While performing a nursing assessment the nurse says to a client, "While growing up, most of us
have heard some half-truths about sexual matters that continue to puzzle us as adults.
Do any come
to your mind now?" The purpose of this question is to
a. determine possible homosexuality.
b. identify sexual misinformation.
c. identify areas of sexual dysfunction for treatment.
d. introduce the topic of masturbation.
B
Misinformation about normal sex and sexuality is common. Lack of knowledge may affect the
individual's sexual adjustment. Once myths have been identified, the nurse can give information to
dispel the myth.
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A client is to be transferred from bed to stretcher, and maximum assistance is required. Which of these steps is essential when two nurses are performing this transfer?
a. Place a lift sheet under the client's back, trunk, and upper legs after logrolling the client to one side. b. Have both nurses on the same side of the bed at all times. c. Place pillows on the stretcher before the client is transferred. d. Clamp any drainage tubes to prevent spills.
An 85-year-old male patient is aware of the need for a colonoscopy; however, he has a history of severe electrolyte imbalances associated with bowel preps for diagnostic tests. Which intervention should the nurse plan?
1. Discuss the option of having a flexible sigmoidoscopy instead. 2. Investigate medications the patient can take after the colonoscopy to correct the electrolyte imbalances. 3. Discuss the option of not having the colonoscopy. 4. Consider the option of delaying the colonoscopy for a year.
Ms. N is a hospice client who has had insulin-dependent diabetes mellitus (type 1 diabetes) for many years. The visiting nurse instructs the caregiver to feed Ms. N 30 to 50 g of carbohydrate every 3 hours:
1. To prevent starvation ketosis 2. To promote water excretion 3. To spare fat for weight gain 4. To show a sign of loving care and concern
A nurse is working with older adults and their caregivers. Which of the following would be the most appropriate intervention for the nurse to implement?
a. Work with legislators to advocate for pol-icies that support families b. Refer clients and families to community support groups to reduce stress c. Involve clients and families in case man-agement programs to coordinate care d. Conduct depression screenings with cli-ents and families on a regular basis