nurse should use the nursing process when caring for patients with sexual dysfunction. Determine signs and symptoms (assessment); develop a nursing diagnosis (diagnosis); mutually decide upon goals (planning); use resources to help resolve the problem (implementation); and ask if the dyspareunia is improving (evaluation).
DIF:Apply (application)REF:723-727
OBJ: Use critical thinking skills when helping patients meet their sexual needs.
TOP:ImplementationMSC:Management of Care
MULTIPLE RESPONSE
1. An older couple expresses concern because they are easily fatigued during sexual intercourse and cannot reach climax. Which strategies to increase sexual stamina will the nurse offer? (Select all that apply.)
a. Plan sexual activity around a time when the couple feels rested.
b. Encourage intimate touching, such as hugging and kissing.
c. Use extra lubrication to decrease discomfort.
d. Take pain medication before intercourse.
e. Avoid alcohol and tobacco.
f. Eat well-balanced meals.
ANS: A, E, F
Alcohol, tobacco, and certain medications (such as narcotics for pain) may cause drowsiness and fatigue and negatively affect sexual stamina. Eating well-balanced meals can help to increase energy levels. Planning sexual activity when the couple is well rested will help them not get fatigued as quickly. Encouraging intimate touching may help increase libido but not energy levels. Extra lubrication and taking pain medications may ease the dis- comfort of sexual intercourse but are not appropriate interventions for fatigue.
DIF:Analyze (analysis)REF:728
OBJ: Use critical thinking skills when helping patients meet their sexual needs. TOP: Implementation MSC: Health Promotion and Maintenance [Show Less]