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Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test

Bank
Chapter 40
Question 1
Type: MCSA
The client considering a mammoplasty asks the nurse if she will still be able to breastfeed if she has the
procedure. The nurse's best response includes what information?
1. The removal of adipose tissue disturbs the flow of milk, so she likely will not be able to breast feed.
2. The insertion of a saline device can be pocketed under the muscle to allow for future breastfeeding.
3. The likelihood of producing milk is slim, because the duct system is interrupted by the surgical procedure and
implant.
4. Breastfeeding is discouraged postprocedure because it can change the shape of the breast and damage the
implant.
Correct Answer: 3
Rationale 1: Cutting into the mammary tissue and placing a saline implant disturbs the duct system in the breast
and makes the likelihood of breastfeeding very low but not impossible.
Rationale 2: Cutting into the mammary tissue and placing a saline implant disturbs the duct system in the breast
and makes the likelihood of breastfeeding very low but not impossible.
Rationale 3: Cutting into the mammary tissue and placing a saline implant disturbs the duct system in the breast
and makes the likelihood of breastfeeding very low but not impossible.
Rationale 4: Cutting into the mammary tissue and placing a saline implant disturbs the duct system in the breast
and makes the likelihood of breastfeeding very low but not impossible.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Review the structure and function of the female and male reproductive systems.
Question 2
Type: MCSA

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

The nurse working in a Planned Parenthood clinic admits a woman who requests a pregnancy test. While waiting
for the results, the client asks the nurse, "If I'm pregnant, the father could be either of two men I've been seeing.
Can you tell me what day I got pregnant if you know how far along I am, so I can figure out who the father is?"
The nurse's best response is:
1. "Women usually ovulate on the 11-14th day, with the first day of your period being day one. However, every
woman is different, so there is no way to know what day you ovulated or became pregnant."
2. "Women usually ovulate on the 14-18th day, with the last day of your period being day one. However, every
woman is different, so there is no way to know what day you ovulated or became pregnant"
3. "Women usually ovulate on the 14-18th day, with the first day of your period being day one. However, every
woman is different, so there is no way to know what day you ovulated or became pregnant"
4. "Women usually ovulate on the 11-14th day, with the last day of your period being day one. However, every
woman is different, so there is no way to know what day you ovulated or became pregnant"
Correct Answer: 1
Rationale 1: The first day of the menstrual period is considered day one of the menstrual cycle. While most
women ovulate between the 11th and 14th day of the cycle, every woman is different, and it is possible to ovulate
any day of the cycle. While most women have a 28-day cycle, some have shorter cycles and others have longer
cycles. It is virtually impossible to determine what day a woman became pregnant.
Rationale 2: The first day of the menstrual period is considered day one of the menstrual cycle. While most
women ovulate between the 11th and 14th day of the cycle, every woman is different, and it is possible to ovulate
any day of the cycle. While most women have a 28-day cycle, some have shorter cycles and others have longer
cycles. It is virtually impossible to determine what day a woman became pregnant.
Rationale 3: The first day of the menstrual period is considered day one of the menstrual cycle. While most
women ovulate between the 11th and 14th day of the cycle, every woman is different, and it is possible to ovulate
any day of the cycle. While most women have a 28-day cycle, some have shorter cycles and others have longer
cycles. It is virtually impossible to determine what day a woman became pregnant.
Rationale 4: The first day of the menstrual period is considered day one of the menstrual cycle. While most
women ovulate between the 11th and 14th day of the cycle, every woman is different, and it is possible to ovulate
any day of the cycle. While most women have a 28-day cycle, some have shorter cycles and others have longer
cycles. It is virtually impossible to determine what day a woman became pregnant.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Review the structure and function of the female and male reproductive systems.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Question 3
Type: MCMA
The nurse is preparing to obtain a comprehensive sexual history from the client in the reproductive clinic. What
actions can the nurse take to help the client feel comfortable enough to share this information?
Standard Text: Select all that apply.
1. The nurse presents a nonjudgmental and nonthreatening environment.
2. Provide privacy for the client.
3. The nurse should act like a friend of the client.
4. The nurse should use medical terminology to reduce embarrassment.
5. The nurse should maintain good eye contact with the client.
Correct Answer: 1,2
Rationale 1: Making sure the environment is nonjudgmental and nonthreatening is important to make the client
feel more comfortable sharing private information. Strict privacy should be maintained, and the client might
prefer to exclude other family members or friends from the conversation to allow full disclosure. The nurse should
not act like a friend, but should maintain professionalism. Medical terminology might not be understood by the
client, and should be avoided. The amount of eye contact to use in a given situation depends on the culture and
comfort level of the client.
Rationale 2: Making sure the environment is nonjudgmental and nonthreatening is important to make the client
feel more comfortable sharing private information. Strict privacy should be maintained, and the client might
prefer to exclude other family members or friends from the conversation to allow full disclosure. The nurse should
not act like a friend, but should maintain professionalism. Medical terminology might not be understood by the
client, and should be avoided. The amount of eye contact to use in a given situation depends on the culture and
comfort level of the client.
Rationale 3: Making sure the environment is nonjudgmental and nonthreatening is important to make the client
feel more comfortable sharing private information. Strict privacy should be maintained, and the client might
prefer to exclude other family members or friends from the conversation to allow full disclosure. The nurse should
not act like a friend, but should maintain professionalism. Medical terminology might not be understood by the
client, and should be avoided. The amount of eye contact to use in a given situation depends on the culture and
comfort level of the client.
Rationale 4: Making sure the environment is nonjudgmental and nonthreatening is important to make the client
feel more comfortable sharing private information. Strict privacy should be maintained, and the client might
prefer to exclude other family members or friends from the conversation to allow full disclosure. The nurse should
not act like a friend, but should maintain professionalism. Medical terminology might not be understood by the
client, and should be avoided. The amount of eye contact to use in a given situation depends on the culture and
comfort level of the client.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 5: Making sure the environment is nonjudgmental and nonthreatening is important to make the client
feel more comfortable sharing private information. Strict privacy should be maintained, and the client might
prefer to exclude other family members or friends from the conversation to allow full disclosure. The nurse should
not act like a friend, but should maintain professionalism. Medical terminology might not be understood by the
client, and should be avoided. The amount of eye contact to use in a given situation depends on the culture and
comfort level of the client.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Identify points to cover in obtaining a comprehensive sexual history.
Question 4
Type: MCSA
The nurse working in a urologist's office is caring for a male client admitted with concerns regarding erectile
dysfunction. The nurse suspects a contributing factor to the client's condition is:
1. History of hypertension.
2. History of wearing tight-fitting underwear.
3. History of vasectomy.
4. History of psoriasis.
Correct Answer: 1
Rationale 1: Clients with hypertension can experience erectile dysfunction due to inability of the vascular system
to properly engorge. This can be related to the increased pressure within the arteries, as well as a side effect of
antihypertensives. The other answer options would not create a risk for erectile dysfunction.
Rationale 2: Clients with hypertension can experience erectile dysfunction due to inability of the vascular system
to properly engorge. This can be related to the increased pressure within the arteries, as well as a side effect of
antihypertensives. The other answer options would not create a risk for erectile dysfunction.
Rationale 3: Clients with hypertension can experience erectile dysfunction due to inability of the vascular system
to properly engorge. This can be related to the increased pressure within the arteries, as well as a side effect of
antihypertensives. The other answer options would not create a risk for erectile dysfunction.
Rationale 4: Clients with hypertension can experience erectile dysfunction due to inability of the vascular system
to properly engorge. This can be related to the increased pressure within the arteries, as well as a side effect of
antihypertensives. The other answer options would not create a risk for erectile dysfunction.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Describe common disorders of the male reproductive system, treatment, and nursing
interventions.
Question 5
Type: MCSA
The nurse is caring for a woman newly diagnosed with breast cancer who asks the nurse to explain the difference
between a mastectomy and a radical mastectomy. The nurse's best response is:
1. "They are both the same except that a radical mastectomy removes muscles from the chest wall."
2. "Both remove the breast tissue, but a radical mastectomy removes muscles and lymph nodes."
3. "The radical mastectomy takes more tissue from the chest and improves the chances of survival."
4. "The mastectomy removes more tissue and reduces the risk of metastasis, thereby improving survival rates."
Correct Answer: 2
Rationale 1: Both a mastectomy and a radical mastectomy remove breast tissue, but a radical mastectomy also
removes underlying muscle structure and surrounding lymph nodes, and is usually indicated when cancer cells
have been found in the lymph nodes. In the absence of lymph node involvement, a radical mastectomy does not
improve survival rates or decrease the risk of metastasis.
Rationale 2: Both a mastectomy and a radical mastectomy remove breast tissue, but a radical mastectomy also
removes underlying muscle structure and surrounding lymph nodes, and is usually indicated when cancer cells
have been found in the lymph nodes. In the absence of lymph node involvement, a radical mastectomy does not
improve survival rates or decrease the risk of metastasis.
Rationale 3: Both a mastectomy and a radical mastectomy remove breast tissue, but a radical mastectomy also
removes underlying muscle structure and surrounding lymph nodes, and is usually indicated when cancer cells
have been found in the lymph nodes. In the absence of lymph node involvement, a radical mastectomy does not
improve survival rates or decrease the risk of metastasis.
Rationale 4: Both a mastectomy and a radical mastectomy remove breast tissue, but a radical mastectomy also
removes underlying muscle structure and surrounding lymph nodes, and is usually indicated when cancer cells
have been found in the lymph nodes. In the absence of lymph node involvement, a radical mastectomy does not
improve survival rates or decrease the risk of metastasis.
Global Rationale:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Cognitive Level: Applying


Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Discuss common breast disorders, treatment, and nursing interventions.
Question 6
Type: MCSA
The nurse is preparing a woman for discharge following a left radical mastectomy. Important teaching for this
client includes:
1. Abstaining from sex for at least 6-8 weeks following surgery.
2. Resuming her oral birth control medication immediately.
3. Range of motion exercises for the involved arm.
4. Use of a splint for the involved arm until the tissue fully heals.
Correct Answer: 3
Rationale 1: Following a radical mastectomy, it is important that the client begin range of motion exercises, such
as climbing the wall with her fingers, in order to regain full range of motion in the affected arm. There is no need
to abstain from sex once she feels well enough to consider it, and oral birth control medications will most likely
be discontinued by the doctor because breast cancer is often hormone-dependent, and could increase the risk of
metastasis. The arm should not be splinted, and gentle movement and activity will be encouraged.
Rationale 2: Following a radical mastectomy, it is important that the client begin range of motion exercises, such
as climbing the wall with her fingers, in order to regain full range of motion in the affected arm. There is no need
to abstain from sex once she feels well enough to consider it, and oral birth control medications will most likely
be discontinued by the doctor because breast cancer is often hormone-dependent, and could increase the risk of
metastasis. The arm should not be splinted, and gentle movement and activity will be encouraged.
Rationale 3: Following a radical mastectomy, it is important that the client begin range of motion exercises, such
as climbing the wall with her fingers, in order to regain full range of motion in the affected arm. There is no need
to abstain from sex once she feels well enough to consider it, and oral birth control medications will most likely
be discontinued by the doctor because breast cancer is often hormone-dependent, and could increase the risk of
metastasis. The arm should not be splinted, and gentle movement and activity will be encouraged.
Rationale 4: Following a radical mastectomy, it is important that the client begin range of motion exercises, such
as climbing the wall with her fingers, in order to regain full range of motion in the affected arm. There is no need
to abstain from sex once she feels well enough to consider it, and oral birth control medications will most likely
be discontinued by the doctor because breast cancer is often hormone-dependent, and could increase the risk of
metastasis. The arm should not be splinted, and gentle movement and activity will be encouraged.
Global Rationale:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Cognitive Level: Analyzing


Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Discuss common breast disorders, treatment, and nursing interventions.
Question 7
Type: MCSA
The nurse is preparing a female client for discharge who will be prescribed Coumadin (warfarin) secondary to a
diagnosis of thrombophlebitis. The nurse instructs the woman to:
1. Stop taking oral contraceptives.
2. Wear a peripad during menstruation and notify the doctor if the pad fills more than once an hour.
3. Continue medication if she learns she is pregnant.
4. Anticipate heavier-than-normal periods and call the doctor if bleeding continues for more than one week.
Correct Answer: 2
Rationale 1: The client taking anticoagulants might have heavier than normal periods, and should plan to use a
peripad because it is impossible to determine amount of blood loss with a tampon. If the peripad fills more than
once an hour, or hourly for more than two hours, the client should call her provider, because this is defined as
heavy bleeding, and must be treated to prevent hemorrhagic shock. The physician will determine if oral
contraceptives should be continued or changed to a different formula. Pregnancy should be avoided while on
Coumadin (warfarin) because of the risk of fetal hemorrhage. Heavy bleeding should be reported immediately, not
after a week.
Rationale 2: The client taking anticoagulants might have heavier than normal periods, and should plan to use a
peripad because it is impossible to determine amount of blood loss with a tampon. If the peripad fills more than
once an hour, or hourly for more than two hours, the client should call her provider, because this is defined as
heavy bleeding, and must be treated to prevent hemorrhagic shock. The physician will determine if oral
contraceptives should be continued or changed to a different formula. Pregnancy should be avoided while on
Coumadin (warfarin) because of the risk of fetal hemorrhage. Heavy bleeding should be reported immediately, not
after a week.
Rationale 3: The client taking anticoagulants might have heavier than normal periods, and should plan to use a
peripad because it is impossible to determine amount of blood loss with a tampon. If the peripad fills more than
once an hour, or hourly for more than two hours, the client should call her provider, because this is defined as
heavy bleeding, and must be treated to prevent hemorrhagic shock. The physician will determine if oral
contraceptives should be continued or changed to a different formula. Pregnancy should be avoided while on
Coumadin (warfarin) because of the risk of fetal hemorrhage. Heavy bleeding should be reported immediately, not
after a week.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 4: The client taking anticoagulants might have heavier than normal periods, and should plan to use a
peripad because it is impossible to determine amount of blood loss with a tampon. If the peripad fills more than
once an hour, or hourly for more than two hours, the client should call her provider, because this is defined as
heavy bleeding, and must be treated to prevent hemorrhagic shock. The physician will determine if oral
contraceptives should be continued or changed to a different formula. Pregnancy should be avoided while on
Coumadin (warfarin) because of the risk of fetal hemorrhage. Heavy bleeding should be reported immediately, not
after a week.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Identify common uterine disorders and changes with menopause, as well as treatment and
nursing care for them.
Question 8
Type: MCSA
The nurse is providing discharge teaching for a client in the gynecologist's office who has been diagnosed with
premenstrual syndrome. The nurse determines the client understood instructions when she states:
1. "I will drink only diet cola in my daily rum and Coke, and eat more fruits and vegetables."
2. "I will avoid carbohydrates and increase my intake of vitamin C."
3. "I will take a calcium supplement and eat more pasta."
4. "I will allow myself a few pieces of chocolate and eat a diet high in protein."
Correct Answer: 3
Rationale 1: The client with PMS should follow a diet high in complex carbohydrates and limit simple sugars
while reducing sodium, caffeine, and alcohol. Increased intake of calcium, magnesium, and vitamin B6 might be
helpful. Complex carbohydrates are found in grains, pasta, beans, and peas. Fruits and most vegetables have
simple sugars in them. Chocolate contains both caffeine and simple sugar.
Rationale 2: The client with PMS should follow a diet high in complex carbohydrates and limit simple sugars
while reducing sodium, caffeine, and alcohol. Increased intake of calcium, magnesium, and vitamin B6 might be
helpful. Complex carbohydrates are found in grains, pasta, beans, and peas. Fruits and most vegetables have
simple sugars in them. Chocolate contains both caffeine and simple sugar.
Rationale 3: The client with PMS should follow a diet high in complex carbohydrates and limit simple sugars
while reducing sodium, caffeine, and alcohol. Increased intake of calcium, magnesium, and vitamin B6 might be
helpful. Complex carbohydrates are found in grains, pasta, beans, and peas. Fruits and most vegetables have
simple sugars in them. Chocolate contains both caffeine and simple sugar.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 4: The client with PMS should follow a diet high in complex carbohydrates and limit simple sugars
while reducing sodium, caffeine, and alcohol. Increased intake of calcium, magnesium, and vitamin B6 might be
helpful. Complex carbohydrates are found in grains, pasta, beans, and peas. Fruits and most vegetables have
simple sugars in them. Chocolate contains both caffeine and simple sugar.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: Identify common uterine disorders and changes with menopause, as well as treatment and
nursing care for them.
Question 9
Type: MCSA
The nurse is teaching a class for adolescent girls on the topic of cervical cancer prevention. The nurse informs the
class that risk can be reduced by:
1. Smoking.
2. Use of oral contraceptives.
3. Limiting sexual partners.
4. Following a low-calorie diet.
Correct Answer: 3
Rationale 1: Multiple sexual partners, especially when younger than 16 years of age, increase the risk of cervical
cancer, possibly due to the increased risk of exposure to HPV. Smoking, use of oral contraceptives for longer than
five years, and poor nutrition all increase the risk of cervical cancer.
Rationale 2: Multiple sexual partners, especially when younger than 16 years of age, increase the risk of cervical
cancer, possibly due to the increased risk of exposure to HPV. Smoking, use of oral contraceptives for longer than
five years, and poor nutrition all increase the risk of cervical cancer.
Rationale 3: Multiple sexual partners, especially when younger than 16 years of age, increase the risk of cervical
cancer, possibly due to the increased risk of exposure to HPV. Smoking, use of oral contraceptives for longer than
five years, and poor nutrition all increase the risk of cervical cancer.
Rationale 4: Multiple sexual partners, especially when younger than 16 years of age, increase the risk of cervical
cancer, possibly due to the increased risk of exposure to HPV. Smoking, use of oral contraceptives for longer than
five years, and poor nutrition all increase the risk of cervical cancer.
Global Rationale:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Cognitive Level: Applying


Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Discuss tumors of the female reproductive system, their treatment, and appropriate nursing
care.
Question 10
Type: MCSA
The nurse working in the Emergency Department admits a woman who states she has been raped. The nurse's
priority of care includes:
1. Assist the woman to bathe to remove the dirty feeling she reports.
2. Have the woman tested for blood alcohol level.
3. Provide emotional support.
4. Ask the woman to explain exactly what happened.
Correct Answer: 3
Rationale 1: The nurse's priority of care is providing emotional support and helping to collect data. Bathing
would destroy physical evidence, and should be avoided until after the physical examination is conducted by the
provider. The physician will determine if a blood alcohol level is needed, which is unlikely. Asking the woman to
explain what happened is inappropriate, and she will be questioned by the police. The nurse should supply
emotional support and listen to the client without confrontation.
Rationale 2: The nurse's priority of care is providing emotional support and helping to collect data. Bathing
would destroy physical evidence, and should be avoided until after the physical examination is conducted by the
provider. The physician will determine if a blood alcohol level is needed, which is unlikely. Asking the woman to
explain what happened is inappropriate, and she will be questioned by the police. The nurse should supply
emotional support and listen to the client without confrontation.
Rationale 3: The nurse's priority of care is providing emotional support and helping to collect data. Bathing
would destroy physical evidence, and should be avoided until after the physical examination is conducted by the
provider. The physician will determine if a blood alcohol level is needed, which is unlikely. Asking the woman to
explain what happened is inappropriate, and she will be questioned by the police. The nurse should supply
emotional support and listen to the client without confrontation.
Rationale 4: The nurse's priority of care is providing emotional support and helping to collect data. Bathing
would destroy physical evidence, and should be avoided until after the physical examination is conducted by the
provider. The physician will determine if a blood alcohol level is needed, which is unlikely. Asking the woman to
explain what happened is inappropriate, and she will be questioned by the police. The nurse should supply
emotional support and listen to the client without confrontation.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Identify other disorders of the female reproductive system and appropriate nursing care.
Question 11
Type: MCSA
When caring for the client who has been raped, the nurse considers a referral to:
1. Social Services.
2. Rape counseling.
3. Psychiatrist.
4. Obstetrician.
Correct Answer: 2
Rationale 1: Rape counselors are often women who have survived rape and have the resources to provide the
long-term follow up and care required by the rape victim. Social Services would most likely refer to a rape
counselor. A psychiatrist or obstetrician would not be indicated unless other issues existed.
Rationale 2: Rape counselors are often women who have survived rape and have the resources to provide the
long-term follow up and care required by the rape victim. Social Services would most likely refer to a rape
counselor. A psychiatrist or obstetrician would not be indicated unless other issues existed.
Rationale 3: Rape counselors are often women who have survived rape and have the resources to provide the
long-term follow up and care required by the rape victim. Social Services would most likely refer to a rape
counselor. A psychiatrist or obstetrician would not be indicated unless other issues existed.
Rationale 4: Rape counselors are often women who have survived rape and have the resources to provide the
long-term follow up and care required by the rape victim. Social Services would most likely refer to a rape
counselor. A psychiatrist or obstetrician would not be indicated unless other issues existed.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Identify other disorders of the female reproductive system and appropriate nursing care.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Question 12
Type: MCSA
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.
Correct Answer: 3
Rationale 1: 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.
Rationale 2: 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.
Rationale 3: 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.
Rationale 4: 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.
Global Rationale:
Cognitive Level: Understanding
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Describe the normal sexual response cycle and list possible causes of reproductive issues.
Question 13
Type: MCSA
The nurse admits a 62-year-old man who reports, "I always feel like I need to void, but it takes so long for me to
get my flow started, and then I only go a few drops." The nurse suspects:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

1. Bladder infection.
2. Benign prostatic hypertrophy.
3. Renal failure.
4. Prostatitis.
Correct Answer: 2
Rationale 1: Enlargement of the prostate places pressure on the urethra, making it difficult to begin the stream,
and causes inadequate emptying, leading to frequency. Prostatitis manifests with fever, chills, frequency, and
nocturia, and can include back pain and pain after ejaculation. Renal failure would result in reduced urine output
and edema. Bladder infection will need to be ruled out, but with the client's age, BPH would be a higher
likelihood.
Rationale 2: Enlargement of the prostate places pressure on the urethra, making it difficult to begin the stream,
and causes inadequate emptying, leading to frequency. Prostatitis manifests with fever, chills, frequency, and
nocturia, and can include back pain and pain after ejaculation. Renal failure would result in reduced urine output
and edema. Bladder infection will need to be ruled out, but with the client's age, BPH would be a higher
likelihood.
Rationale 3: Enlargement of the prostate places pressure on the urethra, making it difficult to begin the stream,
and causes inadequate emptying, leading to frequency. Prostatitis manifests with fever, chills, frequency, and
nocturia, and can include back pain and pain after ejaculation. Renal failure would result in reduced urine output
and edema. Bladder infection will need to be ruled out, but with the client's age, BPH would be a higher
likelihood.
Rationale 4: Enlargement of the prostate places pressure on the urethra, making it difficult to begin the stream,
and causes inadequate emptying, leading to frequency. Prostatitis manifests with fever, chills, frequency, and
nocturia, and can include back pain and pain after ejaculation. Renal failure would result in reduced urine output
and edema. Bladder infection will need to be ruled out, but with the client's age, BPH would be a higher
likelihood.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Describe common disorders of the male reproductive system, treatment, and nursing
interventions.
Question 14
Type: MCMA

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

When admitting the client diagnosed with toxic shock syndrome, the nurse would question the client about which
of the following to gather data related to the cause of the infection? Select all that apply.
Standard Text: Select all that apply.
1. Recent surgery
2. Use of a diaphragm
3. Use of tampons
4. Presence of IUD
5. Type of underwear worn
Correct Answer: 1,2,3
Rationale 1: Cause of toxic shock syndrome is infrequent tampon changing in 70% of cases. Other causes include
improper use of a diaphragm, infected surgical wounds, and subcutaneous abscesses. IUDs have not been
associated with TSS, but could result in PID. Type of underwear is not related to TSS.
Rationale 2: Cause of toxic shock syndrome is infrequent tampon changing in 70% of cases. Other causes include
improper use of a diaphragm, infected surgical wounds, and subcutaneous abscesses. IUDs have not been
associated with TSS, but could result in PID. Type of underwear is not related to TSS.
Rationale 3: Cause of toxic shock syndrome is infrequent tampon changing in 70% of cases. Other causes include
improper use of a diaphragm, infected surgical wounds, and subcutaneous abscesses. IUDs have not been
associated with TSS, but could result in PID. Type of underwear is not related to TSS.
Rationale 4: Cause of toxic shock syndrome is infrequent tampon changing in 70% of cases. Other causes include
improper use of a diaphragm, infected surgical wounds, and subcutaneous abscesses. IUDs have not been
associated with TSS, but could result in PID. Type of underwear is not related to TSS.
Rationale 5: Cause of toxic shock syndrome is infrequent tampon changing in 70% of cases. Other causes include
improper use of a diaphragm, infected surgical wounds, and subcutaneous abscesses. IUDs have not been
associated with TSS, but could result in PID. Type of underwear is not related to TSS.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Name three infectious disorders that have an impact on family planning issues.
Question 15
Type: FIB
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

The nurse teaches adolescents that which method of birth control is 100% effective?
Standard Text:
Correct Answer: Abstinence
Rationale : No contraceptive is 100% effective 100% of the time. The only form of birth control that is 100%
effective is abstinence.
Global Rationale:
Cognitive Level: Remembering
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Discuss common contraceptive methods and the effectiveness of each.
Question 16
Type: MCSA
The nurse caring for a client with strong prolife beliefs recommends which of the following contraceptives
because it prevents fertilization of the ova?
1. Condom
2. Intrauterine device
3. Oral hormonal contraceptives
4. Plan B contraceptives
Correct Answer: 1
Rationale 1: The condom prevents the sperm from contact with the ova, and prevents fertilization. The IUD and
hormonal contraceptives, including plan B, do not prevent fertilization but create a hostile uterine environment
that does not allow implantation of the fertilized ovum.
Rationale 2: The condom prevents the sperm from contact with the ova, and prevents fertilization. The IUD and
hormonal contraceptives, including plan B, do not prevent fertilization but create a hostile uterine environment
that does not allow implantation of the fertilized ovum.
Rationale 3: The condom prevents the sperm from contact with the ova, and prevents fertilization. The IUD and
hormonal contraceptives, including plan B, do not prevent fertilization but create a hostile uterine environment
that does not allow implantation of the fertilized ovum.

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 4: The condom prevents the sperm from contact with the ova, and prevents fertilization. The IUD and
hormonal contraceptives, including plan B, do not prevent fertilization but create a hostile uterine environment
that does not allow implantation of the fertilized ovum.
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Discuss common contraceptive methods and the effectiveness of each.
Question 17
Type: MCSA
The clients come to the fertility clinic to determine the cause of their inability to become pregnant. The nurse
anticipates the first action will be:
1. Semen analysis.
2. Ultrasound of the woman's reproductive organs.
3. Administration of hormone therapy.
4. Measurement of hormone levels.
Correct Answer: 1
Rationale 1: Because it is noninvasive, generally the first test to be performed when examining for the cause of
infertility is a semen analysis, which includes measuring sperm mobility and number. If this is normal, the
mother's hormone levels will be checked. Ultrasound and more invasive tests are performed if cause of infertility
is not indicated by other tests.
Rationale 2: Because it is noninvasive, generally the first test to be performed when examining for the cause of
infertility is a semen analysis, which includes measuring sperm mobility and number. If this is normal, the
mother's hormone levels will be checked. Ultrasound and more invasive tests are performed if cause of infertility
is not indicated by other tests.
Rationale 3: Because it is noninvasive, generally the first test to be performed when examining for the cause of
infertility is a semen analysis, which includes measuring sperm mobility and number. If this is normal, the
mother's hormone levels will be checked. Ultrasound and more invasive tests are performed if cause of infertility
is not indicated by other tests.
Rationale 4: Because it is noninvasive, generally the first test to be performed when examining for the cause of
infertility is a semen analysis, which includes measuring sperm mobility and number. If this is normal, the
mother's hormone levels will be checked. Ultrasound and more invasive tests are performed if cause of infertility
is not indicated by other tests.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Global Rationale:
Cognitive Level: Applying
Client Need: Safe Effective Care Environment
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Describe some of the issues involved in infertility and possible methods of treatment.

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.