Download Ignatavicius: Medical-Surgical Nursing, 7th Edition

Ignatavicius: Medical-Surgical Nursing, 7th Edition
Care of Patients with Sexually Transmitted Disease & Repro Problems
Answer Key – NCLEX® Examination Challenges and Decision-Making Challenges
Answer Key—NCLEX® Examination Challenges
p. 1656, Physiological Integrity
1. The nurse gives a client an IM dose of penicillin G for syphilis. What is the priority
action for the nurse after giving the drug?
A. Monitor the client for at least 30 minutes for any reaction to the drug.
B. Rub the site with an alcohol prep to ensure even distribution of the drug.
C. Teach the client the importance of not having sexual intercourse for 7 days.
D. Ask the client if she is allergic to any drugs, especially penicillin.
p. 1665, Physiological Integrity
2. A client is being treated with oral antibiotics in the clinic for pelvic inflammatory
disease. Which of these changes will the nurse teach the client to report immediately to
the health care provider?
A. Increased anxiety that her partner may “catch” the disease
B. Mild nausea after taking some doses of the antibiotic
C. One or two diarrheal stools every day since taking the antibiotic
D. Temperature of 102° F after 3 days of taking the antibiotic
3. A client reports new onset of vulvar burning, redness, and pruritus. Which of these
questions by the nurse would be the most appropriate?
A. “Have you recently changed clothes detergents?”
B. “Have you seen your health care provider about this problem?”
C. “Have you had your HPV vaccine yet?”
D. “Does this problem run in your family?”
4. A client returns from surgery after a total vaginal hysterectomy. What is the nurse’s
priority action immediately after surgery?
A. Assess for excessive vaginal bleeding.
B. Monitor temperature for infection.
C. Assess for deep vein thrombosis.
D. Check dressing for intactness.
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Answer Key – NCLEX® Examination Challenges and Decision-Making Challenges 76-2
p. 1661, Patient-Centered Care; Teamwork and Collaboration Case Scenario
A 49-year-old woman develops a heavy greenish vaginal discharge with a very foul odor.
She visits her gynecologist, who tells her that she has gonorrhea. When the patient learns
how the infection is transmitted, she tells her physician that she has not “slept with any
other man” since she was married 29 years ago and that the diagnosis cannot be correct.
When her husband returns home from work, she confronts him about her diagnosis. He
initially denies that he has had sex with any other woman but then confesses that he has
been “seeing” a young woman who works at his store for about three months. He admits
that he has symptoms of the infection, too. The patient is very upset and returns to her
gynecologist in 1 week. Her husband refuses to come with her. She tells you, the office
nurse, that she just can’t understand how her husband can be so unfaithful after all the
years they have had together. She is considering filing for a divorce, but she is worried
about her three children, ranging in age from 28 to 15.
1. What is the most appropriate way for you to respond to the patient at this time?
2. You tell the patient that her husband and the young woman involved need to be
treated for the disease, and suggest expedited partner therapy. How will you
explain this treatment method?
3. The patient tells you that she “never wants to meet that slut who stole my
husband.” How will you respond to this statement?
4. What emotional feelings is this patient experiencing? Develop a collaborative
plan of care for this patient to ensure that desired patient and family outcomes will
be met.
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Answer Key – NCLEX® Examination Challenges and Decision-Making Challenges 76-3
Suggested Responses to STD Case Scenario:
1. What is the most appropriate way for you to respond to the patient at this time?
A nonjudgmental approach should be used in the discussion. Provide privacy and educate
the patient on the spread of the disease. Dispel myths such as acquiring gonorrhea from
sitting on a toilet seat. Stress the importance of treatment and the importance of her
sexual partner getting treated to prevent reinfection. Include a discussion of potential
complications if treatment is not obtained and followed for both partners.
2. You tell the patient that her husband and the young woman involved need to be
treated for the disease, and suggest expedited partner therapy. How will you explain this
treatment method?
Explain that her husband will need to be examined to determine if he has gonorrhea and
that treatment should be started to prevent reinfection and other complications. Needless
to say, this is a very sensitive issue concerning their relationship, and empathy must be
used during discussion with both parties involved. Stress the confidentiality of medical
records to meet the psychological needs of both parties.
1. The patient tells you that she “never wants to meet that slut who stole my
husband.” How will you respond to this statement?
The patient will require emotional support, and you may suggest that she might benefit
from marriage counseling. Actively listening to her concerns will establish a trusting
relationship, and the patient may share important information that may be too
embarrassing to discuss unless she feels the nurse is truly concerned and remains
nonjudgmental. Early treatment would be simple and fast, involving a single dose of
antibiotics.
2. What emotional feelings is this patient experiencing? Develop a collaborative
plan of care for this patient to ensure that desired patient and family outcomes
will be met.
The patient is likely experiencing feelings of betrayal, sadness, anger, and concern for her
health and her family. The plan of care will require the nurse to provide information on
the disease and establish referrals for both physiologic and psychological care. Teaching
about sexually transmitted disease should be approached in a compassionate,
nonjudgmental manner. Provide literature to the patient that discusses the disease and
treatment. Referral to a social worker to assist with coping with fidelity issues in the
marriage may be appropriate. If the patient is religious, suggest that she may feel
comfortable discussing her concerns with clergy or other spiritual leader. Any referral
should be made with the permission of the patient. Maintaining confidentiality is vital to
ensure privacy in this delicate matter and will meet the psychological needs of the
patient.
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Answer Key – NCLEX® Examination Challenges and Decision-Making Challenges 76-4
Answers to Questions
1. ANS: A
Rationale: Allergic reactions to antibiotics often occur. Therefore monitor the client for
allergic manifestations for at least 30 minutes after the injection (e.g., rash, edema,
shortness of breath, chest tightness, anxiety). The injection site should not be rubbed after
administration of the drug. The client should be urged to adhere to the treatment regimen,
which includes abstinence from sexual activity until treatment of both the client and
partner(s) is completed, which lasts longer than 7 days. The client who has never had
penicillin should have a skin test before receiving the injection.
2. ANS: D
Rationale: If the client has not responded to oral antibiotics and continues to have a fever
or develops a fever, she should be hospitalized for IV antibiotic therapy and further
evaluation. The client’s anxiety should be addressed, but it is not the top concern. Mild
nausea and diarrhea are common side effects of antibiotic therapy.
3. ANS: A
Rationale: This client may be experiencing vulvovaginitis, an inflammation of the
lower genital tract resulting from a disturbance of the balance of hormones and
flora in the vagina and vulva. It may be characterized by itching, change in
vaginal discharge, odor, or lesions. A common cause is chemical irritants or
allergens (vaginal spray, fabric dyes, detergent) or a foreign body (tampon).
Asking the client if she has seen her provider lately is not therapeutic, does not
address the client’s problem, and may result in embarrassment. Asking about the
HPV vaccine will not assist the nurse in collecting more information about the
onset of symptoms. Vulvovaginitis is not a hereditary disorder.
4. ANS: A
Rationale: The priority of care for a client after a total vaginal hysterectomy is assessing
for excessive vaginal bleeding. There should be less than one saturated perineal pad in 4
hours. Although assessing vital signs and checking the dressing are important actions,
they are not the priority. Homans’s sign is a very poor predictor for deep vein thrombosis.
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Answer Key – NCLEX® Examination Challenges and Decision-Making Challenges 76-5
p. 1624, Patient-Centered Care; Evidence-Based Practice; Informatics; Teamwork
and Collaboration
A 58-year-old woman is diagnosed with ovarian cancer today. She begins to cry and tells
you that she “had a feeling all along” that she had the disease. No one is her family has
had ovarian cancer, but she has two friends who recently died of the disease. She is
scheduled for an exploratory laparotomy and tumor debulking in three days. Her
oncologist told her that after she recovers from surgery, she will have brachytherapy and
external beam radiation therapy (EBRT).
1. What preoperative teaching will you provide for this patient and why?
2. What will you tell her about restrictions associated with brachytherapy and EBRT?
3. Where would you search for evidence about her expected quality of life and prognosis?
4. What members may need to be involved in her care?
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.
Answer Key – NCLEX® Examination Challenges and Decision-Making Challenges 76-6
Suggested Responses to Ovarian Cancer Scenario
1. What preoperative teaching will you provide for this patient and why?
The nurse should explain the laparotomy and debulking procedures to the patient and
explain that they will be performed via laparoscopic technique to decrease recovery time,
minimize pain, and reduce postoperative complications. Her ovarian cancer will also be
staged during this surgery. The patient should understand that, because of its size, the
tumor will be reduced but not removed.
2. What will you tell her about restrictions associated with brachytherapy and EBRT?
With brachytherapy, an applicator is placed within the uterus through the vagina, and a
radioactive isotope is placed and remains in the applicator for several minutes. This
procedure may be repeated between 2 and 5 times once or twice per week. Even though
there is a radioactive element to this procedure, there are no restrictions for the patient to
stay away from her family or the public between treatments. The patient will be restricted
to bedrest during the treatment session; excessive movement must be avoided to prevent
dislodgment of the radioactive source.
With EBRT, the patient will be required to monitor for signs of skin breakdown,
especially in the perineal area; to avoid sunbathing; and to avoid washing the markings
outlining the treatment site.
3. Where would you search for evidence about her expected quality of life and prognosis?
Gilda’s Club (www.gildasclub.org) and the National Ovarian Cancer Coalition (NOCC)
(www.ovarian.org) are good sources for information. In Canada, the National Ovarian
Cancer Association (www.ovariancanada.org) is available for the same purpose. The
American Cancer Society is also a good resource for information.
4. What members may need to be involved in her care?
Health care team members may include the oncologist, radiologist, social worker and/or
case manager, physical therapist, registered dietitian, and home care nurse. Clergy or a
psychologist or psychiatrist may also be consulted for support. A genetic counselor may
be beneficial if the patient fears passing the BRCA1 or BRCA2 gene to her daughter.
Copyright © 2013, 2010, 2006, 2002 by Saunders, an imprint of Elsevier Inc.