ATI LPN
Test Bank for Medical Surgical Nursing: Concepts for Interprofessional Collaborative Care 10th Edition
Chapter 73 : Care of Transgender Patients Questions
Question 1 of 5
A transgender client taking spironolactone (Aldactone) is in the internal medicine clinic reporting heart palpitations. What action by the nurse takes priority?
Correct Answer: C
Rationale: Spironolactone is a potassium-sparing diuretic, and hyperkalemia can cause cardiac dysrhythmias. The nurse's priority is to obtain an ECG, then to facilitate a serum potassium level being drawn. Having the client sit down and obtaining vital signs are also important care measures, but do not take priority.
Question 2 of 5
The nurse is teaching a transgender client about the medication goserelin (Zoladex). What action by the client indicates good understanding?
Correct Answer: B
Rationale: Goserelin is administered via subcutaneous injection. The other actions are not related to self-management while on this medication.
Question 3 of 5
A client is preparing for gender reassignment surgery and will transition from male to female. The client is concerned about the possibility of having a voice change. What should the nurse tell the client?
Correct Answer: B
Rationale: Male-to-female clients can consult with a speech-language pathologist for vocal training to help with intonation and pitch. While vocal surgery is possible, it may not be the best first option due to cost and invasiveness. Telling the client there will be no change in the voice does not give the client information to address the concern. While the hormones this client is taking will not affect the voice, simply stating that fact does not help the client manage this issue.
Question 4 of 5
A client has returned from the postanesthesia care unit after a vaginoplasty. What comfort measure does the nurse provide for this client?
Correct Answer: A
Rationale: Ice is applied to the perineum to reduce pain and discomfort. Elevating the legs on pillows is not recommended after a lengthy procedure in the lithotomy position, which predisposes the client to venous thromboembolism.
Question 5 of 5
A client had a vaginoplasty under epidural anesthetic. Which action by the nurse is most important?
Correct Answer: B
Rationale: Epidural anesthesia will cause the client to not be able to move (or feel) the legs for several hours. It is important to monitor the client closely and help the client to move in the dressing to get out of bed. Securing the catheter to the leg and monitoring dressings and drainage are important for any client after surgery. Positioning the drain to the contralateral side is not needed.