The nurse is performing a sexual assessment on a newly admitted married 60-year-old female patient. Which question should the nurse omit from the nursing assessment?
a. "Are you sexually active?"
b. "How often do you have sexual intercourse?"
c. "Do you experience any discomfort during sex?"
d. "What method of birth control are you currently using?"
D
A woman aged 60 is not capable of becoming pregnant, so questions about birth control are not needed, but use of barrier methods to prevent STIs may be asked when appropriate. People aged 60 and older may or may not be sexually active. Marriage is not an indicator of sexual activity because some married people are not sexually active. Asking about frequency of sexual activity can be an indicator of health, exercise tolerance, and other important factors, so should be asked of this patient. Questions about discomfort during sex are important because patients may not bring up the subject if not asked directly.
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During a myocardial infarction (MI), a patient with a 97% occlusion of his left descending artery develops ventricular arrhythmias due to the amount of ischemia occurring in the myocardium
While educating the patient about MIs, the nurse will base her teaching on the fact that A) permanent damage will occur in the myocardium if the vessel is not opened within a 1- to 2-minute window following the occlusion. B) treatment needs to be sought immediately so that the buildup of lactic acid is limited and cellular changes can be reversed. C) once the oxygen supply has been occluded, cellular changes are irreversible even if oxygenation is restored. D) the body will grow new genes through the process of angiogenesis, thereby avoiding any permanent damage to the myocardium.
The nurse teaches the immobilized client range of motion to improve muscle strength, endurance, and to help maintain cardiorespiratory function. Which activity is not appropriate for the nurse to include in the teaching session?
1. Active range of motion 2. Passive range of motion 3. Active-assistive range of motion 4. Active or active-assistive range of motion
Immediately following an epidural block, a woman's blood pressure suddenly falls to 90/50 . Your first action would be to
A) raise her head off the bed. B) ask her to inhale deeply at least five times. C) administer oxygen by facemask. D) turn her on her left side or raise her legs.
A 12-month-old infant has been diagnosed with failure to thrive (FTT). Which assessment findings does the nurse expect to be documented with this infant? (Select all that apply.)
a. Fear of strangers b. Minimal smiling c. Avoidance of eye contact d. Meeting developmental milestones e. Wide-eyed gaze and continual scan of the environment