Course point: the ones making me defecate

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? A. "I know this is probably unpleasant, but it's important for me to determine if your uterus is where it's expected." B. I know this is probably unpleasant, but it's important for me to determine if your ovaries are where it's expected." C. "Unfortunately, this technique is the only way I can determine how strong your pelvic muscles are." D. "Unfortunately, this technique is the only way I can determine if your cervix is the right consistency."

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

When assessing a newborn, the nurse finds areas at the base of the spine that look like bruises. The nurse knows that these areas are most common in infants of which of the following ethnic backgrounds? A. African Americans B. Pacific islander C. Irish American D. Italian American

A. African Americans

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 A. Infection B. Trauma C. Prolapse

A. Infection

A nurse measures an 18-month-old child's head circumference (HC) and finds that it is in the 3rd percentile. Which of the following conditions should the nurse suspect in this child? A. Microcephaly B. Macrocephaly C. Normal D. separation of cranial sutures

A. Microcephaly; A finding greater than 95% may indicate macrocephaly. A finding under the 5th percentile may indicate microcephaly.

A new mother tells the nurse that the newborn has a small yellow lesion on the hard palate of the mouth and is worried about the baby's ability to suck properly. What should the nurse tell the mother about this finding? A. "I will get an order to culture this for infection." B. "This is common and will disappear after the first few weeks." C. "This is of no concern and should not affect the baby's ability to suckle".

B. "This is common and will disappear after the first few weeks."

The parent of a 2 year old is concerned her child is talking but she cannot understand her. The nurse explains that this should occur by what age? A. 5 B. 3 C. 4

B. 3

The nurse working in the emergency department is assessing an intoxicated driver involved in a motor vehicle crash when the client insists on ambulating to the bathroom. The nurse escorts the client and calls for help while anticipating which abnormal gait in this client that places him at risk for falls? A. Sensory ataxia B. Cerebellar ataxia C. Spastic hemiparesis D. Parkinson's gate

B. Cerebellar ataxia a wide-based gait with staggering and lurching, is often due to alcohol intake or cerebral palsy.

A nurse auscultates the heart rate in a young child and notes an irregular rhythm. No other abnormal vital signs are present and the child is not in any distress. What is an appropriate action by the nurse in regards to this finding? A. Turn the child to the left side and listen with the bell of the stethoscope B. Count the apical pulse for a full minute to obtain an accurate rate C. Document as a normal finding

B. Count the apical pulse for a full minute to obtain an accurate rate

A nurse notes the respiratory rate of a 2-year-old to be 28 breaths per minute. What is an appropriate action by the nurse in regards to this finding? A. Call the provider B. Document the finding as normal C. Assess lung sounds D. Percuss for consolidation

B. Document the finding as normal. The normal respiratory rate for a child between the ages of 2 and 10 is 20 to 28 breaths per minute.

When assessing a child with respiratory distress, it is important to ask further questions. What is the priority question that the nurse needs to ask? A. Has the child had all of their immunizations? B. Has the infant been exposed to anyone with a communicable illness? C. Does the infant to go to daycare?

B. Has the infant been exposed to anyone with a communicable illness?

The nurse is performing an eye assessment on a newborn and is unable to elicit a red reflex. What is the priority intervention that the nurse should do at this time? A. Although of no clinical significance, document the finding on the clinical record. B. Notify the physician C. There is no such thing as the red reflex

B. Notify the physician. The inability to elicit a red reflex from a newborn can be clinically significant. The infant should be referred to a specialist. Absence of a red reflex can indicate congenital cataracts or neuroblastoma.

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? A. Ovarian cancer B. Ovarian cyst C. Uterine fibroids D. PID

B. Ovarian cyst

A young mother visits the clinic with her 18-month-old child. The mother asks the nurse when she should begin toilet training with the child. The nurse should explain to the mother that A. Nighttime bladder control is usually achieve by 3 years of age. B. She can begin bowel training as soon as the child appears ready. C. She can begin bowel training as soon as the child is 3 years of age.

B. She can begin bowel training as soon as the child appears ready.

A nurse understands that which sleep pattern is considered normal for a preschooler? A. Sleep comfortably without difficulty B. Sleep 11 to 13 hours per day C. Preschoolers typically don't need an afternoon nap until the age of five

B. Sleep 11 to 13 hours per day

What should a nurse keep in mind when palpating for the testes in a male infant? A. They must be milked because they are still in the inguinal canal B. Touch or cold may pull the testicles back into the inguinal canal C. The right testicle is larger then the left D. The left testicle is larger than the right

B. Touch or cold may pull the testicles back into the inguinal canal

The nurse suspects that a newborn has pyloric stenosis. What assessment finding caused the nurse to make this clinical determination? A. Rigid abdomen B. Visible peristaltic waves C. Bowel sounds every 10 seconds D. Soft abdomen

B. Visible peristaltic waves

A mother visits the clinic for a routine visit with her 5-year-old son. The mother asks the nurse when the child's permanent teeth will erupt. The nurse should explain to the mother that permanent teeth usually begin to erupt by age A. 7 years old B. 5 1/2 years old C. 6 years old D. 6 1/2 years old

C. 6 years old

The nurse notes that a sleeping newborn's heart rate is 102 bpm. What action should the nurse take first? A. Apply oxygen B. Call the provider C. Document heart rate D. Increase temperature of incubator

C. Document heart rate A pulse rate of 100 bpm when the infant is sleeping is considered normal and should be documented.

The mother of an 8 year old girl expresses concern about feeling a lump at each of the child's areolas. What is the nurse's best response? A. Is there a history of breast cancer in your family? B. Pubertal changes at age 8 are abnormal and require further evaluation. C. It is likely a breast but which is a normal finding at this age.

C. It is likely a breast but which is a normal finding at this age. Onset of pubertal changes before 8 years in girls and 9 years in boys may be too early and needs further evaluation.

GA client who was injured by a fall at a construction site has been admitted to the hospital. He has suffered nerve damage such that his gag reflex is no longer intact, requiring him to receive intravenous total parenteral nutrition. Which nerve should the nurse suspect to be involved in this client's injury? A. Vagus (X) B. Spinal accessory (XI) C. Glossopharyngeal (IX) D. Hypoglosssal (XII)

C. glossopharyngeal (IX)

Which action by the nurse demonstrates the correct technique to elicit Ortolani's maneuver? A. Adduct the legs until the nurse's thumbs touch B. Buttocks are spread with gloved hands to examine the anus C. Assessing the symmetry of the gluteal fold D. Abduct the legs and move the knees outward

D. Abduct the legs and move the knees outward

The nurse is assessing an newly admitted client with a seizure disorder. The nurse would asses the client for what? A. lighteheadedness B. hallucinations C. delusions D. Aura

D. Aura for impending seizures

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? A. Enlarged inguinal lymph nodes B. Nabothian cysts C. Genital fissures D. Pediculosis pubis

D. Pediculosis pubis (crab lice)

The nurse notes that a newborn developed sepsis shortly after delivery. What should the nurse consider as being the reason for the development of this infection in the baby? Select all that apply. Undiagnosed vaginal infection Gestational diabetes Prolonged labor Prolonged rupture of membranes

Undiagnosed vaginal infection Prolonged labor Prolonged rupture of membranes