Sexuality
A nurse is assessing sexual health in an older adult. Which statement demonstrates correct understanding of sexuality in older adulthood?
A. “Older adults lose interest in sexual activity.”
B. “Physiological changes occur, but sexuality does not disappear with aging.”
C. “Testosterone and estrogen levels do not change with aging.”
D. “Sexual health assessments are unnecessary for older adults.”
Correct Answer: B
Rationale: Older adults continue to have sexual needs; while physiological changes occur, sexuality does not diminish.
A nurse suspects an STI in a patient. Which symptom is most common among STIs?
A. Complete absence of signs
B. Fever, discharge, or painful urination
C. Hypertension
D. Night sweats only
Correct Answer: B
Rationale: Common STI symptoms include discharge, dysuria, sores, and fever.
The nurse recognizes the normal 24-hour urine output for an adult is:
A. 400–600 mL
B. 600–1000 mL
C. 1200–1500 mL
D. 2000–3000 mL
Correct Answer: C
A patient presents with abdominal distention and reports no bowel movement for a week. The nurse suspects impaction. What finding supports this?
A. Watery seepage of stool
B. Hemorrhoids
C. Black tarry stool
D. Increased bowel sounds
Correct Answer: A
Rationale: Stool may leak around a fecal impaction.
A patient with a tracheostomy requires frequent suctioning. Which finding indicates the most immediate need for suctioning?
A. Low-grade fever
B. Rhonchi on auscultation
C. Increased thin secretions
D. Audible gurgling in the airway
Answer: D
Rationale: Audible gurgling indicates airway obstruction risk and requires immediate suctioning.
To prevent aspiration during enteral tube feeding, the nurse should:
A. Lower the head of bed
B. Check placement every 12 hours
C. Keep the head of bed elevated at least 30°
D. Clamp the tube between feedings
Answer: C
Rationale: Elevating the HOB ≥30° reduces aspiration risk during feeding.
A patient reports pain rated 8/10. The nurse notes no grimacing or guarding. Which principle applies?
A. The patient is exaggerating the pain.
B. Pain expression must match behavior to be believed.
C. The patient’s report is the most reliable indicator of pain.
D. Objective data are required before treating pain.
Correct Answer: C
Rationale: Pain is subjective; the patient is the expert on their own pain.
Which statement by a nurse reflects appropriate care for a patient with an alteration in sexual health?
A. “Sexual concerns are not part of routine nursing assessments.”
B. “Medications, illness, and surgery can influence sexuality.”
C. “Older adults are not typically sexually active.”
D. “Sexual health should only be discussed if the patient brings it up.”
Correct Answer: B
Rationale: Illness, medications, and surgery frequently affect sexual functioning and must be assessed.
Which of the following STIs are curable? (Select all that apply.)
A. Chlamydia
B. HPV
C. Gonorrhea
D. Trichomoniasis
E. Herpes simplex virus type II
Correct Answers: A, C, D
Rationale: Bacterial and protozoal infections (chlamydia, gonorrhea, trichomoniasis) are curable; HPV and HSV-2 are viral and not curable.
Which patient finding indicates oliguria?
A. 75 mL/hr
B. 40 mL/hr
C. 1500 mL/day
D. 100 mL/24 hr
Correct Answer: B
Rationale: Oliguria = low urine output (<400 mL/day or <30–50 mL/hr).
A nurse auscultates the abdomen of a postoperative patient and hears absent bowel sounds. What condition is suspected?
A. Impaction- constipation
B. Ileus
C. Diarrhea
D. Flatulence
Correct Answer: B
Rationale: Postoperative ileus = absence of peristalsis, leading to absent bowel sounds.
A patient is experiencing fatigue, pallor, and shortness of breath. The nurse suspects decreased oxygen-carrying capacity. Which condition most commonly causes this?
A. Hypovolemia
B. Anemia
C. Atelectasis
D. Increased metabolic rate
Answer: B
Rationale: Anemia reduces hemoglobin levels, decreasing oxygen-carrying capacity and leading to fatigue and dyspnea.
Which action is appropriate when caring for a patient receiving TPN?
A. Hang TPN for up to 48 hours
B. Use a central line for TPN
C. Use peripheral IV access
D. Check blood glucose weekly
Answer: B
Rationale: TPN requires central venous access due to osmolarity.
A patient is transitioning from IV to PO opioids. The nurse explains that:
A. The oral dose is lower because PO opioids are more potent.
B. The oral dose is higher because of the first-pass effect.
C. The IV and PO doses are equal.
D. The oral dose causes fewer side effects.
Correct Answer: B
Rationale: Oral medications undergo first-pass metabolism; thus higher doses are needed to achieve the same effect.
A patient states they are embarrassed to discuss sexual concerns. What is the nurse’s best response?
A. “Let’s skip that part of the assessment.”
B. “It’s important for your health; we can go at your pace.”
C. “Most people aren’t embarrassed about this.”
D. “It's a natural thing amongst adults, it's okay, there is nothing to be embarrassed about.”
Correct Answer: B
Rationale: A supportive, patient-centered, non-dismissive response is best.
Which STI can lead to infertility if untreated?
A. HIV
B. Chlamydia
C. HPV
D. HSV-2
Correct Answer: B
The nurse identifies which patient as being at highest risk for a UTI?
A. Male runner
B. Postmenopausal woman
C. 25-year-old who drinks 2 L/day
D. Patient without a catheter
Correct Answer: B
Rationale: Menopausal women are listed as high-risk due to decreased estrogen and vaginal flora changes.
SATA: Which patients should AVOID the Valsalva maneuver?
A. Patient with heart disease
B. Patient with glaucoma
C. Patient with recent eye surgery
D. Healthy athlete
E. Patient with increased ICP
Correct Answers: A, B, C, E
Rationale: Valsalva increases intracranial, intrathoracic, and intraocular pressure.
A chest tube drainage system is observed with continuous bubbling in the water-seal chamber. The nurse should:
A. Document this expected finding
B. Increase suction
C. Notify the provider
D. Strip the tubing to remove clots
Answer: C
Rationale: Continuous bubbling indicates an air leak, requiring provider notification.
A patient receiving enteral feeding has residuals of 500 mL on one check. The nurse should:
A. Continue feeding
B. Reduce feeding rate
C. Hold feeding and notify provider
D. Flush the tube with water and restart
Answer: C
Rationale: A single residual of 500 mL indicates delayed gastric emptying.
A patient has chronic neuropathic pain. Which medication class is most effective?
A. Antibiotics
B. NSAIDs
C. Tricyclic antidepressants or anticonvulsants
D. Acetaminophen
Correct Answer: C
Rationale: They affect pain signals by inhibiting the reuptake of norepinephrine and serotonin in the central nervous system.
A patient with suspected elder sexual abuse is admitted. What must the nurse do?
A. Ignore it unless the patient confirms abuse
B. Report to authorities as required by law
C. Wait for a physician’s order
D. Ask family members for clarification
Correct Answer: B
Rationale: Nurses are mandated reporters of suspected child or elder abuse.
SATA: Which are primary treatments for curable STIs?
A. Antibiotics
B. Vaccination
C. Antivirals
D. Antiprotozoals
E. Warm compresses
Correct Answers: A, D
Rationale: Bacterial STIs (chlamydia, gonorrhea, syphilis) and protozoal infections (trichomoniasis) are treated with antibiotics/antiprotozoals.
SATA: Which are characteristics of normal urine?
A. Light yellow to amber
B. Clear without sediment
C. Fruity odor
D. Cloudy
E. Faint odor
Correct Answers: A, B, E
Rationale: Normal urine: light yellow to amber, clear, faint odor.
BONUS: can anyone tell me what medical condition a fruity odor in urine can be indicative of?
A patient with a new colostomy states, “I can’t look at it.” What is the nurse’s priority?
A. Force patient to participate in care
B. Assess body image concerns
C. Tell them this is normal
D. Remove the pouching system
Correct Answer: B
A patient with COPD is on 2 L/min O₂ via nasal cannula. Which is the priority?
A. Increase O₂ to 5 L/min
B. Monitor for decreased respiratory drive
C. Encourage rapid deep breathing
D. Remove the cannula during meals
Answer: B
Rationale: Excess oxygen can suppress respiratory drive in COPD patients.
Acceptable tube-feeding safety practices: (Select all that apply)
A. Verify placement by X-ray on initiation
B. Check pH every 4–6 hours
C. Always check residual volume
D. Place patient flat after feeding
E. Flush tube with water as ordered
Answers: A, B, C, E
Rationale: All support safe feeding; never place patient flat.
SATA: Which are signs of opioid respiratory depression?
A. Respiratory rate 8/min
B. Pinpoint pupils
C. Increased alertness
D. Sedation
E. Elevated blood pressure
Correct Answers: A, B, D
Which patient action indicates effective understanding of breast or testicular self-exams?
A. Performing them only when symptoms occur
B. Performing them regularly
C. Asking a partner to complete the exam
D. Scheduling them only during provider visits
Correct Answer: B
Rationale: Teaching includes promoting regular self-exams.
Which infection is the most common STI in the United States?
A. Syphilis
B. Herpes simplex virus II
C. Human papillomavirus (HPV)
D. HIV
Answer: C
Rationale: HPV is the most common STI and can cause cancer; it spreads via direct contact with genital fluids or warts
SATA: Which factors increase urinary frequency in older adults?
A. Decreased bladder muscle tone
B. Increased bladder capacity
C. Nocturia
D. Decreased bladder contractility
Correct Answers: A, C, D
Rationale: Aging affects tone, contractility, and ability to concentrate urine.
SATA: Nursing priorities for ostomy patients include:
A. Meticulous skin care
B. Hydration
C. Encouraging frequent laxative use
D. Assessing body image concerns
E. Teaching ostomy management
Correct Answers: A, B, D, E
Which factors increase aspiration risk? (Select all that apply)
A. Decreased LOC
B. Flat positioning
C. Coughing
D. Suctioning
E. GERD
Answers: A, B, C, D, E
Indications for parenteral nutrition include: (Select all that apply)
A. Severe burns
B. Sepsis
C. Difficulty swallowing
D. Short bowel syndrome
E. Severe malabsorption
Answers: A, B, D, E
Rationale: PN is for patients unable to use GI tract or in high-stress states.
SATA: Which are examples of cutaneous stimulation for pain management?
A. Massage
B. TENS
C. Heat/cold therapy
D. Guided imagery
E. Biofeedback
Correct Answers: A, B, C
Rationale: Cutaneous stimulation involves physical techniques acting on the skin.