Chapter 03: Assessment and Health Promotion

To promote wellness and prevent illness throughout the life span, it is important for the nurse to be cognizant of immunization recommendations for women older than 18 years. Match each immunization with the correct schedule. a. Tetanus-diphtheria-pertussis (Tdap) b. Measles, mumps, rubella c. Herpes Zoster d. Hepatitis B e. Influenza f. Human papillomavirus (HPV) ------------------------------------------------------------------1.) Three injections for girls between the ages 9 to 26 2.) Primary series of three injections. 3.) Annually. 4.) Once and then a booster every 10 years. 5.) One dose after age 65. 6.) Once if born after 1956.

1.)Three injections for girls between the ages 9 to 26. - F 2.) Primary series of three injections. - D 3.) Annually. - E 4.) Once and then a booster every 10 years. - A 5.) One dose after age 65. - C 6.) Once if born after 1956. - B

Individual irregularities in the ovarian (menstrual) cycle are most often caused by: a. Variations in the follicular (preovulatory) phase. b. An intact hypothalamic-pituitary feedback mechanism. c. A functioning corpus luteum. d. A prolonged ischemic phase.

ANS: A Almost all variations in the length of the ovarian cycle are the result of variations in the length of the follicular phase. An intact hypothalamic-pituitary feedback mechanism is regular, not irregular. The luteal phase begins after ovulation. The corpus luteum depends on the ovulatory phase and fertilization. During the ischemic phase, the blood supply to the functional endometrium is blocked, and necrosis develops. The functional layer separates from the basal layer, and menstrual bleeding begins.

A common effect of both smoking and cocaine use in the pregnant woman is: a. Vasoconstriction b. Increased appetite c. Changes in insulin metabolism d. Increased metabolism

ANS: A Both smoking and cocaine use cause vasoconstriction, which results in impaired placental blood flow to the fetus. Smoking and cocaine use decrease the appetite. Smoking and cocaine use do not change insulin metabolism. Smoking can increase metabolism.

Which statement would indicate that the client requires additional instruction about breast self-examination? a. "Yellow discharge from my nipple is normal if I'm having my period." b. "I should check my breasts at the same time each month, like after my period." c. "I should also feel in my armpit area while performing my breast examination." d. "I should check each breast in a set way, such as in a circular motion."

ANS: A Discharge from the nipples requires further examination from a health care provider. "I should check my breasts at the same time each month, like after my period," "I should also feel in my armpit area while performing my breast examination," and "I should check each breast in a set way, such as in a circular motion" all indicate successful learning.

Despite warnings, prenatal exposure to alcohol continues to exceed by far exposure to illicit drugs. A diagnosis of fetal alcohol syndrome (FAS) is made when there are visible markers in each of three categories. Which is category is not associated with a diagnosis of FAS? a. Respiratory conditions b. Impaired growth c. CNS abnormality d. Craniofacial dysmorphologies

ANS: A Respiratory difficulties are not a category of conditions that are related to FAS. Abnormalities related to FAS include organ deformities, genital malformations, and kidney and urinary defects. Impaired growth is a visible marker for FAS. CNS abnormalities with neurologic and intellectual impairments are categories used to assist in the diagnosis of FAS. An infant with FAS manifests at least two craniofacial abnormalities, such as microcephaly, short palpebral fissures, poorly developed philtrum, thin upper lip, or flattening of the maxilla.

The transition phase during which ovarian function and hormone production decline is called: a. The climacteric. b. Menarche. c. Menopause. d. Puberty.

ANS: A The climacteric is a transitional phase during which ovarian function and hormone production decline. Menarche is the term that denotes the first menstruation. Menopause refers only to the last menstrual period. Puberty is a broad term that denotes the entire transitional stage between childhood and sexual maturity.

When the nurse is alone with a battered patient, the patient seems extremely anxious and says, "It was all my fault. The house was so messy when he got home and I know he hates that." The best response by the nurse is: a. "No one deserves to be hurt. It's not your fault. How can I help you?" b. "What else do you do that makes him angry enough to hurt you?" c. "He will never find out what we talk about. Don't worry. We're here to help you." d. "You have to remember that he is frustrated and angry so he takes it out on you."

ANS: A The nurse should stress that the patient is not at fault. Asking what the patient did to make her husband angry is placing the blame on the woman and would be an inappropriate statement. The nurse should not provide false reassurance. To assist the woman, the nurse should be honest. Often the batterer will find out about the conversation.

Because of the effect of cyclic ovarian changes on the breast, the best time for breast self-examination (BSE) is: a. 5 to 7 days after menses ceases. b. Day 1 of the endometrial cycle. c. Midmenstrual cycle. d. Any time during a shower or bath.

ANS: A The physiologic alterations in breast size and activity reach their minimal level about 5 to 7 days after menstruation stops. All women should perform BSE during this phase of the menstrual cycle.

The uterus is a muscular, pear-shaped organ that is responsible for: a. Cyclic menstruation. b. Sex hormone production. c. Fertilization. d. Sexual arousal.

ANS: A The uterus is an organ for reception, implantation, retention, and nutrition of the fertilized ovum; it also is responsible for cyclic menstruation. Hormone production and fertilization occur in the ovaries. Sexual arousal is a feedback mechanism involving the hypothalamus, the pituitary gland, and the ovaries.

The female reproductive organ(s) responsible for cyclic menstruation is/are the: a. Uterus. b. Ovaries. c. Vaginal vestibule. d. Urethra.

ANS: A The uterus is responsible for cyclic menstruation. It also houses and nourishes the fertilized ovum and the fetus. The ovaries are responsible for ovulation and production of estrogen; the uterus is responsible for cyclic menstruation. The vaginal vestibule is an external organ that has openings to the urethra and vagina; the uterus is responsible for cyclic menstruation. The urethra is not a reproductive organ, although it is found in the area.

Many pregnant teens wait until the second or third trimester to seek prenatal care. The nurse should understand that the reasons behind this delay include: a. Lack of realization that they are pregnant. b. Uncertainty as to where to go for care. c. Continuing to deny the pregnancy. d. A desire to gain control over their situation. e. Wanting to hide the pregnancy as long as possible.

ANS: A, B, C, E These are all valid reasons for the teen to delay seeking prenatal care. An adolescent often has little to no understanding of the increased physiologic needs that a pregnancy places on her body. Once care is sought, it is often sporadic, and many appointments are missed. The nurse should formulate a diagnosis that assists the pregnant teen to receive adequate prenatal care. Planning for her pregnancy and impending birth actually provides some sense of control for the teen and increases feelings of competency. Receiving praise from the nurse when she attends her prenatal appointments will reinforce the teen's positive self-image.

During a health history interview, a woman states that she thinks that she has "bumps" on her labia. She also states that she is not sure how to check herself. The correct response would be to: a. Reassure the woman that the examination will not reveal any problems. b. Explain the process of vulvar self-examination to the woman and reassure her that she should become familiar with normal and abnormal findings during the examination. c. Reassure the woman that "bumps" can be treated. d. Reassure her that most women have "bumps" on their labia.

ANS: B During the assessment and evaluation, the responsibility for self-care, health promotion, and enhancement of wellness is emphasized. The pelvic examination provides a good opportunity for the practitioner to emphasize the need for regular vulvar self-examination. Providing reassurance to the woman concerning the "bumps" would not be an accurate response.

During which phase of the cycle of violence does the batterer become contrite and remorseful? a. Battering phase b. Honeymoon phase c. Tension-building phase d. Increased drug-taking phase

ANS: B During the tension-building phase, the batterer becomes increasingly hostile, swears, threatens, and throws things. This is followed by the battering phase where violence actually occurs, and the victim feels powerless. During the honeymoon phase, the victim of IPV wants to believe that the battering will never happen again, and the batterer will promise anything to get back into the home. Often the batterer increases the use of drugs during the tension-building phase.

Certain fatty acids classified as hormones that are found in many body tissues and that have roles in many reproductive functions are known as: a. Gonadotropin-releasing hormone (GnRH). b. Prostaglandins (PGs). c. Follicle-stimulating hormone (FSH). d. Luteinizing hormone (LH).

ANS: B PGs affect smooth muscle contraction and changes in the cervix. GnRH, FSH, and LH are part of the hypothalamic-pituitary cycle, which responds to the rise and fall of estrogen and progesterone.

Physiologically, sexual response can be characterized by: a. Coitus, masturbation, and fantasy. b. Myotonia and vasocongestion. c. Erection and orgasm. d. Excitement, plateau, and orgasm.

ANS: B Physiologically, according to Masters (1992), sexual response can be analyzed in terms of two processes: vasocongestion and myotonia. Coitus, masturbation, and fantasy are forms of stimulation for the physical manifestation of the sexual response. Erection and orgasm occur in two of the four phases of the sexual response cycle. Excitement, plateau, and orgasm are three of the four phases of the sexual response cycle.

The body part that both protects the pelvic structures and accommodates the growing fetus during pregnancy is the: a. Perineum. b. Bony pelvis. c. Vaginal vestibule. d. Fourchette.

ANS: B The bony pelvis protects and accommodates the growing fetus. The perineum covers the pelvic structures. The vaginal vestibule contains openings to the urethra and vagina. The fourchette is formed by the labia minor.

Unique muscle fibers make the uterine myometrium ideally suited for: a. Menstruation. b. The birth process. c. Ovulation. d. Fertilization.

ANS: B The myometrium is made up of layers of smooth muscle that extend in three directions. These muscles assist in the birth process by expelling the fetus, ligating blood vessels after birth, and controlling the opening of the cervical os.

A 62-year-old woman has not been to the clinic for an annual examination for 5 years. The recent death of her husband reminded her that she should come for a visit. Her family doctor has retired, and she is going to see the women's health nurse practitioner for her visit. To facilitate a positive health care experience, the nurse should: a. Remind the woman that she is long overdue for her examination and that she should come in annually. b. Listen carefully and allow extra time for this woman's health history interview. c. Reassure the woman that a nurse practitioner is just as good as her old doctor. d. Encourage the woman to talk about the death of her husband and her fears about her own death.

ANS: B The nurse has an opportunity to use reflection and empathy while listening and to ensure open and caring communication. Scheduling a longer appointment time may be necessary because older women may have longer histories or may need to talk. A respectful and reassuring approach to caring for women older than age 50 can help ensure that they continue to seek health care. Reminding the woman about her overdue examination, reassuring the woman that she has a good practitioner, and encouraging conversation about the death of her husband and her own death are not the best approaches with women in this age group.

A woman who is 6 months pregnant has sought medical attention, saying she fell down the stairs. What scenario would cause an emergency department nurse to suspect that the woman has been a victim of intimate partner violence (IPV)? a. The woman and her partner are having an argument that is loud and hostile. b. The woman has injuries on various parts of her body that are in different stages of healing. c. Examination reveals a fractured arm and fresh bruises. d. She avoids making eye contact and is hesitant to answer questions.

ANS: B The patient may have multiple injuries in various stages of healing that indicates a pattern of violence. An argument is not always an indication of battering. A fractured arm and fresh bruises could be caused by the reported fall and doesn't necessarily indicate IPV. It is normal for the woman to have a flat affect.

Which statement by the patient indicates that she understands breast self-examination? a. "I will examine both breasts in two different positions." b. "I will perform breast self-examination 1 week after my menstrual period starts." c. "I will examine the outer upper area of the breast only." d. "I will use the palm of the hand to perform the examination."

ANS: B The woman should examine her breasts when hormonal influences are at their lowest level. The patient should be instructed to use four positions: standing with arms at her sides, standing with arms raised above her head, standing with hands pressed against hips, and lying down. The entire breast needs to be examined, including the outer upper area. The patient should use the sensitive pads of the middle three fingers.

A woman arrives at the clinic for her annual examination. She tells the nurse that she thinks she has a vaginal infection and she has been using an over-the-counter cream for the past 2 days to treat it. The nurse's initial response should be to: a. Inform the woman that vaginal creams may interfere with the Papanicolaou (Pap) test for which she is scheduled. b. Reassure the woman that using vaginal cream is not a problem for the examination. c. Ask the woman to describe the symptoms that indicate to her that she has a vaginal infection. d. Ask the woman to reschedule the appointment for the examination.

ANS: C An important element of the history and physical examination is the client's description of any symptoms she may be experiencing. Although vaginal creams may interfere with the Pap test, the best response is for the nurse to inquire about the symptoms the patient is experiencing. Women should not douche, use vaginal medications, or have sexual intercourse for 24 to 48 hours before obtaining a Pap test. Although the woman may need to reschedule a visit for her Pap test, her current symptoms should still be addressed.

As a girl progresses through development, she may be at risk for a number of age-related conditions. While preparing a 21-year-old client for her first adult physical examination and Papanicolaou (Pap) test, the nurse is aware of excessiveness shyness. The young woman states that she will not remove her bra because, "There is something wrong with my breasts; one is way bigger." What is the best response by the nurse in this situation? a. "Please reschedule your appointment until you are more prepared." b. "It is okay; the provider will not do a breast examination." c. "I will explain normal growth and breast development to you." d. "That is unfortunate; this must be very stressful for you."

ANS: C During adolescence, one breast may grow faster than the other. Discussion regarding this aspect of growth and development with the patient will reassure her that there may be nothing wrong with her breasts. Young women usually enter the health system for screening (Pap tests begin at age 21 or 3 years after first sexual activity). Situations such as these can produce great stress for the young woman, and the nurse and health care provider should treat her carefully. Asking her to reschedule would likely result in the client's not returning for her appointment at all. A breast examination at her age is part of the complete physical examination. Young women should be taught about normal breast development and begin doing breast self-examinations. Although the last response shows empathy on the part of the nurse and acknowledges the patient's stress, it does not correct the patient's deficient knowledge related to normal growth and development.

Prostaglandins are produced in most organs of the body, including the uterus. Other source(s) of prostaglandins is/are: a. Ovaries. b. Breast milk. c. Menstrual blood. d. The vagina.

ANS: C Menstrual blood is a potent source of prostaglandins. Prostaglandins are produced in most organs of the body and in menstrual blood. The ovaries, breast milk, and vagina are neither organs nor a source of prostaglandins.

Menstruation is periodic uterine bleeding: a. That occurs every 28 days. b. In which the entire uterine lining is shed. c. That is regulated by ovarian hormones. d. That leads to fertilization.

ANS: C Menstruation is periodic uterine bleeding that is controlled by a feedback system involving three cycles: endometrial, hypothalamic-pituitary, and ovarian. The average length of a menstrual cycle is 28 days, but variations are normal. During the endometrial cycle, the functional two thirds of the endometrium is shed. Lack of fertilization leads to menstruation.

A woman who is older than 35 years may have difficulty achieving pregnancy primarily because: a. Personal risk behaviors influence fertility b. She has used contraceptives for an extended time c. Her ovaries may be affected by the aging process d. Prepregnancy medical attention is lacking

ANS: C Once the mature woman decides to conceive, a delay in becoming pregnant may occur because of the normal aging of the ovaries. Older adults participate in fewer risk behaviors than younger adults. The past use of contraceptives is not the problem. Prepregnancy medical care is both available and encouraged.

A pregnant woman who abuses cocaine admits to exchanging sex for her drug habit. This behavior places her at a greater risk for: a. Depression of the central nervous system b. Hypotension and vasodilation c. Sexually transmitted diseases d. Postmature birth

ANS: C Sex acts exchanged for drugs places the woman at increased risk for sexually transmitted diseases because of multiple partners and lack of protection. Cocaine is a central nervous system stimulant that causes hypertension and vasoconstriction. Premature delivery of the infant is one of the most common problems associated with cocaine use during pregnancy.

The microscopic examination of scrapings from the cervix, endocervix, or other mucous membranes to detect premalignant or malignant cells is called: a. Bimanual palpation. b. Rectovaginal palpation. c. A Papanicolaou (Pap) test. d. A four As procedure.

ANS: C The Pap test is a microscopic examination for cancer that should be performed regularly, depending on the client's age. Bimanual palpation is a physical examination of the vagina. Rectovaginal palpation is a physical examination performed through the rectum. The four As is an intervention procedure to help a patient stop smoking.

Which statement regarding female sexual response is inaccurate? a. Women and men are more alike than different in their physiologic response to sexual arousal and orgasm. b. Vasocongestion is the congestion of blood vessels. c. The orgasmic phase is the final state of the sexual response cycle. d. Facial grimaces and spasms of hands and feet are often part of arousal.

ANS: C The final state of the sexual response cycle is the resolution phase after orgasm. Men and women are surprisingly alike. Vasocongestion causes vaginal lubrication and engorgement of the genitals. Arousal is characterized by increased muscular tension (myotonia).

A 20-year-old patient calls the clinic to report that she has found a lump in her breast. The nurse's best response is: a. "Don't worry about it. I'm sure it's nothing." b. "Wear a tight bra, and it should shrink." c. "Many women have benign lumps and bumps in their breasts. However, to make sure that it's benign, you should come in for an examination by your physician." d. "Check it again in 1 month and call me back if it's still there."

ANS: C The nurse should try to ease the client's fear, but provide a time for a thorough evaluation of the lump because it may indicate abnormal changes in the breast. Discrediting the patient's findings may discourage her from continuing with breast self-examination. Wearing a tight bra may irritate the skin and would not cause the lump to shrink. Delaying treatment may allow proliferation of abnormal cells.

A fully matured endometrium that has reached the thickness of heavy, soft velvet describes the _____ phase of the endometrial cycle. a. Menstrual c. Secretory b. Proliferative d. Ischemic

ANS: C The secretory phase extends from the day of ovulation to approximately 3 days before the next menstrual cycle. During this phase, the endometrium becomes fully mature. During the menstrual phase, the endometrium is being shed; the endometrium is fully mature again during the secretory phase. The proliferative phase is a period of rapid growth, but the endometrium becomes fully mature again during the secretory phase. During the ischemic phase, the blood supply is blocked, and necrosis develops. The endometrium is fully mature during the secretory phase.

A patient at 24 weeks of gestation says she has a glass of wine with dinner every evening. The nurse will counsel her to eliminate all alcohol intake because: a. A daily consumption of alcohol indicates a risk for alcoholism. b. She will be at risk for abusing other substances as well. c. The fetus is placed at risk for altered brain growth. d. The fetus is at risk for multiple organ anomalies.

ANS: C There is no period during pregnancy when it is safe to consume alcohol. The documented effects of alcohol consumption during pregnancy include mental retardation, learning disabilities, high activity level, and short attention span. The brain grows most rapidly in the third trimester and is vulnerable to alcohol exposure during this time. Abuse of other substances has not been linked to alcohol use.

The nurse guides a woman to the examination room and asks her to remove her clothes and put on an examination gown with the front open. The woman states, "I have special undergarments that I do not remove for religious reasons." The most appropriate response from the nurse would be: a. "You can't have an examination without removing all your clothes." b. "I'll ask the doctor to modify the examination." c. "Tell me about your undergarments. I'll explain the examination procedure, and then we can discuss how you can have your examination comfortably." d. "What? I've never heard of such a thing! That sounds different and strange."

ANS: C This statement reflects cultural competence by the nurse and shows respect for the woman's religious practices. The nurse must respect the rich and unique qualities that cultural diversity brings to individuals. In recognizing the value of these differences, the nurse can modify the plan of care to meet the needs of each woman.

As part of their participation in the gynecologic portion of the physical examination, nurses should: a. Take a firm approach that encourages the client to facilitate the examination by following the physician's instructions exactly. b. Explain the procedure as it unfolds and continue to question the client to get information in a timely manner. c. Take the opportunity to explain that the trendy vulvar self-examination is only for women at risk for cancer. d. Help the woman relax through proper placement of her hands and proper breathing during the examination.

ANS: D Breathing techniques are important relaxation techniques that can help the client during the examination. The nurse should encourage the patient to participate in an active partnership with the care provider. Explanations during the procedure are fine, but many women are uncomfortable answering questions in the exposed and awkward position of the examination. Vulvar self-examination on a regular basis should be encouraged and taught during the examination.

As a powerful central nervous system stimulant, which of these substances can lead to miscarriage, preterm labor, placental separation (abruption), and stillbirth? a. Heroin b. Alcohol c. PCP d. Cocaine

ANS: D Cocaine is a powerful CNS stimulant. Effects on pregnancy associated with cocaine use include abruptio placentae, preterm labor, precipitous birth, and stillbirth. Heroin is an opiate. Its use in pregnancy is associated with preeclampsia, intrauterine growth restriction, miscarriage, premature rupture of membranes, infections, breech presentation, and preterm labor. The most serious effect of alcohol use in pregnancy is fetal alcohol syndrome. The major concerns regarding PCP use in pregnant women are its association with polydrug abuse and the neurobehavioral effects on the neonate.

The hormone responsible for maturation of mammary gland tissue is: a. Estrogen. b. Testosterone. c. Prolactin. d. Progesterone.

ANS: D Progesterone causes maturation of the mammary gland tissue, specifically acinar structures of the lobules. Estrogen increases the vascularity of the breast tissue. Testosterone has no bearing on breast development. Prolactin is produced after birth and released from the pituitary gland. It is produced in response to infant suckling and emptying of the breasts.

The most dangerous effect on the fetus of a mother who smokes cigarettes while pregnant is: a. Genetic changes and anomalies b. Extensive central nervous system damage c. Fetal addiction to the substance inhaled d. Intrauterine growth restriction

ANS: D The major consequences of smoking tobacco during pregnancy are low-birth-weight infants, prematurity, and increased perinatal loss. Cigarettes normally will not cause genetic changes or extensive central nervous system damage. Addiction to tobacco is not a usual concern related to the neonate.

The stimulated release of gonadotropin-releasing hormone and follicle-stimulating hormone is part of the: a. Menstrual cycle. b. Endometrial cycle. c. Ovarian cycle. d. Hypothalamic-pituitary cycle.

ANS: D The menstrual, endometrial, and ovarian cycles are interconnected. However, the cyclic release of hormones is the function of the hypothalamus and pituitary glands.

The long-term treatment plan for an adolescent with an eating disorder focuses on: a. Managing the effects of malnutrition. b. Establishing sufficient caloric intake. c. Improving family dynamics. d. Restructuring perception of body image.

ANS: D The treatment of eating disorders is initially focused on reestablishing physiologic homeostasis. Once body systems are stabilized, the next goal of treatment for eating disorders is maintaining adequate caloric intake. Although family therapy is indicated when dysfunctional family relationships exist, the primary focus of therapy for eating disorders is to help the adolescent cope with complex issues. The focus of treatment in individual therapy for an eating disorder involves restructuring cognitive perceptions about the individual's body image.

The two primary functions of the ovary are: a. Normal female development and sex hormone release. b. Ovulation and internal pelvic support. c. Sexual response and ovulation. d. Ovulation and hormone production.

ANS: D The two functions of the ovaries are ovulation and hormone production. The presence of ovaries does not guarantee normal female development. The ovaries produce estrogen, progesterone, and androgen. Ovulation is the release of a mature ovum from the ovary; the ovaries are not responsible for internal pelvic support. Sexual response is a feedback mechanism involving the hypothalamus, anterior pituitary gland, and the ovaries. Ovulation does occur in the ovaries.