Author Question: Which assessment finding in a woman who recently started taking hormone therapy (HT) is most ... (Read 27 times)

jCorn1234 · **on:** Jun 25, 2018

Which assessment finding in a woman who recently started taking hormone therapy (HT) is most important for the nurse to report to the health care provider?

a. Breast tenderness
b. Left calf swelling
c. Weight gain of 3 lb
d. Intermittent spotting

Question 2

A 58-year-old patient who has undergone a radical vulvectomy for vulvar carcinoma returns to the medical-surgical unit after the surgery. The priority nursing diagnosis for the patient at this time is

a. risk for infection related to contact of the wound with urine and stool.
b. self-care deficit: bathing/hygiene related to pain and difficulty moving.
c. imbalanced nutrition: less than body requirements related to low-residue diet.
d. risk for ineffective sexual pattern related to disfiguration caused by the surgery.

KKcool · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

ANS: B
Unilateral calf swelling may indicate deep vein thrombosis caused by the changes in coagulation associated with HT and would indicate that the HT should be discontinued. Breast tenderness, weight gain, and intermittent spotting are common side effects of HT and do not indicate a need for a change in therapy.

Answer to Question 2

ANS: A
Complex and meticulous wound care is needed to prevent infection and delayed wound healing. The other nursing diagnoses may also be appropriate for the patient but are not the highest priority immediately after surgery.