The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?
Dizziness can occur during cleansing.
The pubic area should be kept shaved.
The foreskin should not be retracted.
An erection may occur while providing care.
The Correct Answer is D
Choice A reason: Dizziness is not typically associated with perineal care and is not relevant to the instructions.
Choice B reason: Advising to keep the pubic area shaved is not a standard part of perineal care instructions and is a personal choice.
Choice C reason: The statement about not retracting the foreskin is incorrect; the foreskin should be retracted gently for cleaning and then returned to its normal position to prevent infection.
Choice D reason: It is important to inform the caregiver that an erection may occur as a natural reflex during perineal care, and it does not indicate any sexual intent. This helps prepare the caregiver to handle the situation professionally.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
This postoperative nursing scenario requires the application of non-pharmacological pain management strategies and safety protocols. Knowledge of gate control theory and surgical contraindications is essential to address breakthrough pain effectively while awaiting provider orders without compromising the integrity of the surgical site.
Choice A rationale: While massage can be soothing, 20 minutes of back massage and effleurage is physically demanding and may not be feasible in an acute care setting. Additionally, positioning a thoracic surgery client for a back massage might cause more incisional discomfort.
Choice B rationale: Guided imagery and slow rhythmic breathing are effective non-pharmacological interventions that reduce the perception of pain by decreasing autonomic nervous system arousal. These techniques empower the client and provide immediate relief without risk of injury to the incision.
Choice C rationale: Applying heat to a fresh surgical site is contraindicated because it increases vasodilation, which can lead to increased edema, bleeding, and potential incision dehiscence. Thermal devices should never be placed directly over a fresh operative site without specific orders.
Choice D rationale: Distraction through television or music can be a helpful adjunct, but it is often less effective than active cognitive-behavioral strategies like guided imagery for a pain level of 5. It serves as a passive intervention rather than an active coping skill.
Correct Answer is C
Explanation
Choice A reason: Offering positive reinforcement is a good practice in teaching, but it does not directly facilitate the learning of problem-solving strategies.
Choice B reason: Physical demonstrations are more suited to teaching psychomotor skills rather than problem-solving strategies.
Choice C reason: Simulation activities allow individuals to practice problem-solving in a controlled environment, which can enhance learning and retention of these strategies.
Choice D reason: Verbal analogies can aid in understanding concepts, but they are less interactive and engaging than simulation activities when it comes to learning problem-solving strategies.
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