Study Points

Health Issues Distinctive to Women

Course #93313 - $75 • 15 Hours/Credits

  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.
Learning Tools - Study Points
Study Points

Click on any objective to view test questions.

  1. Consider factors that may influence access to and quality of health services for women, including economic, cultural, and demographic issues.
  2. Review the historical and current context of the inclusion of women in health research.
  3. Review gender-specific health theories and models.
  4. Compare and contrast the presentation of sexually transmitted infections in men and women.
  5. Explain communication skills that foster a non-judgmental attitude regarding sexual activity.
  6. Identify issues related to gynecologic health, including the recommended Pap screening schedules.
  7. Discuss the risk factors for cervical cancer and the holistic therapeutic plan of care for a woman with gynecologic cancer.
  8. Define menarche, perimenopause, and menopause, and identify care issues that may arise in these life stages.
  9. Discuss the risks, benefits, and contraindications for hormone replacement therapy.
  10. Discuss various health promotion and pharmacologic options for women experiencing menopause.
  11. Discuss recommendations regarding breast cancer screening.
  12. Identify the various factors that should be considered when making treatment choices for women with breast cancer.
  13. Compare and contrast gender differences in women and men with cardiovascular disease.
  14. Explain the relationship between a balanced diet and exercise to maintain health across the lifespan.
  15. List the risk factors and treatment and screening guidelines for obesity, diabetes, and heart disease.
  16. Discuss osteoporosis risk factors and the risks, benefits, and side effects of the common medications used in the treatment of the disease.
  17. Discuss common mental health issues in women's health, including depression and domestic violence.
  18. Review culturally specific risk factors and health disparities for women of color.
  19. Identify complementary therapies, including those that have been effective in various women's health issues, such as cancer, heart disease, and menopause.
  20. Review health screening guidelines and immunization recommendations for women across the lifespan.
  1. Many of the health problems that are distinctive to women may be avoided or lessened through better

    WOMEN'S HEALTH AND HEALTH PROMOTION

    Many of the health problems that plague women today may be avoided or lessened through better health education and community and public health programs. Nurses and other health professionals are in a position to make a difference. Sharing concerns about issues that affect women's health is a prerequisite to making a change in the way nurses and other health professionals practice. The information should also be used as resource material for teaching plans. There is a distinct need for more health education and comprehensive preventive programs to improve access and quality of health care for women of all ages.

    Click to Review
  2. The demographic increase in the female population is mainly comprised of

    WOMEN'S HEALTH AND HEALTH PROMOTION

    The Office on Women's Health (OWH) has noted that women are living longer, facing more chronic conditions by virtue of lifespan, and coming from a variety of cultural backgrounds, necessitating a focus on the health of women across the lifespan to encourage well-being and functional outcomes. Both demographic changes and increasing incidence rates of conditions such as heart disease, diabetes, and breast cancer provide justification for further advancement of health issues facing women. The population increase of aging or elderly women is significant. An estimated 47.8 million Americans are 65 years of age and older, approximately 55% of whom are women. This percentage of older persons, which now comprises 14.9% of the population, is expected to grow to 98.2 million by the year 2060, or approximately 25% of the population [3,4,5,6]. The older population is also becoming more racially and ethnically diverse. Between 2014 and 2060, the share of the older population that is non-Hispanic white is projected to drop by 24%, from 78.3% to 54.6% [6]. Blacks accounted for 9% of this population in 2017. This number is projected to grow to 13% by 2060 [7]. Hispanics accounted for 8% in 2017 and are expected to account for 21% by 2060 [7]. Asians represented 4% in 2017 and are expected to represent 8% by 2060 [7].

    Click to Review
  3. In the past, women were not included in research studies, resulting in

    WOMEN'S HEALTH AND HEALTH PROMOTION

    Despite the evolution and political strength of the women's health movement, women's health advocacy in the United States does not consistently address experiences specific to women in ethnic, socioeconomic, and aging subgroups. In the past, women were generally excluded from research studies, leaving gaps in the body of knowledge relating to ways women respond to and deal with health and illness and creating assumptions that findings were the same for women as for men. Today, the NIH closely monitors the inclusion of women and minorities in research. In addition, extensive studies on women's health issues, such as the Women's Health Initiative (WHI), have provided scientific information previously lacking.

    Click to Review
  4. The federal agency that closely monitors the inclusion of women and minorities in research studies is the

    WOMEN'S HEALTH AND HEALTH PROMOTION

    Despite the evolution and political strength of the women's health movement, women's health advocacy in the United States does not consistently address experiences specific to women in ethnic, socioeconomic, and aging subgroups. In the past, women were generally excluded from research studies, leaving gaps in the body of knowledge relating to ways women respond to and deal with health and illness and creating assumptions that findings were the same for women as for men. Today, the NIH closely monitors the inclusion of women and minorities in research. In addition, extensive studies on women's health issues, such as the Women's Health Initiative (WHI), have provided scientific information previously lacking.

    Click to Review
  5. A major component of gender-sensitive care is

    WOMEN'S HEALTH AND HEALTH PROMOTION

    Gender-sensitive care should be the direction for the philosophical and theoretical development of women's health. Overcoming the limitations imposed by the dominant medical model in women's health requires theoretical bases that do not reduce women's health and illness experience into a disease. The gender-sensitive philosophy incorporates explanations of health and empowers women to effectively and adequately deal with their situations. The major components incorporated into the development of gender-sensitive care include:

    • Gender is a central feature.

    • Women's own voices and experiences are reflected.

    • Diversities and complexities are incorporated into women's experiences.

    • Theorists reflect about underlying andro­centric and ethnocentric assumptions.

    • Sociopolitical contexts and constraints of women's experiences are considered.

    • Guidelines for practice with specific groups of women are provided.

    Click to Review
  6. Compared with men's experiences with sexually transmitted infections (STIs), women experience

    SEXUAL AND REPRODUCTIVE HEALTH

    It has been said that STIs are biologically sexist. This is because women experience a disproportionate amount of the STI burden and complications, including sterility, perinatal infections, genital tract neoplasm, and death. STIs in women are often asymptomatic, but the silent process is both infectious and damaging. Vertical transmission of the disease in the perinatal period places the fetus at risk for developing illness, congenital anomalies, and developmental disabilities, or may result in fetal death [16,18,19].

    Click to Review
  7. A patient presents to the clinic because her boyfriend was treated for nongonococcal urethritis. The STI she has probably been exposed to is

    SEXUAL AND REPRODUCTIVE HEALTH

    Chlamydia is also a major cause of nongonococcal urethritis (NGU) and lymphogranuloma venereum (LGV) in men [16]. Diagnosis is frequently made in men as NGU and in women after treatment of a male partner for NGU, or on a routine pregnancy screening in asymptomatic women. Laboratory testing has become more sophisticated, with NAAT used to detect the specific DNA of C. trachomatis, (e.g., polymerase chain reaction tests) [16]. A vaginal swab, either collected by a provider or self-collected in a clinic, is the recommended test for women. Antibiotic treatment is doxycycline, 100 mg orally twice per day for one week. Azithromycin and levofloxacin are alternative options [16,29].

    Click to Review
  8. Which of the following communication skills foster a frank discussion of sexual health needs?

    SEXUAL AND REPRODUCTIVE HEALTH

    Despite the availability of public health information, the discussion of contraception, safer sex, and sexual concerns are complex communication issues. Conflict with religious beliefs, inconvenience, cost, stigma, and responsibility are just a few communication barriers that persist between the woman and the provider. Communication techniques to enhance a frank discussion of sexual health needs should include:

    • Discuss the woman's experiences of sexual risk behavior.

    • Challenge myths to help protect women against unsafe sexual demands (e.g., having unprotected sex because "they love each other")

    • Explore situations with the woman to establish a realistic assessment of her sexual risks.

    • Demonstrate value to the woman by establishing rapport and taking time to discuss her situation.

    Click to Review
  9. The organism most often responsible for vulvovaginal yeast infections is

    GYNECOLOGIC HEALTH

    The incidence of yeast infections may be increasing, in part due to the widespread, often improper use of antimicrobial therapy. Other factors, such as positive HIV status, diabetes, and recent IV drug use, are also believed to contribute to yeast colonization [39]. The organism most often responsible for vulvovaginal candidiasis is a fungus called Candida albicans. Other species (e.g., C. glabrata, C. tropicalis) may also cause vulvovaginal candidiasis and are more resistant to treatment [39]. The number of healthy, asymptomatic women who harbor Candida organisms is also increasing. A change in the vaginal environment and pH may cause the candidal organisms to grow, resulting in irritation. Certain health situations may increase the risk of yeast infections [16,18,27,34]:

    • Taking an antibiotic for an infection in another part of the body may destroy bacteria that are the normal flora of the vagina. Because these bacteria normally keep candidal fungi from flourishing, their removal may allow a yeast infection to develop.

    • Hormonal changes present during pregnancy or when taking high-dose estrogen oral contraceptives may change the environment of the vagina and make it conducive to the growth of yeast cells. For example, during pregnancy, vaginal secretions become less acidic; the pH changes from about 4 or 5 to about 5.5 or 6.5.

    • HIV infection or the use of immunosuppressive medications may promote yeast infections. An impaired immune system may allow yeast to grow unchecked.

    • Diabetes may foster the growth of the fungi because high blood sugar reduces the body's natural ability to resist infection. Diabetes also increases the glucose in the body's tissues, which makes it easier for yeast to grow.

    Click to Review
  10. According to guidelines from the American Cancer Society (ACS), the first Pap test should be done

    GYNECOLOGIC HEALTH

    Recommendations vary regarding how frequently women should have Pap tests. National health organizations, such as the American Cancer Society (ACS), the National Cancer Institute (NCI), and the American Medical Association (AMA), have adopted consensus recommendations. Other organizations, such as the ACS, the CDC, and the U.S. Preventive Services Task Force (USPSTF) have developed guidelines for cervical cancer screening. Recommendations from the ACS, the CDC, and the USPSTF are similar and summarized below [16,41,56]:

    • Pap tests should initiate at 21 years of age (regardless of sexual debut). A conventional or liquid-based Pap test should be done every three years; annual Pap testing is no longer recommended. HPV testing is not recommended alone or in combination with cytology for women younger than 30 years of age.

    • Beginning at 30 years of age, women who have had three or more consecutive normal Pap results should be screened every five years with HPV and cytology co-testing. However, more frequent screening may be recommended for women with certain high-risk conditions, such as HIV.

    • Women of any age with abnormal cytology should be screened according to the American Society for Colposcopy and Cervical Pathology 2019 Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors.

    • Women older than 65 years of age and who have had two consecutive normal Pap tests and no abnormal findings for the last 10 years may stop Pap tests.

    • Most women who have had a total hysterectomy with removal of the cervix do not need Pap tests unless the hysterectomy was done as treatment for cervical cancer or precancerous conditions.

    • Because cervical precancers grow slowly, having a test every three to five years will find those that can be treated successfully. Most cases of cervical cancers are caused by HPV, and this condition warrants close follow-up and/or treatment.

    Click to Review
  11. According to ACS guidelines, a woman older than 65 years of age who has had two consecutive normal Pap tests and no abnormal findings over the last 10 years

    GYNECOLOGIC HEALTH

    Recommendations vary regarding how frequently women should have Pap tests. National health organizations, such as the American Cancer Society (ACS), the National Cancer Institute (NCI), and the American Medical Association (AMA), have adopted consensus recommendations. Other organizations, such as the ACS, the CDC, and the U.S. Preventive Services Task Force (USPSTF) have developed guidelines for cervical cancer screening. Recommendations from the ACS, the CDC, and the USPSTF are similar and summarized below [16,41,56]:

    • Pap tests should initiate at 21 years of age (regardless of sexual debut). A conventional or liquid-based Pap test should be done every three years; annual Pap testing is no longer recommended. HPV testing is not recommended alone or in combination with cytology for women younger than 30 years of age.

    • Beginning at 30 years of age, women who have had three or more consecutive normal Pap results should be screened every five years with HPV and cytology co-testing. However, more frequent screening may be recommended for women with certain high-risk conditions, such as HIV.

    • Women of any age with abnormal cytology should be screened according to the American Society for Colposcopy and Cervical Pathology 2019 Risk-Based Management Consensus Guidelines for Abnormal Cervical Cancer Screening Tests and Cancer Precursors.

    • Women older than 65 years of age and who have had two consecutive normal Pap tests and no abnormal findings for the last 10 years may stop Pap tests.

    • Most women who have had a total hysterectomy with removal of the cervix do not need Pap tests unless the hysterectomy was done as treatment for cervical cancer or precancerous conditions.

    • Because cervical precancers grow slowly, having a test every three to five years will find those that can be treated successfully. Most cases of cervical cancers are caused by HPV, and this condition warrants close follow-up and/or treatment.

    Click to Review
  12. Infections linked to squamous cervical cancers are most frequently caused by

    GYNECOLOGIC CANCERS

    Most risk factors for cervical cancer are related to sexual history. Although the exact cause is unknown, it is thought that cervical cancer is the result of cellular changes in the cervix due to insult from viruses (as discussed) and multiple partners. Women with cervical cancer often report a history of cervical infection and virtually all test positive for HPV [41]. Infections that may lead to cervical carcinoma are caused by HSV-2; HPV types 16, 18, 31, 33, 45, and 58; HIV; and perhaps cytomegalovirus.

    HPV 16 is most frequently linked to squamous cancers and HPV 18 to adenocarcinomas [16,22,27,41]. These viruses alter the DNA of nuclei of immature cervical cells. HPV DNA testing may be performed to identify women at high risk for disease. Women whose high-risk HPV infection persists in genital skin cells are at greatest risk for subsequently developing cervical cancer [41]. These women require close follow-up treatment and repeat Pap tests. For example, a patient with ASC-US may often require repeat Pap testing every 3 to 6 months over 6 to 12 months. With an abnormal Pap test, and certainly when three consecutive Pap tests over 12 months demonstrate epithelial cell abnormalities, a cervical biopsy under magnified visualization with colposcopy should be done [16,22,27,41]. Fortunately, most women with an abnormal Pap test have an easily treatable precancerous condition of mild dysplasia (CIN 1).

    Click to Review
  13. Risk factors associated with cervical cancer include all of the following, EXCEPT:

    GYNECOLOGIC CANCERS

    Risk factors for cervical cancer include [16,22,27,41,63]:

    • Multiple sexual partners

    • Early age at first sexual intercourse (i.e., younger than 18 years of age)

    • History of sexually transmitted infections

    • HPV

    • Lack of access to or utilization of health care

    • A nonmonogamous male partner

    • Diethylstilbestrol (DES) exposure

    • Cigarette smoking

    • Lower socioeconomic status

    • Oral contraceptive use

    • Diet

    • Intrauterine device use

    • Multiple full-term pregnancies

    Click to Review
  14. General interactions that should be included in the care of women with gynecologic cancer include all of the following, EXCEPT:

    GYNECOLOGIC CANCERS

    Feelings of guilt, anger, and shame may prevent women from asking questions or initiating a discussion on the subject of sexual activity. The general interactions that should be included in the care of women with gynecologic cancer are [74]:

    • Establish a rapport with the woman. Perform a complete assessment of the woman's preconceived notions about cancer and how the treatment will affect her.

    • Alleviate fears and misconceptions by communicating accurate facts and answering questions.

    • Provide as much privacy and comfort as possible. Explore the woman's feelings about privacy and how you can meet her privacy needs within the scope of the treatment.

    • Encourage verbalization about the causes of the cancer. Reinforce that gynecologic cancer has multiple risk factors and that the exact cause is unknown. Encourage the woman not to blame herself for the cancer.

    • Provide open and sensitive discussions about issues of fertility, sexual expression, body image, and impact of treatment.

    • Encourage women to follow up with the entire course of the treatment plan and future Pap tests. Inform eligible underserved women that the NBCCEDP offers free or low-cost Pap tests and mammograms.

    • Encourage safer sexual practices.

    • Offer the assistance of cancer support groups.

    • Refer the woman and her family or partner to appropriate resources (e.g., family therapists, psychologists, sex therapists).

    • Use a nonjudgmental attitude in developing a relationship, and maintain this attitude throughout the entire treatment plan with the woman and her family.

    Click to Review
  15. The average age of first menstruation in the United States is

    MENARCHE TO PERIMENOPAUSAL YEARS

    Menarche, the initiation of menses, begins when the brain, ovaries, and adrenal glands have matured. Initial menstrual cycles are usually irregular, as the hormonal communications may be erratic. Pregnancy may occur at any time, even before a girl's first menstrual period, if she has already ovulated. On average, girls in the United States begin menstruating at around 12 to 13 years of age [75].

    Click to Review
  16. Perimenopause refers to the stage

    PERIMENOPAUSE AND MENOPAUSE AS NORMAL LIFE EVENTS

    Perimenopause refers to the period of a woman's life when she passes through the stages of regression of ovarian function, which typically begins in the late 30s and can be as long as 7 to 10 years [18,27,79]. Menstrual periods stop occurring because the ovaries no longer produce the hormones progesterone and estrogen. The major source of estrogen before menopause is the ovarian follicle, which accounts for more than 90% of the body's total production. This estrogen deficiency may result in symptoms, such as hot flashes, vaginal dryness, emotional changes, and weight gain [27,79]. Some women experience no symptoms at all.

    Click to Review
  17. Practitioners should advise midlife women to continue contraception

    PERIMENOPAUSE AND MENOPAUSE AS NORMAL LIFE EVENTS

    To work effectively and sensitively with midlife women, health professionals should understand and convey the following information [18,27,79,80]:

    • Menopause is a gradual process, not merely the absence of menses.

    • Menopause takes place over many years, and during this time ovulation may be sporadic. Therefore, contraception should be continued for one year following the last menstrual period.

    • The average life expectancy of women is 80 years of age, meaning that most women still have one-third of their lives to live after menopause.

    • Menopause does not mean the end of a woman's sexuality. Rather, it can free women from periods, fear of pregnancy, and contraceptive concerns.

    • Menopause may be seen as a time of fewer child care responsibilities, with increased opportunities to pursue other goals. This combination of events is often energizing for women who are seeking added dimensions to their careers or relationships.

    • The transition to menopause often provides more leisure time as well as increasing opportunities for self-expression and community involvement.

    • In spite of a strong cultural message that youth is valued above age, women who maintain a positive image and value themselves adapt well to menopause.

    • Menopause is not an illness, but if severe or troubling symptoms persist, a variety of treatments are available.

    Click to Review
  18. Adjustment to menopause is influenced by

    PERIMENOPAUSE AND MENOPAUSE AS NORMAL LIFE EVENTS

    Along with changes in women's rights and roles in our society, many women and healthcare providers want to replace the negative stereotypes of the menopausal woman with a realistic and positive outlook. This new viewpoint is easier to achieve as women learn more about how to manage the changes that occur during middle age with good health and peace of mind. Women's own understanding and expectations, marital or relationship stability, financial resources, family views, physical health, and sociocultural expectations influence their adjustment to menopause.

    Click to Review
  19. The Women's Health Initiative (WHI) findings on the use of combination hormone replacement therapy (HRT) indicated an increased risk of

    PERIMENOPAUSE AND MENOPAUSE AS NORMAL LIFE EVENTS

    The NIH established the WHI in 1991 to address cardiovascular disease, cancer, osteoporosis, and quality of life issues in postmenopausal women [81,82]. One component of the Initiative was a randomized clinical trial involving postmenopausal women 50 to 79 years of age. A portion of the trial was conducted to examine the risks, benefits, and long-term effects of hormone therapy. Women with intact uteruses received combined HRT (estrogen plus progestin) or placebo. The study was halted in 2002, three years early, because the WHI safety board found both an increased risk of breast cancer in study participants and a persistence of previously identified risks (i.e., heart attacks, strokes, blood clots in the lungs and legs). The numbers of women who had hip and other fractures or colorectal cancer were lower, and there were no differences in the incidence or mortality rates for women with endometrial cancer. However, when compared to an equal number of women (10,000) taking placebo, there were 8 more breast cancers, 7 more heart attacks, 8 more strokes, and 18 more instances of blood clots to the lungs or legs in the women taking the combined therapy. These results led the safety board to conclude that estrogen plus progestin therapy neither prevents heart disease nor offers benefits sufficient to outweigh the overall risks [81,82].

    Click to Review
  20. Based on the results of the WHI, the general approach for HRT is that

    PERIMENOPAUSE AND MENOPAUSE AS NORMAL LIFE EVENTS

    While the numbers of adverse events are small, it is important to remember that behind each number are a woman, her family, and her community. The following general approach to HRT has been recommended [81,82,85,86]:

    • HRT may continue to be prescribed to manage menopausal symptoms.

    • The risks and benefits should be explained to each woman. Alternative therapies or other medications should be discussed as options.

    • When prescribing HRT, use the lowest dosage for the shortest period of time. When used, optimally prescribe for less than five years. Assess each woman annually.

    • HRT is not effective for elevated lipids and cardiovascular disease; other therapies and medications should be prescribed. HRT is not a substitute for statins or other lipid-lowering agents.

    • Other treatments exist for the prevention and treatment of osteoporosis.

    • Absolute contraindications for HRT include: women with a personal or family history of breast cancer; any other estrogen-dependent neoplasia; or a history of estrogen-related thromboembolic disease, such as a woman who experienced a deep vein thrombosis while on oral contraceptives.

    Click to Review
  21. A possible candidate for HRT during menopause has

    PERIMENOPAUSE AND MENOPAUSE AS NORMAL LIFE EVENTS

    The decision to take HRT rests with the individual. Women experiencing difficult menopausal symptoms that are dramatically affecting their quality of life and ability to function may be candidates for HRT in the absence of absolute contraindications. It is best for health professionals to perform a thorough personal and family history, educate women about estrogen, and be willing to help them objectively evaluate the pros and cons of HRT. For women who decide to discontinue HRT, it is best to taper off the drugs to decrease symptoms. However, symptoms may recur. The woman's perception of her experiences, her history of cancer, uncontrolled hypertension, or thrombophlebitis, and her knowledge and concerns about sexuality should all be assessed. Also, women who take HRT should be cautioned about the increased risk of breast cancer and instructed to have regular mammograms as well as clinical breast exams for the duration of the HRT.

    Click to Review
  22. A health promotion/pharmacologic option for women experiencing menopause is

    PERIMENOPAUSE AND MENOPAUSE AS NORMAL LIFE EVENTS

    The decision to take HRT rests with the individual. Women experiencing difficult menopausal symptoms that are dramatically affecting their quality of life and ability to function may be candidates for HRT in the absence of absolute contraindications. It is best for health professionals to perform a thorough personal and family history, educate women about estrogen, and be willing to help them objectively evaluate the pros and cons of HRT. For women who decide to discontinue HRT, it is best to taper off the drugs to decrease symptoms. However, symptoms may recur. The woman's perception of her experiences, her history of cancer, uncontrolled hypertension, or thrombophlebitis, and her knowledge and concerns about sexuality should all be assessed. Also, women who take HRT should be cautioned about the increased risk of breast cancer and instructed to have regular mammograms as well as clinical breast exams for the duration of the HRT.

    Click to Review
  23. Testing for breast cancer genes BRCA1 and BRCA2 should be accompanied by

    BREAST HEALTH AND BREAST CANCER

    Approximately 5% to 10% of women diagnosed each year with breast cancer have a form of the disease resulting from inherited alterations in the genes called BRCA1 and BRCA2 (breast cancer 1 and breast cancer 2). The incidence is highest in women with a family history of breast cancer. The risk of developing breast cancer in women with clinically significant gene mutations is 45% to 65% by 70 years of age, compared with 12.3% of the general population [88,89]. Testing for BRCA1 or BRCA2 is done on a blood sample and can range from several hundred to several thousand dollars [90]. Genetic counseling and risk assessment should accompany the testing. Routine referral is not recommended for women with no family history of breast cancer. However, women with one or more relatives with a BRCA mutation should be offered genetic counseling and testing following evaluation with a validated risk stratification tool [88].

    Click to Review
  24. Which of the following signs/symptoms noted during BSE requires follow-up?

    BREAST HEALTH AND BREAST CANCER

    Early detection of potential malignancies continues to be the single most important factor in the successful treatment of breast cancer. While clinical breast exam occurs only periodically or yearly, breast self-exam (BSE) may be done more frequently. BSE is a method for women to check their own breasts by feeling the breast tissue for changes and lumps and observing the breasts in a mirror for changes in appearance. The ACS and the American College of Obstetricians and Gynecologists (ACOG) recommend BSE as an option for women starting in their 20s; other sources suggest that BSE does not reduce mortality and instead increases the number of biopsies performed and the diagnosis of benign lesions [91,92,94]. Generally speaking, women 20 years of age and older should know how their breasts normally look and feel and report any suspicious breast changes to a health professional at a checkup or when they are found. Signs and symptoms that require follow-up are [27,91,92,96]:

    • Lumps

    • Pain (Breast cancer may or may not be painful.)

    • Bloody or other spontaneous discharge (not breast milk)

    • Skin changes (e.g., irritation, dimpling)

    • Nipple changes (e.g., nipple inversion)

    • Lymphadenopathy, with or without other symptoms

    • Any change that the woman finds as unusual for her

    Click to Review
  25. General consensus for routine mammograms in women 40 years of age and older suggests screening

    BREAST HEALTH AND BREAST CANCER

    The ACOG and the ACS have made the following recommendations for mammography screening [93,94]:

    • Annually or biennially for women 40 years of age and older. (Interval to be determined by clinician-patient shared decision making.)

    • If at higher-than-average risk, consider earlier initiation, shorter screening intervals, or the addition of other modalities, such as ultrasound or magnetic resonance imaging (MRI). (The ACS finds no evidence to justify these screening methods, except for instances of BRCA mutation, when annual MRI screening is recommended as an adjunct to mammography. In its 2015 updated guidelines, the ACS indicated it will review this evidence).

    • Women should be counseled about the possibility of false negatives and false positives.

    Click to Review
  26. Treatment choices for breast cancer should consider all of the following, EXCEPT:

    BREAST HEALTH AND BREAST CANCER

    The impact of breast cancer extends beyond the threat of death and includes an altered self-image, role changes, and changes in support systems and family relationships. The many options for treatment contribute to the complexities that the diagnosis of breast cancer brings to the woman, her family, and her friends. The treatment options depend on the stage of the disease and on other factors, including [100,101,102]:

    • The type of cancer

    • Age

    • Menopausal status

    • Extent of the spread of the cancer

    • Lymph node involvement

    • The size of the tumor

    • Hormonal receptors of the tumor

    • Desire to participate in a clinical trial

    • General health status

    Click to Review
  27. The most important prognostic factor in breast cancer is

    BREAST HEALTH AND BREAST CANCER

    The most important prognostic factor is nodal status. The number of positive axillary nodes has a direct relationship to clinical outcome. For women with negative nodes, tumor size is the most important prognostic factor [103]. The significance of progesterone receptors (PRs) is not as clearly understood as that of estrogen receptors (ERs). About 80% of breast cancers are ER-positive, and about 65% of ER-positive cancers are PR-positive. About 13% of breast cancers are ER-positive and PR-negative. About 2% of breast cancers are ER-negative and PR-positive [105]. Patients with ER-positive breast cancer generally respond favorably to the anti-estrogen agent tamoxifen [106].

    Click to Review
  28. Gender differences in heart disease include all of the following, EXCEPT:

    CARDIOVASCULAR HEALTH

    There are several key gender differences in cardiovascular disease that require consideration for healthcare practice [67,137,139,140,141,142,143,144]. Between 25 and 35 years of age, men have three times the incidence of CHD as women. Women tend to show signs of cardiovascular disease at a more advanced age than men. Although menopause decreases women's estrogenic protection from heart disease, this biologic advantage persists until 65 to 70 years of age. At older ages, women who have heart attacks are twice as likely as men to die from them within a few weeks. Women represent slightly more than half of all deaths from cardiovascular disease annually in the United States. Overall, the lifetime risk of a woman dying as a result of heart disease is one in three [140].

    Click to Review
  29. Overall, the lifetime risk of a woman dying as a result of heart disease is

    CARDIOVASCULAR HEALTH

    There are several key gender differences in cardiovascular disease that require consideration for healthcare practice [67,137,139,140,141,142,143,144]. Between 25 and 35 years of age, men have three times the incidence of CHD as women. Women tend to show signs of cardiovascular disease at a more advanced age than men. Although menopause decreases women's estrogenic protection from heart disease, this biologic advantage persists until 65 to 70 years of age. At older ages, women who have heart attacks are twice as likely as men to die from them within a few weeks. Women represent slightly more than half of all deaths from cardiovascular disease annually in the United States. Overall, the lifetime risk of a woman dying as a result of heart disease is one in three [140].

    Click to Review
  30. Which of the following measures help encourage women to develop the habit of lifelong exercise?

    EXERCISE AND NUTRITION

    When counseling women who either need or desire to lose weight, it is important to emphasize that regular physical activity provides major health benefits that are generally independent of body weight. Exercise guidelines should take a lifespan approach that emphasizes lifetime physical activity [153]. Nurses and health professionals may suggest the following measures to encourage the habit of lifelong exercise [147,153,154]:

    • Avoid inactivity. Some physical activity is better than none.

    • Choose physical activities that are fun, and vary them to prevent boredom.

    • Create activity opportunities (e.g., take the stairs instead of the elevator; take quick walking breaks when at work).

    • Exercise with someone else. Women who have exercise partners may feel safer. Also, research has shown that partners help to reinforce consistent exercise patterns.

    • A minimum of 150 minutes of moderate-intensity aerobic exercise spread throughout the week provides substantial health benefits. Examples of moderate-intensity activities include brisk walking (3 miles/hour or faster), bicycling slower than 10 miles/hour, water aerobics, and general gardening. Include a five-minute warm-up and cool-down at the beginning and end of each exercise session to prevent injury.

    • Include muscle-strengthening activities at least two days per week to realize benefits (i.e., increased bone strength, muscular fitness) not achieved through aerobic exercise alone. Examples of muscle-strengthening activities are resistance (weight) training, push-ups, pull-ups, and working with resistance bands.

    Click to Review
  31. Which of the following foods is NOT a good source of calcium?

    EXERCISE AND NUTRITION

    EXAMPLE TEACHING PLAN: NUTRITION

    Ensure that your diet contains a variety of foods, with the majority being fruits, vegetables, and grain products. The majority of your calories should come from grains, fruits, and vegetables. Limit fat intake to 30% of your daily calories. Monitor the type of fat you consume. Choose foods low in saturated fat, trans fat, and cholesterol. Visit the MyPlate site, at https://www.myplate.gov, to determine the recommended daily servings of each of the food groups based on age, sex, and average daily physical activity.

    Tips regarding saturated fat, trans fat, and cholesterol intake include:

    • Choose vegetable oils rather than solid fats.

    • Trim fat from meat and remove skin from poultry.

    • Limit intake of processed meats, such as bacon, sausages, salami, and bologna.

    • Use egg whites and egg substitutes rather than whole eggs.

    • Choose fat-free or low-fat milk, yogurt, and cheese.

    • Always check nutrition labels to determine the amount of saturated fat and cholesterol in prepared foods.

    • When eating out, choose lean meats, limit intake of creamy sauces, and choose fruit as desserts.

    • Read labels on prepared foods, crackers, and breads for types of fats.

    Use sugar and salt in moderation. Drink at least eight glasses of water per day. Consume 1,000–1,500 mg of calcium and 400–600 IU of vitamin D per day. Good sources of calcium include:

    • Vitamin supplement

    • Low-fat, non-fat yogurt

    • Low-fat, non-fat milk

    • Soy-based beverages with added calcium

    • Tofu

    • Breakfast cereal with added calcium

    • Fruit juice with added calcium

    • Dark-green leafy vegetables

    • Canned salmon

    Consume 400 mcg (0.4 mg) of folate per day. Sources of folate include:

    • Vitamin supplement (folic acid)

    • Cooked dry beans and peas, peanuts

    • Oranges, orange juice

    • Dark-green leafy vegetables, such as spinach, mustard greens, and romaine lettuce

    • Green peas

    Obtain 15 mg of iron per day. Sources of iron include:

    • Vitamin supplement

    • Shellfish, such as shrimp, clams, mussels, and oysters

    • Lean meats; especially beef, liver, and other organ meats

    • Cereals with added iron

    • Turkey (dark meat with skin removed)

    • Sardines

    • Spinach

    • Cooked dry beans, peas, and lentils

    • Enriched and whole grain breads

    Consume 20–35 grams of fiber per day. Sources of fiber include:

    • Fruits

    • Vegetables

    • Whole grains

    • Cereals

    • Dried beans and peas

    Click to Review
  32. The risk of developing type 2 diabetes is increased in women with a BMI of

    EXERCISE AND NUTRITION

    There are two main types of diabetes: type 1 and type 2. Type 1 diabetes is caused by autoimmune destruction of the pancreatic islets. Type 2 diabetes, which is more prevalent, is a defect of insulin secretion, actions, and insulin resistance. Risk factors for type 2 diabetes include [163,165]:

    • Hypertension (>130/80 mm Hg in adults on at least two separate occasions and measured in both arms)

    • Family history of diabetes (parents or siblings with diabetes)

    • Overweight (BMI >25)

    • Race/ethnicity (i.e., African Americans, Hispanic Americans, Native Americans, Pacific Islanders)

    • Habitual physical inactivity

    • HDL cholesterol <40 mg/dL and/or a triglyceride level >250 mg/dL

    • History of gestational diabetes or delivery of a baby weighing more than 9 pounds (Women who have had gestational diabetes have a 35% to 60% chance of developing diabetes in the next 10 to 20 years.)

    • Polycystic ovary syndrome

    Click to Review
  33. It is important to emphasize the factors that contribute to the development of osteoporosis when educating women. One risk factor for osteoporosis is

    OSTEOPOROSIS

    Women are at a higher risk for osteoporosis than men primarily because of differences in bone mass and density. It is important to emphasize the factors that contribute to the development of osteoporosis when educating women about preventive screening practices and positive lifestyle behaviors. The risk factors for osteoporosis are [168,170,174]:

    • Family history of osteoporosis. This is primarily known through health history information, particularly if any female relatives have had a broken wrist or hip or had a dowager's hump.

    • Hysterectomy and/or surgical removal of ovaries before 50 years of age. Secondary osteoporosis is used to define the reduction of bone mass developing from reasons other than the aging process. Young women who have had their ovaries surgically removed run the same risk of developing osteoporosis as postmenopausal women.

    • Smoking. Women who smoke increase their odds of developing osteoporosis.

    • Alcohol. Women who consume excessive amounts of alcohol experience a greater calcium loss, which may result in osteoporosis. Women who drink wine, beer, or other alcoholic beverages daily increase their risk of osteoporosis.

    • Small, thin body frame. Slender women of European and Asian descent have a higher incidence of osteoporosis than African American women, largely as a result of differences in peak bone mass and density.

    • Soft drinks and coffee. Women who drink soft drinks or more than a few cups of coffee daily increase their chance of developing osteoporosis due to a loss of calcium.

    • Inactivity. Women who do not exercise at least one hour a week with weight-bearing activities, such as walking, jogging, or low impact aerobics, are at increased risk for developing osteoporosis.

    • Strenuous exercise causing amenorrhea. Exercising so strenuously that the woman has irregular periods or no periods at all is as harmful to bone health as inactivity. A balanced diet and a sound exercise program are key health promotion habits for the prevention of osteoporosis.

    • Low dietary calcium intake. Many background factors contribute to a woman's dietary intake of calcium. Women should be interviewed during the health history to determine any milk allergies or lactose intolerance, eating disorders, such as bulimia or anorexia nervosa, or continued dieting for weight management that often excludes dairy products. Most women do not consume adequate calcium levels in their young adult years to achieve peak bone mass.

    Click to Review
  34. Calcitonin is contraindicated in women with hypersensitivity to

    OSTEOPOROSIS

    Calcitonin prescribed for osteoporosis is a synthetic salmon calcitonin administered intranasally daily (i.e., one spray of 200 units in one nostril); a 100 unit per day intramuscular or subcutaneous injection preparation is also available [29]. Patients should alternate nostrils to avoid irritation. Side effects include rhinorrhea, headache, back pain, and nosebleed. Calcitonin is contraindicated in women with hypersensitivity to salmon protein [29]. Long-term use of calcitonin should be limited [169].

    Click to Review
  35. All of the following are risk factors for depression, EXCEPT:

    PSYCHOLOGIC HEALTH

    Depressive disorders are more common in women than in men, and early detection and treatment of depression may be enhanced with screening as a component of the annual exam. Depression may result in physical and psychologic symptoms that cause a significant amount of distress and impairment to the woman and her family, and it may occur in the absence of mania. The risk factors for depression are [18,184,185]:

    • Family or personal history of depression or postpartum depression

    • Poor self-concept or self-esteem

    • Unemployment

    • Female gender

    • Other chronic health conditions

    • Substance abuse

    • Loss or death

    • Stressful life occurrences

    Click to Review
  36. Which of the following is considered a form of violence against women?

    PSYCHOLOGIC HEALTH

    Intimate partner violence is control by one partner over another [193]. Abusers physically, sexually, verbally, and/or emotionally abuse their partners and/or destroy their partner's property [192]. Economic control, stalking, and control of social contacts are all forms of violence against women. Experiencing fear in a relationship is characteristic of an abusive situation, regardless of whether there is physical violence. The fear of physical harm is enough to consider the relationship abusive [193].

    Click to Review
  37. The leading cause of death for African American women is

    HEALTH DISPARITIES OF WOMEN OF COLOR

    Heart disease, cancer, and stroke are the first, second, and third leading causes of death, respectively, among black women [188]. They have the highest age-adjusted death rate (724.2 per 100,000 population) of all other women of color and the shortest life expectancy at birth (78.7 years) [137,209]. While it is projected that by 2060 all women can expect to live longer, black women will continue to have the shortest life expectancy [209]. Black women have more undetected diseases, higher disease and illness rates, and are sicker during their lifetimes and younger when they die than any other racial/ethnic group in the United States, with the exception of American Indian/Alaska Native women [209]. Rates of intimate partner violence are two to three times higher among black women than white women. Pregnancy-associated intimate partner violence homicides are more common among black females than are live births [209].

    Click to Review
  38. In the United States, Hispanic women are at higher risk than non-Hispanic women for

    HEALTH DISPARITIES OF WOMEN OF COLOR

    Cancer, heart disease, and stroke are the three leading causes of death among Hispanic women [188]. Hispanic women are 40% more likely to be diagnosed with cervical cancer, and 20% more likely to die from it compared with white women, yet Hispanic women undergo significantly fewer Pap tests [223,224]. Hispanic women who have been in the United States for less than 10 years are less likely to have had a Pap test in the last three years compared with those who have been in the country 10 or more years. Hispanic girls have one of the highest rates of HPV vaccination; however, overall rates remain low [224]. Healthcare providers can help improve these rates by emphasizing the importance of completing the vaccination series [224]. More than one in nine Hispanic women have diabetes, including many who are unaware that they have the disease, and approximately one-half of Hispanic women are obese [213]. Approximately one in four Hispanic women have high blood pressure (a main risk factor for stroke), and nearly one-half do not have it controlled. To help Hispanic women manage stroke risk, healthcare providers should emphasize lifestyle changes, such as healthy eating, getting regular physical activity, and managing other health conditions, particularly diabetes and obesity [213].

    Click to Review
  39. All of the following are considered complementary therapies, EXCEPT:

    COMPLEMENTARY THERAPIES

    Complementary therapies are defined as nontraditional therapies that can interface with traditional medicine and surgical therapies. They may also be used as complements to other therapeutic and pharmacologic treatments. Because they are used in addition to, rather than instead of, traditional medicine and surgical therapies, the term complementary therapy is preferable to alternative therapy. Health care has traditionally focused on technology and on the treatment of symptoms that were indicative of pathology. In the holistic model, the emphasis is on achieving maximum body/mind health, and treatment focuses on minimal interventions with appropriate technology and a wide range of noninvasive therapies. Complementary therapies are not a single modality of healing but an array of practices, including diet and clinical nutrition, herbal medicine, hydrotherapy, aromatherapy, guided imagery, therapeutic or healing touch, yoga, and spirituality [231].

    Click to Review
  40. The tetanus, diphtheria, and acellular pertussis vaccine (Td/Tdap) should be given as a booster every

    HEALTH CARE ACROSS A WOMAN'S LIFESPAN

    SUMMARY OF ADOLESCENT/ADULT IMMUNIZATION RECOMMENDATIONS

    AgentIndicationPrimary ScheduleContraindications
    Hepatitis B vaccine
    Sexually active persons not in long-term, mutually monogamous relationships
    Persons seeking evaluation or treatment for a STI
    Persons with occupational risk of exposure to blood or other potentially infectious body fluids
    Persons with diabetes who are <60 years of age
    Persons with end-stage renal disease, including hemodialysis patients
    Persons with chronic liver disease
    Persons with HIV infection
    Household contacts
    Injecting drug users
    Incarcerated persons
    Persons with recently acquired STI
    Travelers to regions where hepatitis B is endemic or epidemic
    Clients and staff members of institutions for persons with developmental disabilities
    Pregnancy if at risk for infection or severe outcome from infection during pregnancy (does not include vaccination with Heplisav-B)
    Two or three doses, depending on vaccineAnaphylactic allergy to yeast
    Meningococcal vaccine
    First-year college students living in dormitories
    Military recruits
    Persons with occupational risk of exposure
    Persons traveling to or residing in areas in which meningococcal disease is hyperendemic or epidemic
    Asplenic patients
    Microbiologists who are at risk for exposure
    HIV-infected persons
    Anyone with an immune system disorder
    Anyone exposed during an outbreak
    One or more doses
    Revaccination may be considered after five years if patient remains at increased risk for infection.
    Two doses at least two months apart for adults with functional asplenia or persistent complement component deficiencies.
    Two doses for HIV-infected persons.
    Hypersensitivity to any component of formulation
    Persons who are moderately or severely ill
    Varicella vaccinePersons of any age without reliable history of varicella vaccine or diseaseAdults who previously received only one dose should receive a second dose.
    Anaphylactic allergy to gelatin or neomycin
    Immunocompromising conditions
    Pregnancy
    HIV infection with CD4+ T lymphocyte count of <200 cells/mL
    Hepatitis A vaccine
    Persons traveling to or working in areas with high or intermediate endemicity of infection
    Persons with chronic liver disease
    Persons with clotting factor disorders
    Illegal drug users
    Persons through 40 years of age who have recently been exposed to hepatitis A virus
    Two doses, 4 to 8 months apartA history of sensitivity to alum or the preservative 2-phenoxyethanol
    Tetanus, diphtheria, and acellular pertussis vaccine (Td/Tdap)Persons of any age without a certain history of Td/Tdap vaccination
    Three doses:
    Second dose at least four weeks after first dose
    Third dose 6 to 12 months after second
    Booster: At 10-year intervals throughout life
    Neurologic or severe hypersensitivity reaction to prior dose
    Pregnant women not vaccinated during pregnancy should receive Tdap immediately postpartum
    Influenza vaccineAll persons 6 months of age and older
    Given annually each fall or winter
    Persons 6 months of age and older, including pregnant women, can receive the inactivated vaccine (IIV).
    Adults 18 years of age or older can receive the recombinant influenza vaccine (RIV) if allergic to eggs.
    Healthy, nonpregnant adults <50 years of age without high-risk medical conditions can receive either intranasally administered live, attenuated influenza vaccine (LAIV), (FluMist), or IIV. Healthcare personnel caring for severely immunocompromised persons should receive IIV or RIV rather than LAIV. Other persons should receive IIV.
    Intramuscular or intradermal administered IIV are options for adults 18 to 64 years of age
    Adults 65 years of age and older can receive the standard dose TIV or the high-dose TIV (Fluzone High-Dose).
    Anaphylactic allergy to eggs (for IIV)
    Acute febrile illness
    Pregnancy (LAIV4)
    Immunocompromising conditions
    Asplenia
    Pneumococcal polysaccharide vaccine (PPSV)
    Adults 65 years of age and older
    Persons with chronic cardiovascular or pulmonary disorders, splenic dysfunction, renal failure, asthma, hematologic malignancy, immunosuppression, alcoholism, diabetes, cerebrospinal fluid leak, cochlear implant
    Smokers
    One dose for most people. Persons vaccinated prior to 65 years of age should be revaccinated if five years or more have passed since the first dose.
    A second dose should be given for immunosuppressed, chronic kidney disease, transplant patients, and asplenic patients at least five years after first.
    Safety during first trimester of pregnancy has not been evaluated.
    Measles, mumps, and rubella vaccine (MMR)
    Adults born after 1957 without written documentation of immunization on or after first birthday.
    Rubella immunity should be determined for women who may become pregnant; they should be vaccinated if not immune and if not currently pregnant.
    One or two doses. If a second dose is necessary, administer at least one month after first.
    Immunosuppression
    Anaphylactic allergy to neomycin
    Pregnancy
    Immune globulin or blood products in the last 3 to 11 months
    Human papillomavirus vaccine
    All women 13 to 26 years of age who have not completed the vaccine series at 9 to 12 years of age
    May be considered for women 27 to 45 years of age
    Three doses:
    Second dose one to two months after first dose
    Third dose six months after first dose
    Pregnancy
    Herpes zoster vaccineAll adults 60 years or age and older, regardless of whether they have experienced a prior episode of herpes zosterOne dose
    Pregnancy
    Immunocompromising conditions
    HIV infection with a CD4+ T lymphocyte count of <200 cells/mL
    Click to Review

  • Back to Course Home
  • Participation Instructions
    • Review the course material online or in print.
    • Complete the course evaluation.
    • Review your Transcript to view and print your Certificate of Completion. Your date of completion will be the date (Pacific Time) the course was electronically submitted for credit, with no exceptions. Partial credit is not available.