The nurse is collecting a sexual history from a female client who was raped four years ago. The client reports the ability to become aroused, and says she becomes excited but cannot orgasm. The nurse documents loss of arousal during:
1. The excitement phase.
2. The plateau phase.
3. The orgasmic phase.
4. The resolution phase.
3
Rationale: Orgasm occurs during the orgasmic phase. The client reports the ability to become excited (excitement phase), and approaches orgasm (the plateau phase), but then the sensation subsides, and she cannot reach orgasm.
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A child has been diagnosed with Wilms' tumor, and is being treated with chemotherapy
Because many chemotherapeutic agents cause bone marrow depression, before administering the chemotherapy, the nurse will determine if this child has any infection-fighting capability by monitoring the: 1. Hemoglobin. 2. Red blood cell count. 3. Absolute neutrophil count (ANC). 4. Platelets.
The nurse is caring for a patient who is receiving total parenteral nutrition (TPN) and notes that the patient becomes dyspneic when transferring from the bed to a chair. The nurse auscultates rales in both lungs. Which action will the nurse take next?
a. Ask the patient to perform the Valsalva maneuver. b. Decrease the TPN rate and request an order for a diuretic medication. c. Obtain an order for a chest radiograph and an antibiotic. d. Stop the TPN and request an order for intravenous isotonic dextrose.
Which of the following nursing actions best reflects a nurse's commitment to the ethical principle of fostering autonomy regarding an older client living in an extended care facility?
1. Providing options regarding the furniture arrangement of the client's room 2. Supporting a client's decision to adopt a DNR (do not resuscitate) status 3. Allowing sufficient time for the client to independently accomplish morning hy-giene 4. Consulting the client regarding personal preferences regarding treatment options
What is Mrs. CL's ideal body weight