Exam 4
When palpating a patient's liver, the nurse feels a firm edge. What would this indicate to the nurse? A. Cirrhosis B. Liver failure C. Calcification of the liver D. Splenomegaly
A Abnormal liver findings include hepatomegaly and the firm edge of cirrhosis. A firm edge does not indicate liver failure or calcification. Splenomegaly is a distractor for this question.
The nurse is caring for a 47-year-old Filipino woman, a 55-year-old African American woman, a 65-year-old Caucasian woman, and a 58-year-old Asian woman. Which patient would be at highest risk for late-stage breast cancer? A. Filipino woman B. African American woman C. Caucasian woman D. Asian woman
A Breast cancer is the leading cause of death among Filipino women. This would place her at highest risk and make options B, C, and D incorrect.
Modifiable risk factors for breast cancer include what? A. Obesity B. Age C. Genetics D. Asthma
A It is important for women to be aware of their specific risk factors for breast cancer. Although many factors are not modifiable, some are. When a patient is aware of her own specific risk factors, she may be more diligent in practicing healthy habits (monthly SBEs, yearly physical examinations, and mammograms if indicated) and adjust other personal behaviors (especially physical inactivity and obesity). Asthma is not correlated with breast cancer. Genetics and age are not modifiable risk factors.
When assessing the breasts, it is important for the patient to lift the arms over the head. Why? A. Adds tension to suspensory ligaments B. Eventuates dimpling and retraction C. De-emphasizes suspensory ligament retraction D. Accentuates signs of unilateral nipple inversion
A Lifting the arms over the head adds tension to the suspensory ligaments and accentuates any dimpling or retraction. Lifting of the arms does not accentuate signs of unilateral nipple inversion, nor does it de-emphasize suspensory ligament retraction. Option B is a distracter for this question.
A 47-year-old man comes to the clinic for his annual physical examination. During the nursing assessment, the nurse asks, "Do you have any current or chronic illnesses such as diabetes, hypertension, neurologic impairment, respiratory problems (asthma, COPD, chronic bronchitis), or cardiovascular disease?" Why does the nurse ask this question? A. To assess risk for erectile dysfunction B. To refer the patient to a pulmonologist C. To assess risk for limited range of motion D. To determine the need for involvement from an internist
A Men with diabetes, hypertension, neurologic impairment, respiratory problems (asthma, COPD, chronic bronchitis), or cardiovascular disease are at increased risk for erectile dysfunction. Options B, C, and D are incorrect.
An anatomy and physiology instructor is discussing the functions of the breasts. A student asks about the function of Montgomery's glands. What would be the instructor's best answer? A. "During lactation, they secrete a protective lubricant." B. "They are the lactiferous ducts." C. "They aid in supporting breast tissue." D. "They are lymph nodes in the axillae."
A Small sebaceous glands called Montgomery's glands secrete a protective lubricant when a woman lactates. Montgomery's glands are not lactiferous ducts; they do not aid in the support of breast tissue; they are not lymph nodes in the axillae.
A 16-year-old girl has been brought to the clinic by her mother, who reports that her daughter has a boyfriend with whom she is considering becoming sexually active. What should the nurse do to make the patient as comfortable as possible during the nursing assessment? (Select all that apply.) A. Reassure the patient that all information is kept confidential B. Ask the patient's permission to share information with her parents C. Obtain the history with the patient still dressed D. Be seated at eye level or lower E. Make sure the room is private and comfortable
A, C, D, E When obtaining the history, the room should be private and comfortable, and the nurse should be seated at eye level or lower to the patient. The nurse should reassure the patient that all information is kept confidential. It is best to obtain the history while the patient is still dressed. This reduces embarrassment and vulnerability of the patient. The nurse would not ask the patient for permission to share her information with her parents.
A nurse is teaching a patient about self breast examination. What would the nurse emphasize? (Mark all that apply.) A. Inspection B. Pain C.Timing D.Palpation E. Pallor
A,C,D It is important to guide patients through SBE that emphasizes timing, inspection, and palpation. Pain and pallor are not emphasized when teaching SBE.
A 24-year-old woman presents at the clinic stating, "I think I have a yeast infection." The nurse notes this is the third time in the past 90 days that this patient has been to the clinic for yeast infections. What should the nurse consider as a comorbidity with this patient? A. Maternal DES use B. Diabetes C. Infectious hepatitis A D. Cervical cancer
B A patient with recurring yeast infections should be evaluated for diabetes and HIV. Options A, C, and D are not associated with recurrent yeast infections.
The nurse is conducting an examination of a 27-year-old male's genitalia during his annual physical examination. The patient has an erection and the nurse reassures him that this is a normal physiologic response and continues the examination. Why would the nurse continue with the examination at this time? A. They do not; they wait until the erection is gone B. Stopping could cause further embarrassment C. To demonstrate to the patient that there is nothing to be embarrassed about D. It is better to assess the penis when it is erect
B If the patient has an erection during the physical examination, reassure him that this is a normal physiologic response to touch that he could not have prevented. Do not stop the examination—doing so could cause further embarrassment. This makes options A, C, and D incorrect.
While assessing a 32-year-old woman new to the clinic, the nurse would perform a subjective assessment of what? A. Onset of menstruation 13 years or after B. Exercise C. High-protein, low-carbohydrate diet D. History of breast cancer in second-degree (grandmother) relatives
B Some risk factors that the nurse assesses during subjective data collection are a family history of breast cancer in first-degree relatives (patient's mother and grandmother), early onset of menstruation (age 11 years), bottle feeding of children, obesity, high-fat diet, and lack of exercise. Options A, C, and D are therefore incorrect.
The nurse is caring for a 72-year-old man who has had surgery on his rectum and perineum. What would be an appropriate intervention for this patient? A. Explain the procedure to the patient B. Teach the patient exercises to strengthen the pelvic floor C. Begin discharge planning for this patient D. Teach the patient how to keep the rectum clean
B Teaching the patient exercises to strengthen the pelvic floor will help restore function to the area. It would not be appropriate to explain the procedure to the patient, because the procedure has already been done. Discharge planning begins when the patient is first admitted. The nurse cannot teach the patient how to keep the rectum clean, because the rectum is an internal organ of the body.
A 37-year-old woman is 2 days postoperative after a right breast mastectomy. Included in the discharge teaching is care of the surgical incision. What would be the most appropriate intervention for this patient? A. Provide for a home health nurse to assist in care of the incision B. Provide a mirror to visualize the incision C. Make a referral to the wound care nurse D. Teach signs and symptoms of wound infection
B The nurse would provide a mirror for the patient to visualize tissue and incisions. A home health referral and wound care referral would not be the most appropriate interventions for this patient nor would teaching signs and symptoms of wound infection.
What is the purpose of the rectovaginal examination? A. Palpate the vaginal wall for evidence of a cystocele B. Palpate the vaginal wall for evidence of a rectocele C. Palpate the vaginal wall for evidence of uterine prolapse D. Palpate the vaginal wall for evidence of a urethral caruncle
B This examination is used to evaluate any rectocele (bulging of rectum into the vagina) or rectovaginal fistula (opening between the vagina and the rectum allowing feces to enter the vagina). Therefore, options A, C, and D are incorrect.
A male infant is born with the urethral meatus opening on the underside of the penis. When providing information to the parents, what is the correct terminology to use for this condition? A. Phimosis B. Hypospadias C. Epispadias D. Paraphimosis
B With hypospadias, the urethral meatus opens on the ventral side of the penis. The deviation of the meatus makes it difficult to urinate when standing. The physical appearance of the penis is altered, sometimes causing body image disturbances. Phimosis is when the prepuce cannot be retracted over the glans. Paraphimosis occurs when the retracted prepuce cannot be placed back over the glans. Epispadias occurs when the urethral meatus opens on the dorsal surface of the penis.
A 36-year-old woman presents at the clinic with a grayish vaginal discharge. What should the nurse suspect? A. Candidiasis B. Bacterial vaginosis C. Chlamydia D. Gonorrhea
B Bacterial vaginosis presents with a creamy white to gray secretion that coats the vaginal walls. This finding is not consistent with candidiasis, chlamydia, or gonnorhea.
What does Healthy People have as its focus areas for the GI tract? (Mark all that apply.) A. Constipation and diarrhea B. Colorectal cancer C. Food-borne illness D. Hepatitis E. Gastroenteritis
B,C, D Three areas of Healthy People focus involving the GI system include colorectal cancer, food-borne illness, and hepatitis. Therefore, options A and E are incorrect.
During the examination of a 72-year-old man, the nurse practitioner (NP) notes the patient has a history of BPH. How would the NP expect the prostate gland to feel? A. Tender B. Hard, nodular C. Rubbery D. Firm, nontender
C A rubbery or boggy glandular consistency suggests BPH, a common finding in men older than 60 years. A tender testicle, one that is hard and nodular, or a firm and nontender testicle is not indicative of BPH.
The nurse is admitting a new patient to the floor and asks if the patient has any dizziness. Why does the nurse do this? A. To assess for heart problems B. To assess for pancreatic problems C. To check for possible dehydration D. To check for an absorption problem
C Dizziness may result from possible dehydration linked to inadequate fluid or caloric intake. The heart is not within the abdomen. Pancreatic problems do not cause dizziness. An absorption problem would not cause dizziness in and of itself.
In what Tanner stage is pubic hair darker, coarser, and curled, spreading sparsely over the junction of the mons pubis. A. Stage 1 B. Stage 2 C. Stage 3 D. Stage 4
C In Tanner Stage 3, hair is considerably darker, coarser, and more curled. It spreads sparsely over the junction of the mons pubis. Stage 1 has no pubic hair; Stage 2 has long, slightly pigmented, downy hair that is straight or only slightly curled chiefly along the labia. Stage 4 has pubic hair that is adult in type, but the area covered by it is still considerably smaller than in most adults. There is no spread to the medial surface of the thighs.
A goal of Healthy People is to reduce the proportion of adolescents and adults with chlamydia, gonorrhea, syphilis, genital herpes, pelvic inflammatory disease, and HIV infections. What related health promotion measure would be most important to teach a patient? A. Teach that "the pill" helps guard against STIs B. Provide information on HIV prevention through use of oral contraceptives C. Provide information about oral sex and its risks D. Teach about use of condoms, especially for those in nonmonogamous relationships
C Oral contraceptives do not protect against STIs. Adolescents need information about oral sex and its risks, including transmission of STIs. Condom use is especially important for those not in monogamous relationships.
An emergency department nurse is caring for a 17-year-old patient who has severe pain in the umbilical area. Documentation shows that the patient exhibits "Rovsing's sign." What might this patient's medical diagnosis be? A.Gastroenteritis B. Liver disease C. Appendicitis D. Enlarged spleen
C Rovsing's sign is an indicator of appendicitis. It is not a sign of gastroenteritis, liver disease, or an enlarged spleen.
A clinic nurse is admitting a 16-year-old boy with complaints of itching and burning in his genital area. He tells you "I am sure I have an STI. This will be the third one in 3 months." What intervention would be most appropriate with this patient? A. Provide samples of spermicides to patient B. Provide patient with educational material on testicular cancer C. Assess the patient's knowledge and understanding of safe sexual practices D. Teach the patient correct use of condom to prevent pregnancy
C The nurse needs to assess this patient's knowledge and understanding of safe sexual practices to ensure correct teaching and prevention. Spermicides will not protect the patient from future STIs. The patient's situation does not involve testicular cancer. Although correct condom use could be important, the patient's most immediate problem is recurring STIs, not pregnancy prevention.
Where is the rectum located in a male? A. Inferior to the anus B. At the junction of the sigmoid and transverse colon C. Superior to the anus D. Superior to the rectal ampulla
C The rectum is approximately 12 cm long and is superior to the anus. Therefore, options A, B, and D are incorrect.
Included in the subjective assessment of the breast are the patient's statements about what? (Mark all that apply.) A. Breast size B. Palpation C.Surgeries D. Nipple discharge E. Personal history
C, D, E Subjective data collection begins with the current health history related to the breast (such as breast discomfort, masses or lumps, or nipple discharge) and continues with questions related to past history (previous breast disease; surgeries; menstrual, pregnancy, and lactation history; and past hormone replacement therapy), family history (of breast cancer or other breast disease), and personal history (breast trauma, surgery, and self-care behaviors). Palpation and breast size are not part of subjective data collection.
While auscultating a patient's abdomen, the student notes abnormal bowel sounds. The nurse's preceptor asks the student to describe the sounds. The student describes them as high-pitched, rushing sounds. The preceptor, an experienced nurse, would know that these sounds indicate what? A. Diarrhea B. Adynamic ileus C. Intestinal fluid D. Partial intestinal obstruction
D High-pitched, rushing sounds indicate partial intestinal obstruction. Increased bowel sounds occur with diarrhea and early intestinal obstruction. Decreased bowel sounds occur with adynamic ileus and peritonitis. High-pitched, tinkling bowel sounds indicate intestinal fluid, air under tension in a dilated bowel, and inadequate bowel sounds.
A group of students is giving a presentation about the spleen. What is one of the functions of the spleen? A. Stores albumin B. Produces white blood cells C. Stores vitamin E D. Activates B and T lymphocytes
D The spleen resides in the abdominal cavity and stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes. The spleen does not store albumin or vitamin E, nor does it produce white blood cells.
A nurse is providing patient teaching related to SBE to a 67-year-old woman. When would be the best time during the month for this patient to perform SBE? A. First day of each month B. Last two weeks of month C. First two weeks of month D. A convenient day of each month
D With the cessation of menses, hormonal changes no longer affect the breasts. For this reason, patients can choose a convenient day of each month to perform SBEs (eg, first day of the month). Therefore, options A, B, and C are incorrect.
