Chapter 27 Health Assessment

The nurse is planning to inspect the anal area of an adult female client. To assess for any bulges or lesions, the nurse should ask the client to breathe normally. breathe deeply through her mouth. bear down. hold her breath.

bear down

The nurse suspects a client weighing 161 pounds may be exhibiting signs of sepsis. Which urinary output value indicates acute oliguria? 120 mL in past 2 hours 50 mL in past 2 hours 100 mL in past 2 hours 80 mL in past 2 hours

50 mL in past 2 hours

A female client with a history of endometriosis tests positive with a urine pregnancy test. She complains of right lower quadrant pain and nausea. During an ultrasound, an empty gestational sac is seen. What is the nurse's priority action? Avoid taking over the counter pain medications while pregnant. Advise client to seek treatment right away. Tell the client the heartbeat is usually not seen until 6 weeks. Emphasize importance of client keeping her one week follow-up appointment.

Advise the client to seek treatment right away

The nurse is taking a sexual history on a new patient. What action is considered appropriate at this time? (Select all that apply.) Explain to the patient what is considered to be normal sexual behavior Explain why you are taking the sexual history Note that you realize this information is highly personal Relate that you gather this history on only high-risk patients Affirm that your conversation is confidential

Affirm that your conversation is confidential Note that you realize this information is highly personal Explain why you are taking the sexual history

After an assessment, the nurse identifies that a female client is at risk for the development of colorectal cancer. Which non-modifiable risk factors did the nurse assess to make this clinical determination? Select all that apply. Age 53 Treatment for type 2 diabetes mellitus African American race Sedentary lifestyle Smokes cigarettes

Age 53 African American race Treatment for type 2 diabetes mellitus

A 27-year-old female client with a history of endometriosis and amenorrhea reports severe right-sided pelvic pain. What is the nurse's priority action? Palpate for liver enlargement. Assess the client's vital signs. Inquire if client has multiple sexual partners. Collect a stool specimen.

Assess the client's vital signs.

A client has been ordered to have a physical examination of the genitalia. Which information should a nurse give a client scheduled for her first Pap test to improve the accuracy of the test? Avoid douching 48 hours before the examination Drink plenty of water and ensure a full bladder Place the hands behind and over the head Lie supine during the examination

Avoid douching 48 hours before the examination

A 24-year-old travel agent comes to your clinic complaining of pain and swelling in her vulvar area. She states that 2 days before she could feel a small tender spot on the left side of her vagina but now it is larger and extremely tender. Her last period was 1 year ago; she is sexually active. She uses the Depo-Provera shot for contraception. She denies any nausea, vomiting, constipation, diarrhea, pain with urination, or fever. Her past medical history is significant for ankle surgery. Her mother is healthy, and her father has type 2 diabetes. On examination she appears her stated age and is standing up. She states she cannot sit down without excruciating pain. Her blood pressure, temperature, and pulse are unremarkable. On visualization of her perineum a large, red, tense swelling is seen to the left of her introitus. Palpation of the mass causes a great deal of pain. What disorder of the vulva is most likely causing her problems? Bartholin's gland infection Condylomata accuminata Secondary syphilis Vulvar carcinoma

Bartholin's gland infection

A client is explaining to the nurse how vaginal dryness has decreased her enjoyment of sexual intercourse. The nurse is aware that which of the following are the glands that produce mucus that lubricates the vagina during intercourse? Bartholin's glands Sebaceous glands Cowper's glands Eccrine glands

Bartholin's glands

Which type of yeast infection is manifested by white, cottage cheese-like discharge? Candidiasis Cevicitis Trichomoniasis Bacterial vaginosis

Candidiasis

The wet mount prepared after a female client's pelvic examination reveals motile organisms greater than 10 WBCs per high powered microscopy. The nurse should gather supplies for which diagnostic follow-up? (Select all that apply.) HIV testing Chlamydia culture Ureteroscopy Syphilis serology Gonorrhea culture

Chlamydia culture Gonorrhea culture HIV testing Syphilis serology

Which of the following is a downward displacement of the bladder toward the vaginal orifice? Cystocele Rectocele Vulvodynia Fistula

Cystocele

A client presents to the health care clinic for a routine pelvic examination. The client tells the nurse that she has experienced several yeast infections over the past year. The nurse should ask the client about the presence of which disease process? Kidney stones Sexually transmitted diseases Diabetes mellitus Heart disease

Diabetes mellitus

Which of the following terms refers to difficult or painful sexual intercourse? Endometriosis Dysmenorrhea Dyspareunia Amenorrhea

Dyspareunia

The nurse is advising a client who is diagnosed with pelvic inflammatory disease (PID) about the side effects of PID. What serious condition may occur as a result of this disease? Sepsis Birth defects Toxic shock syndrome Ectopic pregnancy

Ectopic pregnancy

What is the greatest risk factor for cervical cancer? Age Genetics HIV HPV

HPV

A nurse is teaching a sex education class at the local university. In a prelecture quiz, the nurse asks what the two small folds that extend from the clitoral hood to the posterior fourchette of the vagina are called. What would be the correct answer? Labia minora Labia majora Posterior fourchette Vestibule

Labia minora

A nurse is interviewing a client who is from Bangladesh. Which of the following should the nurse not find unusual, based on this client's country of origin? Late menarche Amenorrhea Severe premenstrual syndrome symptoms Early menarche

Late menarche

Which of the following is the most important risk factor for cervical cancer? Persistent HPV infections Poor nutrition and smoking during adolescence Immunosuppressive illnesses Failure to seek Pap smear screening

Persistent HPV infections

The nurse is reviewing the functions of the ovaries, uterus, clitoris and vagina with a group of nursing students. Based on this information, what would be the best response by a nursing student about the function of the ovaries? Receives the fertilized ovum and provides housing and nourishment for a fetus. Produces female gametes (ova) and secretes female sex hormones. Receives sperm, provides an exit for menstrual flow and serves as the birth canal. Small erectile structure that responds to sexual stimulation.

Produces female gametes (ova) and secretes female sex hormones.

A female patient with HIV has just been diagnosed with condylomata acuminata (genital warts). What information is appropriate to tell this patient? The potential for transmission to her sexual partner will be eliminated if condoms are used every time they have sexual intercourse. The human papillomavirus (HPV), which causes condylomata acuminata, can't be transmitted during oral sex. This condition puts her at a higher risk for cervical cancer; therefore, she should have a Panpanicolaou (Pap) test annually. The most common treatment is metronidazole (Flagyl), which should eradicate the problem within 7 to 10 days.

This condition puts her at a higher risk for cervical cancer; therefore, she should have a Panpanicolaou (Pap) test annually.

Which client should the nurse assess for possible primary amenorrhea? a 49-year-old reporting having no menses for the last 8 months a 35-year-old reporting irritability and anxiety beginning 3 days before menses an 18-year-old who has never started menses a breastfeeding 27-year-old who has not resumed menses

an 18-year-old who has never started menses

An older adult client visits the clinic complaining of urinary incontinence. The nurse should explain to the client that this is often due to atrophy of the vaginal mucosa. decreased urethral elasticity. decreased estrogen production. change in the vaginal pH.

decreased urethral elasticity.

The outer layer of the vaginal wall is under the direct influence of androgen. estrogen. aldosterone. progesterone.

estrogen

What information should a nurse give a client who reports a routine of frequent douching? Can cause abrasion that bleeds easily May cause toxic shock syndrome contaminates the vagina and the urethra predisposes the vagina to yeast infections

predisposes the vagina to yeast infections

To best secure accurate assessment information, the nurse should complete which part of the reproductive history last? menstrual menopausal sexual obstetric

sexual

A female client tells the nurse that she may be experiencing premenstrual syndrome. An appropriate question for the nurse to ask the client is "Are you experiencing regular menstrual cycles?" "How often are your menstrual periods?" "Do you experience mood swings or bloating?" "How old were you when you began to menstruate?"

"Do you experience mood swings or bloating?"

When assessing for factors that increase the risk for pelvic floor muscle weakness, the nurse should ask which questions? Select all that apply. "Do your bowels move regularly with the help of a laxative?" "Have you ever been diagnosed with diabetes?" "How old will you be on your next birthday?" "Has any female family member been treated for a cystocele?" "How many children have you given birth to?"

"How many children have you given birth to?" "Have you ever been diagnosed with diabetes?" "How old will you be on your next birthday?" "Do your bowels move regularly with the help of a laxative?"

A 57-year-old woman calls the clinic reporting painful intercourse followed by spotting. She tells the nurse that she hasn't had a period in 2 years. What should the nurse tell her? "These findings are common in postmenopausal women." "You may have an STI." "Go to the emergency department to be checked right away." "Make an appointment to see the doctor as soon as possible."

"These findings are common in postmenopausal women."

A 35-year-old woman visits her family doctor and reports mood swings, swelling of her breasts, acne, bloating, and weight gain every month, starting about 2 weeks prior to her period. What disorder is this patient describing? Premenstrual syndrome (PMS) Premenstrual dysphoric disorder (PMDD) Ectopic pregnancy Dysmenorrhea

Premenstrual syndrome (PMS)

The nurse is reviewing the functions of the ovaries, uterus, clitoris and vagina with a group of high school students. Based on this information, what would be the best response by a high school student about the function of the vagina? Small erectile structure that responds to sexual stimulation. Produces female gametes or ova and secretes female sex hormones. Receives sperm, provides an exit for menstrual flow and serves as the birth canal. Receives the fertilized ovum and provides housing and nourishment for a fetus.

Receives sperm, provides an exit for menstrual flow and serves as the birth canal.

Which finding in a female client's history would alert the nurse to assess for signs of diabetes mellitus? Vaginal bleeding after intercourse Recurrent candidiasis infections Purulent vaginal discharge and pain Vaginal secretions with a fishy odor

Recurrent candidiasis infections

A nurse inspects the cervix of a 28-year-old, nonpregnant client during a routine assessment. Which coloration of the cervix may indicate inflammation? Blue Red Pink Pale

Red

While examining the perineum of a female patient, the nurse notes an enlarged knot to the right side just below the vaginal opening. The nurse will most likely note this as an enlarged Bartholin gland. True False

True

A client visits the clinic and tells the nurse that her stools have been pale for the past 2 days and her skin has been itching. The nurse should refer the client to a physician for possible gastrointestinal infection. biliary disease. cancer. hemorrhoids.

biliary disease

The nurse notes a white curd-like discharge when inspecting a female client's labia. What should the nurse suspect this client is experiencing? trichomonas vaginalis bacterial overgrowth human papilloma infection candida vaginitis

candida vaginitis

The visible portion of the clitoris is termed the glans. vestibule. crura. corpus.

glans

While performing a gynecologic examination, the nurse observes small, painful, ulcer-like lesions with red bases on the client's labia. The nurse should refer the client to a physician for possible lice. herpes simplex virus infection. herpes zoster virus infection. syphilis.

herpes simplex virus infection.

During assessment of the vaginal area of an adult client, the client tells the nurse that she has had pain in her vaginal area. The nurse should further assess the client for infection. cancer. pregnancy. trauma.

infection

The nurse is performing a genitourinary assessment on a 42-year-old client and has explained to her that the assessment will require rectovaginal palpation. The client winces and asks, "Is that really necessary?" Which of the nurse's responses would provide the best rationale for rectovaginal palpation? "It's important, but difficult, for me to feel your ovaries; this is one of the only ways of doing so." "I know that it's an unpleasant procedure, but I can do it at the same time as your Pap smear to make it go faster." "I know this is probably unpleasant, but it's important for me to determine if your uterus is where it's expected." "Unfortunately, this technique is the only way I can determine how strong your pelvic muscles are."

"I know this is probably unpleasant, but it's important for me to determine if your uterus is where it's expected."

The nurse has provided education about the HPV vaccine to a 20-year-old female client. The client needs further teaching if she makes which statement? "This vaccine targets the types of HPV that cause cervical cancer." "I am going to see if I can quit smoking by using the patch." "I need to return for two more injections after the first one." "I need to have my female health exam every other year."

"I need to have my female health exam every other year."

A mother brings her adolescent daughter to the clinic. The mother is worried that her daughter is sexually active. When assessing the adolescent, it is vital for the nurse to do what? Question the client with the parent present Perform a pregnancy test Establish a trusting and confidential relationship with the client Do a vaginal examination to see if the daughter has been sexually active

Establish a trusting and confidential relationship with the client

A nurse assesses a 22-year-old client who has never had a Pap test. Which factor should the nurse explain to the client as being a risk for cervical cancer? Having the human papillomavirus (HPV) vaccination Lack of exercise Having multiple sexual partners Smoking

Having multiple sexual partners

The nurse is working with an anorexic client who complains that sexual intercourse with her partner is painful. The nurse suspects that the client may lack the fat pad that is typically located over the pubic bone in women and that functions to absorb force and protect the pubic bone. Which of the following is the name of this structure? Vulva Frenulum Clitoris Mons pubis

Mons pubis

A nurse observes a few small, yellow nodules on the cervix of a client during the speculum exam. They are not painful or odorous, and a thin, clear discharge is present. The nurse recognizes that these are most indicative of what type of condition? Cervical eversion Nabothian cysts Chlamydia infection Columnar epithelium

Nabothian cysts

A nurse practitioner documents as follows:"Client reports pain and tenderness over area of right ovary and a history of irregular menses."With which of the following diagnoses are these findings consistent? Ovarian cyst Ovarian cancer Salpingitis Pelvic inflammatory disease

Ovarian cyst

During a comprehensive assessment, a female client complains of intense external genital itching. The nurse should carefully assess for which condition that commonly presents with this symptom? Enlarged inguinal lymph nodes Nabothian cysts Pediculosis pubis Genital fissures

Pediculosis pubis

A 57-year-old woman has come to the OB/GYN clinic for her annual physical. She tells the nurse that it has been 14 months since her last period. What should the nurse further assess? The patient has possibly developed cervical cancer. The patient is premenopausal. The patient is postmenopausal. The patient is perimenopausal.

The patient is postmenopausal

When assessing a pregnant female, the nurse documents Gravida 3, Para 2 regarding obstetrical history in the health record. Which situation correctly corresponds to the obstetrical history of the woman? The woman has been pregnant twice and has delivered three children, including a set of twins. The woman has been pregnant twice times, has delivered twins, and is expecting a third child. The woman has had one miscarriage, one live child, and is pregnant for a third time. The woman has been pregnant three times and has delivered two live children.

The woman has been pregnant three times and has delivered two live children.

During the examination of the external genitalia, the nurse notices drainage from the urethra. The nurse should prepare to assess this client for which condition? Trichomoniasis Urethritis Lice infestation Gonorrhea

Urethritis

A 53-year-old client tells the nurse that she thinks she is starting the menopausal phase of her life. The nurse should instruct the client that she may experience urinary frequency. vaginal discharge. hot flashes. increased appetite.

hot flashes

A female client tells the nurse that she has pain while urinating. Besides obtaining a urinalysis, the nurse should assess the client for tumors. sexually transmitted disease. kidney trauma. infestation.

sexually transmitted disease