A nurse is assessing an older adult client's perception of sexuality. Which of the following statements made by the client indicates a need for intervention?
"I do not have to worry about using protection now that I am in menopause."
use lubricants to help prevent pain during sex."
1 feel more self-conscious with how I look now that I am older."
"I still think about having sex at my age?
The Correct Answer is A
A. This statement reflects a misconception about menopause and sexual health, indicating a need for education on safe sex practices.
B. This statement indicates the client is taking steps to address discomfort during sexual activity, which is appropriate.
C. This statement reflects body image concerns commonly experienced by older adults and may warrant further exploration but does not necessarily indicate a need for immediate intervention.
D. This statement indicates a normal interest in sexual activity and does not necessarily indicate a need for intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Extracellular fluid volume deficit (dehydration) typically leads to decreased venous return and reduced preload, resulting in flat or collapsed neck veins, rather than distended ones.
B. In extracellular fluid volume deficit, there is a decrease in blood volume, which can result in postural hypotension when the client changes positions, due to inadequate fluid volume to maintain blood pressure.
C. Extracellular fluid volume deficit is characterized by decreased fluid volume, which leads to decreased tissue perfusion and fluid shifts out of the interstitial spaces, resulting in reduced or absent edema.
D. Bradycardia is not typically associated with extracellular fluid volume deficit.
Instead, tachycardia may occur as a compensatory mechanism to maintain cardiac output in response to decreased blood volume.
Correct Answer is ["B","C","D"]
Explanation
A. Povidone-iodine is not recommended for cleaning around the stoma as it may cause irritation.
B. Ensuring the pouch opening is slightly larger than the stoma helps prevent irritation and ensures proper fit.
C. Regular emptying of the ostomy pouch prevents leakage and skin irritation. It also prevents it from becoming too heavy and pulling away from the skin.
D. The nurse should advise the client to place a piece of gauze over the stoma while changing the pouch to protect it from injury and contamination.
E. A purplish-blue change in the stoma is an indication of impaired blood supply to the stoma and should be promptly reported to the healthcare provider.
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