NUR 221 EAQ - Chapter 3: Assessment and Health Promotion

A nurse is instructing a woman on how to best perform a breast self-examination (BSE) to screen for cancer. The patient says, "It all feels the same to me." What should be the nurse's reply?

"It's important to know how they normally feel in order to detect changes."

The nurse is assessing a patient with bleeding disorder. Which action should the nurse adopt while interacting with the patient? Select all that apply.

1.) Acknowledge the feelings of the patient. 2.) Maintain stable eye contact with the patient. 3.) Repeat the words mentioned by the patient.

A Muslim woman presents to the emergency room with severe uterine bleeding. Which actions illustrate cultural sensitivity? Select all that apply.

1.) Allow the patient to stay as dressed as possible. 2.) If possible, a female provider should deliver care.

A patient who is about halfway through her pregnancy has started experiencing general pelvic pain. Her physician told her it was "ligament pain." Which ligaments might be affected? Select all that apply.

1.) Broad 2.) Round 3.) Cardinal 4.) Uterosacral

Which statements about teenage pregnancy are true? Select all that apply.

1.) Effective educational programs are crucial. 2.) Most teenage pregnancies are unplanned. 3.) Teenagers lack financial resources to support pregnancies.

What risk factors does the nurse assess in a patient during preconception care? Select all that apply.

1.) Exposure to toxic chemicals 2.) Down syndrome and cystic fibrosis 3.) Hypertension, diabetes, and anemia

The nurse is assessing a pregnant patient who is found to be obese. What are the disease conditions to which the patient is highly susceptible? Select all that apply.

1.) Hypertension 2.) Diabetes mellitus

A student nurse is preparing a project on the work of Masters and Johnson. Which phases did the researchers note in their 1966 research regarding the sexual response cycle? Select all that apply.

1.) Plateau 2.) Orgasm 3.) Excitement 4.) Resolution

During the preconception phase, the nurse should teach about which infectious diseases as risk factors for maternal complications? Select all that apply.

1.) Rubella 2.) HIV/AIDS 3.) Hepatitis B

The nurse prepares to communicate with an abused patient. The nurse finds that the patient has pain due to pelvic fracture. Which points does the nurse keep in mind before communicating with the patient? Select all that apply.

1.) To sit with the patient in a closed room. 2.) To tell the patient, "You are not alone."

The women's health nurse knows which statements regarding sexual response are accurate? Select all that apply.

1.) Vasocongestion is the congestion of blood vessels. 2.) Facial grimaces and spasms of hands and feet are often part of arousal. 3.) Women and men are more alike than different in their physiological response to sexual arousal and orgasm.

What should the clinic nurse include in the instructions for a woman scheduling a pelvic examination with a Papanicolaou test? Select all that apply.

1.) You should avoid intercourse for 24-48 hours before the examination. 2.) If you start your menstrual cycle on the day of the examination, we will need to reschedule.

The nurse observes that a client weighs 169 lb and is 160 cm tall. What is the approximate body mass index (BMI) of the client? Record your answer using a whole number.

30

The nurse is assessing a patient who experienced menopause at 52 years of age. The nurse expects that the patient began perimenopause at what approximate age? Record your answer using a whole number.

48 years

A 65-year-old woman is complaining of increasing stress incontinence and pelvic pressure and fullness. Pelvic examination reveals a bulging in the anterior vaginal wall. What is this woman most likely experiencing?

Cystocele

The nurse is reviewing the laboratory results of a patient and notes that the patient has low levels of gonadotropin-releasing hormone (GnRH). Which physiologic process would be highly affected in the patient?

Development of ovum.

What should the nurse teach to assist a woman in regaining control of the urinary sphincter?

Do Kegel exercises.

What does the nurse regularly monitor in a patient with cocaine addiction to prevent its associated complications?

Blood pressure

The nurse is assessing a pregnant patient with diabetes who has been prescribed an oral hypoglycemic. What instruction does the nurse give to the patient to assist in possible prevention of miscarriage and congenital abnormalities?

Take folic acid supplements during pregnancy.

The nurse is caring for a pregnant patient with injuries and burns. When interacting with the patient, the nurse understands that the patient is being physically abused by the intimate partner. What will be the immediate action of the nurse?

Tell the patient, "It is a crime, and you deserve to be treated with respect."

A 42-year-old woman asks the nurse about mammograms, now that she is "getting older." What should the nurse tell her?

The American Cancer Society recommends mammograms every 1 to 2 years for women ages 40 to 49.

A transgender patient has arrived at the hospital. She is a preoperative trans woman. Some of the hospital staff expresses discomfort with this patient. Some are laughing, and others are refusing to use the pronoun "she." As an advocate for patient respect, what should the nurse do?

Remind the coworkers of the patient's rights, and offer to care for the patient.

A patient with low health literacy is diagnosed with endometriosis and given a brochure to read. The brochure states, "Two of the three endometrial layers are shed, culminating in menstruation." Why might the nurse need to intervene?

The brochure should be revised to eliminate jargon.

When obtaining a reproductive health history from a woman, what should the nurse do?

Explain the purpose for the questions asked and how the information will be used.

Which piece of the usual equipment setup for a pelvic examination is omitted with a Pap test?

Lubricant

A pregnant patient is admitted to the emergency department. The laboratory reports show that there is increased carbon dioxide level in the blood and improper oxygen supply to the fetus. On evaluating the medical history of the patient, the nurse finds that the patient is a drug user. Which drug did the patient use?

Marijuana

During the assessment of a pregnant patient the nurse suspects that the patient may have dysrhythmias, cardiomyopathy, and heart failure. To prevent these complications the nurse suggests the patient maintain a healthy diet and stop rigorous exercise. What is the most likely reason for anticipating these complications in the patient?

Maternal presentation of anorexia nervosa.

A patient who has been diagnosed with precocious puberty has what?

Menarche earlier than her peers.

The nurse is assessing a woman's breast self-examination (BSE) technique. Which action indicates that the woman needs additional instruction regarding BSE?

Performs every month on the first day of her menstrual period.

The nurse is teaching a woman of childbearing age about the purpose of a pelvic examination. Which statement made by the woman indicates further teaching is needed?

"I know they will be able to feel my fallopian tubes and check them during the pelvic exam."

The nurse-midwife is teaching a group of pregnant women about Kegel exercises. Which statement by a participant indicates a correct understanding of the instruction?

"I should hold the Kegel exercise contraction for 10 seconds and rest for 10 seconds between exercises."

While assessing a patient using the SCOFF questionnaire, the nurse finds that the patient has drastically lost weight over several months. What factor responsible for weight loss does the nurse suspect in the patient?

Anorexia nervosa

A woman and her same-sex partner have decided to conceive a child with the help of a male friend. At one of the prenatal checkups, the nurse notices some suspicious bruising on the woman. What conclusions can the nurse make?

More information needs to be gained.

Adding supplemental folic acid preconception has been shown to decrease the incidence of which condition?

Neural tube defects.

A body mass index (BMI) of 32 is calculated for a woman. The nurse knows that this index puts the woman into which category of weight?

Obese

A pregnant patient who is a heavy smoker has decided to quit. What can the nurse do to increase the patient's chances of success?

Offer support and follow-up care.

The nurse is assessing a patient with slightly elevated body temperature (above 37 degrees C). The patient reports thin and clear mucosal discharge from the cervix. The nurse infers that the patient is in which stage?

Ovulating stage

A 47-year-old gravida III, para III, has presented for an annual physical. She had a total hysterectomy and right oophorectomy at age 35 and is not currently sexually active. Which gynecological procedure will be performed?

Pelvic exam

The nurse is preparing to conduct a pelvic exam in a patient with trichomoniasis. The nurse finds that the patient has visual impairment and is physically disabled. Which action does the nurse employ while conducting the test?

The nurse informs about each step to the patient before performing the test.

While assessing a patient 1 week after birth, the nurse notes vaginal atrophy characterized by drying and thinning of the vaginal lining. What can the nurse infer from these findings?

The patient has low levels of estrogen.

After assessing a patient, the nurse understands that the patient may have early menopause and is also at risk for osteoporosis. What could be the reason for this condition?

The patient is a cigarette smoker.

The nurse observes that a patient has severe injuries and avoids interacting due to fear. The nurse finds that the patient is afraid, angry, embarrassed, and shocked. What can the nurse interpret from these patient observations?

The patient is a victim of physical abuse.

A patient is diagnosed with type 1 diabetes during pregnancy. The primary health care provider (PHP) finds that the offspring of the patient was born without any malformations. What is the possible reason for the absence of congenital anomaly in the offspring?

The patient maintained an euglycemic condition during pregnancy.

The nursing instructor is teaching a group of students about preconception counseling and care. The student nurse asks the nurse about interventions that can decrease the incidence of spina bifida in the fetus. Which answer does the nurse give to the student?

The patient should include a daily intake of 400 mcg of folic acid during pregnancy.

The nurse should refer the patient for additional testing if what was noted on inspection of the breasts of a 55-year-old woman?

The small dimple located in the upper outer quadrant of the right breast.

Which statement provides correct information about performing a Papanicolaou (Pap) test?

The woman should not douche, use vaginal medications, or have intercourse for at least 24 hours before the test.

An adult paraplegic patient has presented for an annual Papanicolaou (Pap) smear and physical. What challenges might this present for the nurse/practitioner?

There may need to be accommodations with positioning.

What is the purpose of recommending a Papanicolaou (Pap) test for women over 20 years of age?

To detect if the patient has cervical cancer.

The nurse is preparing to examine a patient with cervical cancer. Which is the most suitable site of examination for the patient?

Transformation zone

Which part of the cervix is the most common site for neoplastic changes?

Transformation zone