NURS 198 Exam 2

A client is brought to the emergency department via ambulance after experiencing difficulty speaking and weakness in the left arm and leg. The nurse understands that the client is most likely experiencing what?

cerebrovascular accident

The thin mucous membrane that lines the inner eyelid and covers the sclera is known as what?

conjunctiva

An adult male client visits the clinic and tells the nurse that he believes he has athlete's foot. The nurse observes that the client has linear cracks in the skin on both feet. The nurse should document the presence of...

fissures

The results of a client's Rinne test suggest that bone conduction and air conduction are both reduced. What nursing action would be most appropriate?

further eval

Symptoms of hyperthyroidism

increased metabolic rate, weight loss, protruding eyes, feelings of excessive warmth, sweating, palpitations

otitis externa, media, interna

inflammation of the outer ear middle ear inner ear

A client presents to the emergency department with reports of neck pain and a sudden onset of a headache. Upon examination, the nurse finds that the client has an increased temperature and neck stiffness. The nurse recognizes these findings as most likely to be caused by what condition?

meningeal inflammation

A nurse is caring for a client admitted with neck pain. The client is febrile. What is the most likely medical diagnosis for this client?

meningitis

A nursing instructor is teaching a group of students how to examine the thyroid gland. The instructor would determine that a student needs additional instruction when the student demonstrates which technique? A) Inspection B) Auscultation C) Palpation D) Percussion

percussion

5 layers of epidermis from most superficial to most deep

stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, stratum basale

Which area of the body should a nurse inspect for possible loss of skin integrity when performing a skin examination on a female who is obese?

under the breasts

Upon inspection of an elderly client's ears using an otoscope, the nurse observes a cloudy appearance to the tympanic membranes with prominent landmarks. What action should the nurse perform first?

Ask whether the client is experiencing ear pain or pressure

A client performs the test for distant visual acuity and scores 20/50. How should the nurse most accurately interpret this finding? How about for 50/20?

At 20 feet from the chart, the client sees what a person with good vision can see at 50 feet At 50 feet from the chart, the client sees what a person with good vision can see at 20 feet

While performing an examination of the head and neck, a nurse notices left sided facial drooping. The nurse recognizes this as what condition?

Bell's Palsy

symptoms of hypothyroidism

Bradycardia; cold intolerance; lethargy; memory loss; dry skin; brittle dry hair; decreased appetite; weight gain; constipation; increased serum lipids; decreased libido; erectile dysfunction

Conductive vs sensorineural hearing loss

Conductive hearing loss occurs when sound conduction is impeded through the external ear, the middle ear, or both. Sensorineural hearing loss occurs when there is a problem within the cochlea or the neural pathway to the auditory cortex. Mixed hearing loss is concomitant conductive and sensorineural loss.

A nurse has performed a head and neck assessment of an adult client and noted that the thyroid gland is not palpable. What is the nurse's most appropriate action?

Document finding as normal

A nurse is educating a client about the function of the parts of the auditory system. Which is the function of the eustachian tube?

Equalizes the pressure in the middle ear with atmospheric pressure. This is the part of the ear where ear infection occurs

On palpation, the nurse notes that a client's thyroid gland is diffusely enlarged. Which of the following health problems is associated with this finding?

Grave's disease

Hypothyroidism effects on hair and skin vs Hyperthyroidism

Hypo- thick coarse hair and dry and cool skin Hyper- smooth skin, thin and silky hair, and brittle nails

How can a nurse accurately assess the distant visual acuity of a client who is non-English speaking?

Snellen E chart

Range for the visual fields

Temporally 95, nasally 65, superiorly 60, and inferiorly 70 degrees

During a pharmacology class the students are told that some drugs need to be closely monitored. What aspect should the nurse closely monitor for in clients who have been administered salicylates, loop diuretics, quinidine, quinine, or aminoglycosides?

Tinnitus and sensorineural hearing loss

The nurse notes unilateral facial drooping and reports the finding immediately to the healthcare provider. The client is diagnosed with Bell palsy. The nurse should include assessment of which affected cranial nerve in the client's head and neck assessment?

VII

A nurse is examining a client's neck and is preparing to palpate the thyroid gland. The nurse would most likely expect to palpate how many lobes?

2

normal pupil size

4 mm

When testing the near reaction, an expected finding from the pupils includes...

Pupillary constriction on near gaze; dilation on distant gaze

Which characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media?

Red, bulging, with an absent light reflex

What is otalgia?

ear pain

While assessing the nails of an older adult, the nurse observes early clubbing. The nurse should further evaluate the client for signs and symptoms of...

hypoxia

A client reports sudden head and neck pain with stiffness, a new sensitivity to light, and has developed a fever. What is a priority action of the nurse?

notify healthcare provider

Which of the following would the nurse document as an abnormal finding with lymph node assessment? Mobile Diameter: 0.75 cm Tender Discrete

tender

A 52-year-old client fails the Romberg test. The nurse explains that this might indicate a dysfunction in what part of the ear?

vestibular portion of the ear

What is the normal capillary refill time?

2 seconds

What is a tophus?

A hard nodule composed of uric acid crystals

A nurse begins the eye examination on a client who presents to the health care clinic for a routine examination. What is the correct action by the nurse to perform the test for near visual acuity?

Have the client hold a Jaeger card 14 inches from the face and read with one eye at a time

4 stages of pressure ulcers

I: red, unbroken skin, does not blanch II: partial thickness skin erosion, loss of dermis / epidermis III: full thickness skin erosion, extends into subcutaneous tissue, resembles crater IV: full thickness skin erosion involving all skin layers, exposes muscle, tendon, bone - eschar or sloughing may be present

During your physical examination of the client you note an enlarged tender tonsillar lymph node. What would you do?

Look for a source such as infection in the area that it drains

Macule, Patch, and Papule

Macule — a small patch of skin that is altered in colour, but is not elevated. Patch — a large area of colour change, with a smooth surface. Papule — elevated, solid, palpable lesion that is ≤ 1 cm in diameter. They may be solitary or multiple.

An older client is concerned about new senile keratoses appearing on the skin. What should the nurse respond to this client's concern?

Normal occurrence with aging

The nurse palpates a client's auricles and notes an enlarged lymph node on one ear. No redness is observed, and the client denies pain or tenderness. What is the nurse's best action?

Notify healthcare provider

A nurse has taught a group of older adults about the high incidence and prevalence of macular degeneration. What health promotion and prevention activity should the nurse encourage these clients to perform?

Post an Amsler grid in their home and perform the test on a regular basis

Primary vs secondary lesions

Primary: lesions arising from previously normal skin Secondary: result from the changes that take place in the primary lesion due to infection, scratching, trauma, or various stages of a disease

Rinne vs. Weber tuning fork test

Rinne test: tuning fork placed on mastoid process behind ear Weber: tuning fork placed on center of forehead

What does SPF 15 mean when considering a sunscreen?

SPF 15 is the ratio of the number of minutes for treated versus untreated skin to redden with exposure to ultraviolet B rays

During a Weber test, the client reports lateralization of sound to the good ear. The nurse interprets this as which the following?

There is a sensorineural hearing impairment, conductive hearing loss would cause lateralization towards the bad ear

The nurse is inspecting the cornea and lens of an elderly client and notices a white arc around the limbus of the client's eye. The nurse recognizes this condition, common in older adults, as which of the following?

arcus senilis

A 82 year old female presents with neck pain, decreased strength and sensation of the upper extremities. The nurse identifies that this could be related to what?

arthritic changes of the cervical spine

During the physical examination of a client, a nurse notes that a client's trachea has been pushed toward the right side. The nurse recognizes that the pathophysiologic cause for this finding is related to what disease process?

atelectasis

The apocrine glands are dormant until puberty and are concentrated in the...

axillae, perineum, and areola of the breast

How to you hold the otoscope to inspect client's ear drum and canal?

between thumb and fingers

A nurse is collecting subjective data during a client's eye and vision assessment. When asking the question, "Do you wear sunglasses during exposure to the sun?" the nurse is addressing a known risk factor for what health problem?

cataracts

A client has conjunctivitis. The nurses understand that conjunctivitis differs from conjunctival hemorrhage in that..

conjunctivitis has a watery, mucoid discharge and is caused by an allergy, bacteria, or virus conjunctival hemorrhage is when a blood vessel breaks in the white of the eye

Assessment of an adult female client's face reveals a moon shape, increased hair distribution, and a reddened tone to the client's cheeks. What collaborative problem is most clearly suggested to the nurse by these assessment data?

cushings syndrome

What causes skin drying with age?

decreased sebum production

A nurse cares for a client of Asian descent and notices that the client sweats very little and produces no body odor. What is an appropriate action by the nurse in regards to this finding?

document findings as normal for this patient

A client diagnosed with goiter has undergone a thyroidectomy. How long must the patient take thyroid replacement medication?

every day for the rest of their lives

A client's history suggests a need to assess eye muscle strength and cranial nerve function. What assessment should the nurse consequently perform?

eye positions test

Exotropia vs esotropia

eye turns outward vs inward

An adult client tells the nurse that her peripheral vision is not what it used to be and she has a blind spot in her left eye. The nurse should refer the client for evaluation of possible...

glaucoma

The nurse is preparing to perform a physical examination of a client who is an Orthodox Jew. Which of the following accommodations should the nurse be prepared to make for this client, based on his religious beliefs?

have a same sex nurse examine them

While the nurse is assessing a client for an unrelated health concern, the client experiences a sudden, severe headache with no known cause. He also complains of dizziness and trouble seeing out of one eye. What associated condition should the nurse suspect in this client?

impending stroke

A client frequently experiences dry, irritated eyes. These findings are consistent with a problem in what part of the eye?

lacrimal apparatus, nasolacrimal sac

When the client reports a problem associated with the drainage of tears from the left eye, the nurse would focus the eye assessment on which eye structure?

lacrimal puncta

A client is 20 weeks pregnant and has melasma. What information can the nurse give the client about melasma, when educating her about the effects of pregnancy?

melasma generally resolves postpartum, however can be permanent in some cases

A client complains of a unilateral headache near the scalp line and double vision. The nurse palpates the space above the cheekbone near the scalp line on the affected side, and the client complains of tenderness on palpation. What is the nurse's next action?

notify healthcare provider immediately

When preparing to examine a client's skin, what is the MOST important for the nurse to do?

only expose the body part being examined

During assessment, the nurse would expect which part of the body to indicate central cyanosis in a client with a severe asthma attack?

oral mucosa

The nurse would pursue additional assessment and evaluation of an older adult client with diabetes upon assessing which of the following? Cherry angioma Seborrheic keratosis Cutaneous horn Pressure ulcer

pressure ulcer

When assessing the client's ear, which finding should the nurse identify as indicating a need for further assessment and possible treatment? Pearly gray tympanic membrane Darwin tubercle Tender tragus Red, flaky cerumen

tender tragus

A 29-year-old computer programmer comes to the office for evaluation of a headache. The tightening sensation of moderate intensity is located all over the head. It used to last minutes, but this time it has lasted for 5 days. He denies photophobia and nausea. He spends several hours at a computer monitor/keyboard. He has tried over-the-counter medication; it has dulled the pain, but not taken it away. Based on this description, what is the most likely diagnosis?

tension

Terminal vs Vellus Hair

terminal is coarse, dark hair on scalp, underarms and pubic area vellus is short, pale, and fine hair on face & body

During the health history, a client describes recent episodes of intermittent facial pain lasting several minutes. The nurse should recognize that this complaint is suggestive of what health problem?

trigeminal neuralgia

When preparing to examine a client's sclera and conjunctiva during an eye examination, the nurse should instruct the client to move both eyes to look in which direction?

up

The nurse is preparing to examine the skin of an adult client with a diagnosis of herpes simplex. The nurse plans to measure the client's symptomatic lesions and measure the size of the client's...

vesicles

You are assessing visual fields on a client newly admitted for eye surgery. The client's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the client has what?

A left temporal hemianopsia

As part of a physical assessment, the nurse performs the confrontation test to assess the client's peripheral vision. Which test result should a nurse recognize as indicating normal peripheral vision for a client using the confrontation test?

The client and the examiner see the examiner's finger at the same time

A client presents to a primary care office with a complaint of double vision (diplopia). On questioning, the client claims to have not suffered any head injuries. Which of the following underlying conditions should the nurse most suspect in this client? Vitamin A deficiency Brain tumor Allergies Viral infection

brain tumor

A nurse shines a light into one eye during ocular exam and the pupil of the other constricts. The nurse interprets this as...

consensual response

A nurse performs an inspection and palpation of the auricle when examining the ear of a client. Which documentation by the nurse demonstrates a normal finding? Nontender, hard tophi Pale blue coloration Ulcerated, crusted nodules Darwin's tubercle

darwins tubercle which is a unique congenital prominence that may be found on the posterior helix of the ear

Which layer of the skin contains blood vessels, nerves, sebaceous glands, lymphatic vessels, hair follicles, and sweat glands?

dermis

The nurse is preparing to test a client's eyes for accommodation. The nurse would have the client focus on an object in which sequence for this test?

far then near

Palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding?

there is an infection in the area that these nodes drain

A client's history reveals that he has been taking oral steroid therapy for several years for the treatment of an autoimmune disorder. During assessment, the nurse would expect the client's skin to have what characteristic?

thinning

A client exhibits many of the most common signs and symptoms of peptic ulcer disease. What interview question addresses the most plausible cause of the client's health problem?

"Do you take painkillers like aspirin on a regular basis?"

Francis is a middle-aged man who noted right sided lower abdominal pain after straining with yardwork. Which of the following findings would make a hernia a more likely diagnosis? Absence of pain with straining Absence of bowel sounds in the scrotum Absence of symmetry of the inguinal areas with straining Absence of a varicocele

Absence of symmetry of the inguinal areas with straining

After teaching a group of students about the external and internal structures of the eye, the instructor determines that the teaching was successful when the students identify which of the following as external structures? Select all that apply. Iris Conjunctiva Lacrimal apparatus Sclera Lens Caruncle

Lacrimal apparatus Conjunctiva Caruncle

A 43-year-old store clerk comes to the office upset because she has found an enlarged lymph node under her left arm. She states she found it yesterday when she was feeling pain under her arm during movement. She states the lymph node is about an inch long and is very painful. She checks her breasts monthly and gets a yearly mammogram (her last was 2 months ago); until now everything has been normal. She states she is so upset because her mother died in her 50s of breast cancer. The client does not smoke, drink, or use illegal drugs. Her father is in good health. Examination shows a tense woman appearing her stated age. Visual inspection of her left axilla reveals a tense red area with no surrounding scarring. On palpation, the examiner feels a 2-cm tender movable lymph node underlying hot skin. Other shoddy nodes are also in the area. Visualization of both breasts is normal. Palpation of her right axilla and both breasts is unremarkable. Examination of the left arm reveals a scabbed-over superficial laceration over her left hand. Upon questioning, the client remembers that she cut her hand gardening last week. What disorder of the axilla is most likely responsible for her symptoms?

Lymphadenopathy of infectious origin

The nurse assigns a nursing diagnosis of fluid volume deficit to an older adult client diagnosed with severe dehydration. Her vital signs are P 120, BP 84/52, respirations 24, and temperature 37.4°C (99.3°F;). Which of the following interventions is appropriate for this client?

Monitor pulse and blood pressure every 15 minutes until stable

A client reports the onset of discomfort and pain in the right upper quadrant of the abdomen after eating. The nurse should assess this finding using which test?

Murphy's Test

A tender painful swelling of the scrotum should suggest

Strangulated inguinal hernia Torsion of the spermatic cord Acute epididymitis

On inspection of a client's penis, the nurse observes a small, silvery-white papule. Which of the following conditions should the nurse suspect in this client?

Syphilitic chancre

Why is it important for the nurse to ask the client what they think caused a skin condition?

The client's perception affects the approach and effectiveness in treating the skin condition

The nurse is assessing the lymph nodes of a client's head and neck. Which anatomical region should nurse palpate to assess the posterior cervical lymph node?

along the edge of the trapezius

An 8-year-old girl comes with her mother for evaluation of hair loss. The girls denies pulling or twisting her hair, and her mother has not noted this behavior at all. She does not put her daughter's hair in braids. Physical examination reveals a clearly demarcated, round patch of hair loss without visible scaling or inflammation. No hair shafts are visible. Based on this description, what is the most likely diagnosis?

alopecia areata

The nurse suspects that a male client may have a hernia. The nurse should further assess the client for

bowel sounds at the buldge

While studying the breast and axillae, students learn that variations in the color of the skin and nipple are primarily influenced by

ethnic background

The rectum is lined with folds of mucosa, and each fold contains a network of arteries, veins, and visceral nerves. When these veins undergo chronic pressure, the result may be

hemorrhoids

The nurse is assessing male genitalia and finds clusters of pimple-like clear vesicles. The nurse recognizes this as what?

herpes

An adolescent present at the free clinic with a collection of fluid in the tunica vaginalis of the testes. The nurse knows that the term that defines this condition is what?

hydrocele

When performing the physical assessment of a client, the nurse notes the presence of a small cyst that contains hair, which is located midline in the sacrococcygeal area and has a palpable sinus tract. How should the nurse document this finding?

pilonidal cyst

The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. Which of the following age-related changes is the nurse likely to have observed?

presbyopia

The nurse is assessing the breasts of a Caucasian woman who has just been diagnosed with Paget disease. What would the nurse expect to find?

red, scaly areolas

The nurse can best palpate the superficial cervical nodes, the deep cervical chain, and the supraclavicular nodes by first locating which muscle?

sternomastoid

A nurse is assessing a male client's abdomen. Which of the following would lead the nurse to suspect a problem? a) Abdominal respiratory movements b) Visible peristaltic waves c) Symmetric appearance d) no bulging with head raising

visible peristaltic waves

A new mother brings her newborn to the clinic. She states that the baby has been having black tarry stools. What could be the cause?

vitamin k deficiency

A nurse performs a comprehensive assessment on a client. The nurse observes the following findings: enlarged hands, feet, and facial features (nose, ears). Which of the following disorders do these findings indicate?

acromegaly

What is presbycusis?

age related hearing loss

The exact cause of benign prostatic hypertrophy (BPH) is unknown, but the condition is believed to be associated with what factors?

age related hormone factors

A woman brings her 1-month-old infant to the ED. She says the baby is not eating or drinking well. The nurse finds the fontanels are depressed slightly. Why does this require further assessment?

could be sign of dehydration

When examining a client's thyroid gland, the nurse ensures that what is readily available?

cup of water

A 68-year-old man comes to the clinic reporting that he is having difficulty obtaining an erection. When reviewing the client's history what might the nurse note that contributes to impotence?

history of hypertension

Upon observation, the nurse documents that a male child's urethral meatus is located on the underside of his penis. What is the term for this structural abnormality?

Hypospadias

The lymph nodes that are responsible for drainage from the arms are the

lateral lymph nodes

Which position should a nurse assist a client to assume to ensure comfort during the examination of the anus, rectum, and prostate of a male client?

left lateral

To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the

left upper quadrant.

A nurse auscultates for bowel sounds on a client admitted for nausea and vomiting and hears no gurgling in the right lower quadrant after 1 minute. What is an appropriate action by the nurse?

listen for 5 minutes

An older client asks why vision is not as sharp as it used to be when the eyes are focused forward. What should the nurse realize this client is describing?

macular degeneration

During the physical examination of a female client, the nurse notes that the client's axillary lymph nodes are enlarged, hard, and fixed. The nurse recognizes that these findings are consistent with what disease process?

malignancy

While interviewing a client who complains of earache, the nurse asks, "Is there anything that makes it better or worse?" The client replies, "It hurts much worse when I wiggle my ear." Which of the following conditions should the nurse most suspect?

otitis externa

The nurse is planning to assess a client's abdomen for rebound tenderness. The nurse should

palpate deeply while quickly releasing pressure.

The conjunctiva of the eye is divided into the...

palpebral portion and the bulbar portion

A client tells the nurse he has been having gray-colored stools after recent travel out of the country to an area with known poor sanitation. The nurse needs to investigate the possibility of which condition?

viral hepatitis

A 55-year-old client is being evaluated for a suspected hearing impairment. Which of the nurse's health interview questions is most likely to yield relevant data? "Are you experiencing any pain in your ears?" "Have you felt any popping sensations in your ears?" "Are you having difficulty hearing high-frequency sounds?" "Do you notice any drainage from your ears?"

"Are you having difficulty hearing high-frequency sounds?"

To palpate an adult client's appendix, the nurse should begin the abdominal assessment at the client's

right lower quadrant

A client reports having chronic discomfort in the upper abdomen. The nurse can be certain that this client is experiencing dyspepsia when which symptoms are present? regurgitation feeling fullness after eating dysphagia epigastric burning satiation early in a meal

- feeling fullness after eating - satiation early in a meal - epigastric burning

A nurse is instructing a client on how to perform testicular self-examination (TSE). Which of the following should the nurse mention? Select all that apply. Roll the testis gently in a horizontal plane between thumb and fingers If one testis is larger than the other, report it to your physician Perform the TSE just before showering Stand in front of a mirror and check for scrotal swelling Perform the TSE once a month Use one hand to palpate the testis

-Perform the TSE once a month -Stand in front of a mirror and check for scrotal swelling -Roll the testis gently in a horizontal plane between thumb and fingers

abdominal assessment order

1. inspection 2. auscultation 3. palpation 4. percussion

Tanner stages for girls

1: prepuberty 8 years 2: breast bud, pubes start to form 9-11 years 3: breast and areola one mound, Acne first appears; armpit hair forms; height increases at its fastest rate 12 years 4: breast and areola secondary mount, first period around 13 years 5: adult pattern around 15

When should a woman conduct self breast examination with respect to her menses (period)?

5-7 days following menses

Which of the following groups has the highest incidence of prostate cancer? Caucasian men African American men Native American men Asian American men

African American men

A nurse is inspecting a client's breasts. The nurse notices that one breast is larger than the other. Which action should the nurse take next?

Ask the client whether the larger breast has increased in size recently

During a prostate examination, the prostate is noted to have a rubbery or boggy glandular consistency. The nurse recognizes that this is what?

BPH

A nurse is preparing to palpate a client's spleen. Which position would the nurse use to facilitate palpation?

right side lying

Rovsing's sign

Pain in RLQ with palpation of LLQ indicative of appendicitis

An adult client has sought care because he has a two-day history of stool that is "black like road tar." How should the nurse best respond to this aspect of the client's history?

Refer the client for treatment of a possible gastrointestinal bleed.

A nurse is examining the breasts of a 75-year-old woman. Which of the following are normal findings in the breasts of an older adult? Select all that apply. Spontaneous discharge Smaller, flatter nipples Peau d'orange skin Nipples that are less erectile on stimulation Pendulous breasts

Smaller, flatter nipples Nipples that are less erectile on stimulation Pendulous breasts

Tanner stages for boys

Stage 1: After the 9th or 10th birthday Stage 2: Around age 11, Pubic hair starts to form Stage 3: Around age 13, Voice begins to change or "crack"; muscles get larger Stage 4: Around age 14, Acne may appear; armpit hair forms Stage 5: Around age 15, Facial hair comes in

Why is it hard to assess the gallbladder?

The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically. Pain is usually in the right upper quadrant and also in the right shoulder

A male patient tells the nurse about experiencing problems with urination. what should the nurse assess in this patient? (Select all that apply.) If there is any blood or semen in the urine The number of times the client voids during the day If there is any pain at the base of the penis If there is any difficulty starting the urine stream If the client has ever been diagnosed with a sexually transmitted infection

a) The number of times the patient voids during the day b) if there is any blood or semen in the urine c) if there is any difficulty starting the urine stream d) if there is any pain at the base of the penis

When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what?

abdominal aortic aneurysm

The nurse suspects an abdominal aortic aneurysm when what is assessed?

abdominal bruit

A 26-year-old woman comes to the clinic complaining of leakage of stool despite generally normal pain-free bowel movements. She denies any blood in her stool or on the toilet paper. She has had no recent episodes of diarrhea. Her past medical history includes a spontaneous vaginal birth 3 months ago. She had a fourth-degree tear of the perineal area (from the vagina through the rectum) that was surgically repaired. A few days later the client developed an abscess in the anal area that had to be incised and drained. She denies using any tobacco, alcohol, or illegal drugs. Her mother and father are both in good health. She denies any weight gain, weight loss, fever, or night sweats. She is still breastfeeding her baby without any problems. Inspection reveals a small opening anterior to the anus with some surrounding erythema. There is not a mass or other inflammation. Digital rectal examination reveals smooth walls with no blood. She has no pain during the rectal examination. Bimanual vaginal examination is also normal. What anal or rectal disorder is the most likely cause of her symptom?

anorectal fistula

When assessing a client during the physical examination of the genitalia, the nurse palpates the scrotal contents. What finding should the nurse recognize as an indication that an infection or cysts are present? Beaded or thickened cord Left testicle is slightly lower than the right Palpable and tortuous veins Smooth, nontender cord

beaded or thickened cord

A 72-year-old retired saleswoman comes to the office with a bloody discharge from her left breast for 3 months. She denies any trauma to her breast. Her past medical history includes high blood pressure and abdominal surgery for colon cancer. Her aunt died of ovarian cancer and her father died of colon cancer. Her mother died of a stroke. The client denies tobacco, alcohol, or drug use. She is a widow and has three healthy children. On examination her breasts are symmetrical with no skin changes. The nurse can express bloody discharge from the client's left nipple. No discrete masses are palpable, but her left axilla has a hard 1-cm fixed node. The remainder or her heart, lung, abdominal, and pelvic examinations are unremarkable. What is the most likely cause of nipple discharge in her circumstance?

breast cancer

During the health interview, the nurse asks a client at what age she began menstruating. This question addresses a risk factor for what health problem?

breast cancer

The nurse observes dimpling in an adult female client's breasts. The nurse should explain to the client that dimpling of the breast may indicate

cancer

The nurse plans to assess an adult client's kidneys for tenderness. The nurse should assess the area at the

costovertebral angle.

A nurse is planning to assess a male client for urethral discharge. Which technique would be best for the nurse to use?

gently squeeze glans between thumb and fingers

The corpora spongiosum extends distally to form the acorn-shaped

glans

A male client is complaining of pain with urination, rectal pain and urethral discharge. The nurse suspects this is what?

gonnorhea

The nurse has discussed the risks for breast cancer with a group of high school seniors. The nurse determines that one of the students needs further instructions when the student says that one risk factor is a family history of breast cancer. consumption of a high-fat diet. having a baby before the age of 20 years. late menopause.

having a baby before the age of 20 years

The nurse notes that a client's left breast feels significantly warmer than the right breast. What should the nurse consider is occurring with this client?

inflammation

The nurse is assessing an adult client's areolas and nipples. What assessment finding would most clearly warrant referral? The client's nipple has recently become inverted. Supernumerary nipples are present. Small Montgomery tubercles are present on the areolas. The client's areola puckers upon palpation.

inverted nipples can signify cancer

A 31-year-old woman has presented to her family physician 3 weeks after giving birth to her first child. The woman complains of exquisitely tender breasts that are reddened on inspection and warm on palpation. The client has a temperature of 37.8°C orally. What diagnosis should be first suspected?

mastitis

The prostate gland consists of two lobes separated by the

median sulcus

What can cause increased breast discharge?

medications, pregnancy, infections, hormones, mammary duct ectasia (blocked duct), prolactinoma, a noncancerous tumor of the pituitary gland, and more

Which of the following is a sign or symptom of benign prostatic hypertrophy (BPH)? Bone pain Fever Nocturia Weight loss

nocturia

When palpating the prostate, the nurse detects a nontender, rubbery prostate with lateral lobes that are 2.5 cm and heart-shaped. The nurse would interpret this finding as...

normal

A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present, and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. How would the nurse document this finding?

positive Rovsing's sign

Montgomery glands secrete

protective lubricant

Layers of the eye

sclera, choroid, retina

Which organ that resides in the abdominal cavity stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes

spleen

A nurse is performing a comprehensive assessment on an older female client. Which of the following observations about the breasts does the nurse determine as abnormal and requiring further assessment? decrease in size unilateral dark discharge flatter, smaller nipples pendulous

unilateral dark discharge

A nurse is examining the breasts of a client. In which quadrant should the nurse most expect to find a tumor?

upper outer quadrant

During a physical examination of an adult client, the nurse is preparing to auscultate the client's abdomen. The nurse should

use the diaphragm of the stethoscope

What is the Braden Scale?

used to assess chance of skin breakdown and ulcer formation

A client voices a concern about a milky discharge coming from her nipples. She is not pregnant and her youngest child is 7 years old. The nurse should ask questions with the understanding that causes of this milky discharge can be related to (Select all that apply.) dopamine agonist drugs Paget disease intraductal papilloma hypothyroidism pituitary prolactinoma

• hypothyroidism • pituitary prolactinoma • dopamine agonist drugs