Ha Final Exam
52. The nurse is reviewing a patients medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma? a. 6 b. 12 c. 15 d. 24
A 6
During an examination of a child, the nurse considers that physical growth is the best index of a child's: a .General health. b. Genetic makeup. c. Nutritional status. d. Activity and exercise patterns.
A: General health
The nurse has just recorded a positive obturator test on a patient who has abdominal pain. This test is used to confirm a(n): A) inflamed liver. B) perforated spleen. C) perforated appendix. D) enlarged gallbladder.
C
Put the following patient situations in order according to the level of priority. a. A patient newly diagnosed with type 2 diabetes mellitus does not know how to check his own blood glucose levels with a glucometer. b. A teenager who was stung by a bee during a soccer match is having trouble breathing. c. An older adult with a urinary tract infection is also showing signs of confusion and agitation.
1. B = First-level priority problem 2. C = Second-level priority problem 3. A = Third-level priority problem
The nurse is assessing a patient's pulses and notices a difference between the patient's apical pulse and radial pulse. The apical pulse was 118 beats per minute, and the radial pulse was 105 beats per minute. What is the pulse deficit?
13 The nurse should count a serial measurement (one after the other) of the apical pulse and then the radial pulse. Normally, every beat heard at the apex should perfuse to the periphery and be palpable. The two counts should be identical. If they are different, then the nurse should subtract the radial rate from the apical pulse and record the remainder as the pulse deficit.
A patient tells the nurse that she has had abdominal pain for the past week. What would be the nurse's best response? a."Can you point to where it hurts?" b."We'll talk more about that later in the interview." c."What have you had to eat in the last 24 hours?" d."Have you ever had any surgeries on your abdomen
A
A patient's uvula rises midline when she says "ahh" and she has a positive gag reflex. The nurse has just tested which cranial nerves? A) IX, X B) IX, XII C) X, XII D) XI, XII
A
After the health history has been obtained, and before beginning the physical examination, the nurse should ask the patient to first: A) empty the bladder. B) completely disrobe. C) lie on the examination table. D) walk around the room.
A
During an examination, the patient tells the nurse that she sometimes feels as if objects are spinning around her. The nurse would document that she occasionally experiences: A) vertigo. B) tinnitus. C) syncope. D) dizziness.
A
The nurse is asking a patient for his reason for seeking care and asks about the signs and symptoms he is experiencing. Which of these is an example of a symptom? a.Chest pain b.Clammy skin c.Serum potassium level at 4.2 mEq/L d.Body temperature of 100° F
A
The nurse is obtaining a history from a 30-year-old male patient and is concerned about health promotion activities. Which of these questions would be appropriate to use to assess health promotion activities for this patient? a."Do you perform testicular self-examinations?" b."Have you ever noticed any pain in your testicles?" c."Have you had any problems with passing urine?" d."Do you have any history of sexually transmitted diseases?"
A
The nurse is performing a vision examination. Which of these charts is most widely used for vision examinations? A) Snellen B) Shetllen C) Smoollen D) Schwellon
A
The nurse should use which location for eliciting deep tendon reflexes? A) Achilles B) Femoral C) Scapular D) Abdominal
A
A 75-year-old woman is at the office for a preoperative interview. The nurse is aware that the interview may take longer than interviews with younger persons. What is the reason for this? a. An aged person has a longer story to tell. b. An aged person is usually lonely and likes to have someone with whom to talk. c. Aged persons lose much of their mental abilities and require longer time to complete an interview. d. As a person ages, he or she is unable to hear; thus the interviewer usually needs to repeat much of what is said
A An aged person has a longer story to tell.
When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurses best response to this behavior? a. Be silent, and allow him to continue when he is ready. b. Smile at him and say, Dont worry about all of this. Im sure we can find out why youre having these pains. c. Lean back in the chair and ask, You are looking at me kind of funny; there isnt anything wrong, is there? d. Stand up and say, I can see that this interview is uncomfortable for you. We can continue it another time.
A Be silent, and allow him to continue when he is ready.
49. The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)? a. Cerebrum b. Cerebellum c. CNs d. Medulla oblongata
A Cerebrum
The nurse is interviewing a male patient who has a hearing impairment. What techniques would be most beneficial in communicating with this patient? a. Determine the communication method he prefers. b. Avoid using facial and hand gestures because most hearing-impaired people find this degrading. c. Request a sign language interpreter before meeting with him to help facilitate the communication. d. Speak loudly and with exaggerated facial movement when talking with him because doing so will help him lip read.
A Determine the communication method he prefers.
The nurse is performing a health interview on a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation? a. Do you take medicine? b. Do you sterilize the bottles? c. Do you have nausea and vomiting? d. You have been taking your medicine, havent you?
A Do you take medicine?
37. To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate? Ask the child to: a. Hop on one foot. b. Stand on his head. c. Touch his finger to his nose. d. Make funny faces at the nurse.
A Hop on one foot.
46. In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect? a. Hyperreflexia b. Fasciculations c. Loss of muscle tone and flaccidity d. Atrophy and wasting of the muscles
A Hyperreflexia
47. A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual? a. Hyporeflexia b. Increased muscle tone c. Positive Babinski sign d. Presence of pathologic reflexes
A Hyporeflexia
In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding note-taking? a. Note-taking may impede the nurses observation of the patients nonverbal behaviors. b. Note-taking allows the patient to continue at his or her own pace as the nurse records what is said. c. Note-taking allows the nurse to shift attention away from the patient, resulting in an increased comfort level. d. Note-taking allows the nurse to break eye contact with the patient, which may increase his or her level of comfort.
A Note-taking may impede the nurses observation of the patients nonverbal behaviors.
43. During an assessment of a 62-year-old man, the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements. These findings would be consistent with: a. Parkinsonism. b. Cerebral palsy. c. Cerebellar ataxia. d. Muscular dystrophy.
A Parkinsonism.
The sac that surrounds and protects the heart is called the: a. Pericardium. b. Myocardium. c. Endocardium. d. Pleural space.
A Pericardium The pericardium is a tough, fibrous double-walled sac that surrounds and protects the heart. It has two layers that contain a few milliliters of serous pericardial fluid.
The nurse makes which adjustment in the physical environment to promote the success of an interview? a. Reduces noise by turning off televisions and radios b. Reduces the distance between the interviewer and the patient to 2 feet or less c. Provides a dim light that makes the room cozy and helps the patient relax d. Arranges seating across a desk or table to allow the patient some personal space
A Reduces noise by turning off televisions and radios
A female nurse is interviewing a man who has recently immigrated. During the course of the interview, he leans forward and then finally moves his chair close enough that his knees are nearly touching the nurses knees. The nurse begins to feel uncomfortable with his proximity. Which statement most closely reflects what the nurse should do next? a. The nurse should try to relax; these behaviors are culturally appropriate for this person. b. The nurse should discreetly move his or her chair back until the distance is more comfortable, and then continue with the interview. c. These behaviors are indicative of sexual aggression, and the nurse should confront this person about his behaviors. d. The nurse should laugh but tell him that he or she is uncomfortable with his proximity and ask him to move away.
A The nurse should try to relax; these behaviors are culturally appropriate for this person.
38. During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. No associated rigidity is observed with movement. Which of these statements is most accurate? a. These findings are normal, resulting from aging. b. These findings could be related to hyperthyroidism. c. These findings are the result of Parkinson disease. d. This patient should be evaluated for a cerebellar lesion.
A These findings are normal, resulting from aging.
. During a follow-up visit, the nurse discovers that a patient has not been taking his insulin on a regular basis. The nurse asks, Why havent you taken your insulin? Which statement is an appropriate evaluation of this question? a. This question may place the patient on the defensive. b. This question is an innocent search for information. c. Discussing his behavior with his wife would have been better. d. A direct question is the best way to discover the reasons for his behavior.
A This question may place the patient on the defensive.
A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice? a. Trained interpreter b. Male family member c. Female family member d. Volunteer college student from the foreign language studies department
A Trained interpreter
15. During the taking of the health history, a patient tells the nurse that it feels like the room is spinning around me. The nurse would document this finding as: a. Vertigo. b. Syncope. c. Dizziness. d. Seizure activity.
A Vertigo.
As the nurse enters a patients room, the nurse finds her crying. The patient states that she has just found out that the lump in her breast is cancer and says, Im so afraid of, um, you know. The nurses most therapeutic response would be to say in a gentle manner: a. Youre afraid you might lose your breast? b. No, Im not sure what you are talking about. c. Ill wait here until you get yourself under control, and then we can talk. d. I can see that you are very upset. Perhaps we should discuss this later.
A Youre afraid you might lose your breast?
29. The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. The nurses next response should be to: a. Ask the patient to lock her fingers and pull. b. Complete the examination, and then test these reflexes again. c. Refer the patient to a specialist for further testing. d. Document these reflexes as 0 on a scale of 0 to 4+.
A Ask the patient to lock her fingers and pull.
The nurse is preparing for a class on risk factors for hypertension and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world? a. Black b. Whites c. American Indians d. Hispanics
A Black According to the American Heart Association, the prevalence of hypertension is higher among Blacks than in other racial groups.
When assessing the tongue, the examiner should: A) palpate the U-shaped area under the tongue B) check tongue color for cyanosis C) use a tongue blade to elevate the tongue while placing your finger under the jaw D) ask the person to say "ahhh" and note a rise in the midline
A) palpate the U-shaped area under the tongue
The frenulum is: A) the midline fold of tissue that connects the tongue to the floor of the mouth B) the anterior border of the oral cavity C) the arching roof of the mouth D) the free projection hanging down from the middle of the soft palate
A) the midline fold of tissue that connects the tongue to the floor of the mouth
A nasal polyp may be distinguished from the nasal turbinates for 3 of the following reasons. Which is false? A) the polyp is highly vascular B) the polyp is movable C) the polyp is pale gray in color D) the polyp is nontender
A) the polyp is highly vascular
The function of the nasal turbinates is to: A) warm the inhaled air B) detect odors C) stimulate tear formations D) lighten the weight of the skull bones
A) warm the inhaled air
The larges salivary gland is located: A) within the cheeks in the front of the ear B) beneath the mandible at the angle of the jaw C) within the floor of the mouth under the tongue D) at the base of the tongue
A) within the cheeks in the front of the ear
While measuring a patient's blood pressure, the nurse uses the proper technique to obtain an accurate reading. Which of these situations will result in a falsely high blood pressure reading? Select all that apply. a. The person supports his or her own arm during the blood pressure reading. b. The blood pressure cuff is too narrow for the extremity. c. The arm is held above level of the heart. d. The cuff is loosely wrapped around the arm. e. The person is sitting with his or her legs crossed. f. The nurse does not inflate the cuff high enough.
A, B, D, E: A: The person supports his or her own arm during the blood pressure reading. B: The blood pressure cuff is too narrow for the extremity. D: The cuff is loosely wrapped around the arm. E: The person is sitting with his or her legs crossed.
The nurse is performing a digital examination of a patient's prostate gland and notices that a normal prostate gland includes which of the following characteristics? Select all that apply. a.1 cm protrusion into the rectum b.Heart-shaped with a palpable central groove c.Flat shape with no palpable groove d.Boggy with a soft consistency e.Smooth surface, elastic, and rubbery consistency f.Fixed mobility
A, B, E a.1 cm protrusion into the rectum b.Heart-shaped with a palpable central groove e.Smooth surface, elastic, and rubbery consistency The size of a normal prostate gland should be 2.5 cm long by 4 cm wide and should not protrude more than 1 cm into the rectum. The prostate should be heart-shaped, with a palpable central groove, a smooth surface, and elastic with a rubbery consistency. Abnormal findings include a flat shape with no palpable groove, boggy with a soft consistency, and fixed mobility.
The nurse is assessing a patient's headache pain. Which questions reflect one or more of the critical characteristics of symptoms that should be assessed? Select all that apply. a."Where is the headache pain?" b."Did you have these headaches as a child?" c."On a scale of 1 to 10, how bad is the pain?" d."How often do the headaches occur?" e."What makes the headaches feel better?" f."Do you have any family history of headaches?"
A, C, D, E
2. The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husbands personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the __________ lobe. a. Frontal b. Parietal c. Occipital d. Temporal
A. Frontal
11. A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patients deep tendon reflexes? a. Reflexes will be normal. b. Reflexes cannot be elicited. c. All reflexes will be diminished but present. d. Some reflexes will be present, depending on the area of injury.
A. Reflexes will be normal.
The nurse is assessing an 8-year-old child whose growth rate measures below the third percentile for a child his age. He appears significantly younger than his stated age and is chubby with infantile facial features. Which condition does this child have?a. Hypopituitary dwarfism b. Achondroplastic dwarfism c. Marfan syndrome d. Acromegaly
A: Hypopituitary dwarfism
A patient tells the nurse that "all my life I've been called 'knock knees.'" The nurse knows that another term for "knock knees" is: A) genu varum. B) genu valgum. C) pes planus. D) metatarsus adductus.
ANS: genu valgum. Genu valgum is also known as "knock knees" and is present when there is more than 2.5 cm between the medial malleoli when the knees are together.
The uterus is usually positioned tilting forward and superior to the bladder. This position is known as: A) anteverted and anteflexed. B) retroverted and anteflexed. C) retroverted and retroflexed. D) superiorverted and anteflexed.
ANS: A The uterus is freely movable, not fixed, and usually tilts forward and superior to the bladder (a position labeled as anteverted and anteflexed).
When assessing a patient's pulse, the nurse should also notice which of these characteristics? a. Force b. Pallor c. Capillary refill time d. Timing in the cardiac cycle
A: Force
Which technique is correct when the nurse is assessing the radial pulse of a patient? The pulse is counted for: a.1 minute, if the rhythm is irregular. b .15 seconds and then multiplied by 4, if the rhythm is regular. c. 2 full minutes to detect any variation in amplitude. d. 10 seconds and then multiplied by 6, if the patient has no history of cardiac abnormalities.
A: 1 minute, if the rhythm is irregular.
When auscultating the blood pressure of a 25-year-old patient, the nurse notices the phase I Korotkoff sounds begin at 200 mm Hg. At 100 mm Hg, the Korotkoff sounds muffle. At 92 mm Hg, the Korotkoff sounds disappear. How should the nurse record this patient's blood pressure?a. 200/92 b. 200/100 c. 100/200/92 d. 200/100/92
A: 200/92
A student is late for his appointment and has rushed across campus to the health clinic. The nurse should: a. Allow 5 minutes for him to relax and rest before checking his vital signs. b. Check the blood pressure in both arms, expecting a difference in the readings because of his recent exercise. c. Immediately monitor his vital signs on his arrival at the clinic and then 5 minutes later, recording any differences. d. Check his blood pressure in the supine position, which will provide a more accurate reading and will allow him to relax at the same time.
A: Allow 5 minutes for him to relax and rest before checking his vital signs.
A 75-year-old man with a history of hypertension was recently changed to a new antihypertensive drug. He reports feeling dizzy at times. How should the nurse evaluate his blood pressure? a. Blood pressure and pulse should be recorded in the supine, sitting, and standing positions. b. The patient should be directed to walk around the room and his blood pressure assessed after this activity. c. Blood pressure and pulse are assessed at the beginning and at the end of the examination. d. Blood pressure is taken on the right arm and then 5 minutes later on the left arm.
A: Blood pressure and pulse should be recorded in the supine, sitting, and standing positions.
The nurse is performing a general survey. Which action is a component of the general survey? a. Observing the patient's body stature and nutritional status. b. Interpreting the subjective information the patient has reported c. Measuring the patient's temperature, pulse, respirations, and blood pressured. Observing specific body systems while performing the physical assessment
A: Observing the patient's body stature and nutritional status
The nurse knows that one advantage of the tympanic membrane thermometer (TMT) is that: a. Rapid measurement is useful for uncooperative younger children. b. Using the TMT is the most accurate method for measuring body temperature in newborn infants. c. Measuring temperature using the TMT is inexpensive. d. Studies strongly support the use of the TMT in children under the age 6 years.
A: Rapid measurement is useful for uncooperative younger children.
The nurse is preparing to measure the vital signs of a 6-month-old infant. Which action by the nurse is correct? a. Respirations are measured; then pulse and temperature. b. Vital signs should be measured more frequently than in an adult .c. Procedures are explained to the parent, and the infant is encouraged to handle the equipment. d. The nurse should first perform the physical examination to allow the infant to become more familiar with her and then measure the infant's vital signs.
A: Respirations are measured; then pulse and temperature.
The nurse is assessing the vital signs of a 3-year-old patient who appears to have an irregular respiratory pattern. How should the nurse assess this child's respirations? a. Respirations should be counted for 1 full minute, noticing rate and rhythm. b. Child's pulse and respirations should be simultaneously checked for 30 seconds. c. Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his orher respiratory pattern. d. Patient's respirations should be counted for 15 seconds and then multiplied by 4 to obtain the number of respirations per minute.
A: Respirations should be counted for 1 full minute, noticing rate and rhythm.
When evaluating the temperature of older adults, the nurse should remember which aspect about an older adult's body temperature? a. The body temperature of the older adult is lower than that of a younger adult. b. An older adult's body temperature is approximately the same as that of a young child. c. Body temperature depends on the type of thermometer used. d. In the older adult, the body temperature varies widely because of less effective heat control mechanisms.
A: The body temperature of the older adult is lower than that of a younger adult.
To assess a rectal temperature accurately in an adult, the nurse would: a. Use a lubricated blunt tip thermometer. b. Insert the thermometer 2 to 3 inches into the rectum. c. Leave the thermometer in place up to 8 minutes if the patient is febrile d. Wait 2 to 3 minutes if the patient has recently smoked a cigarette.
A: Use a lubricated blunt tip thermometer.
The nurse is examining a 62-year-old man and notes that he has gynecomastia bilaterally. The nurse should explore his history for which related conditions? Select all that apply. a. Malnutrition b. Hyperthyroidism c. Type 2 diabetes mellitus d. Liver disease e. History of alcohol abuse
ANS: Hyperthyroidism Liver disease History of alcohol abuse Gynecomastia occurs with obesity, Cushing's syndrome, liver cirrhosis, adrenal disease, hyperthyroidism, and numerous drugs: alcohol and marijuana use, estrogen treatment for prostate cancer, antibiotics (metronidazole, isoniazid), digoxin, ACE inhibitors, diazepam, and tricyclic antidepressants.
The nurse is preparing to teach a woman about breast self-examination (BSE). Which statement by the nurse is correct? a. "BSE is more important than ever for you because you have never had any children." b. "BSE is so important because one out of nine women will develop breast cancer in her lifetime." c. "BSE on a monthly basis will help you become familiar with your own breasts and feel their normal variations." d. "BSE will save your life because you are likely to find a cancerous lump between mammograms."
ANS: "BSE on a monthly basis will help you feel familiar with your own breasts and their normal variations." The nurse should stress that a regular monthly self-examination will familiarize her with her own breasts and their normal variations. This is a positive step that will reassure her of her healthy state. While teaching, the nurse should focus on the positive aspects of breast self-examination and should avoid citing frightening mortality statistics about breast cancer. This may generate excessive fear and denial that actually obstructs a woman's self-care action.
A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a breast lump in her right breast for years. Recently, it has begun to change in consistency and is becoming harder. She reports that 5 years ago her physician evaluated the lump and determined that it "was nothing to worry about." The examination validates the presence of a mass in the right upper outer quadrant at 1 o'clock, approximately 5 cm from the nipple. It is firm, mobile, nontender, with borders that are not well defined. The nurse's recommendation to her is: a. "Because of the change in consistency of the lump, it should be further evaluated by a physician." b. "The changes could be related to your menstrual cycles. Keep track of the changes in the mass each month." c. "The lump is probably nothing to worry about because it has been present for years and was determined to be noncancerous 5 years ago." d. "Because you are experiencing no pain and the size has not changed, you should continue to monitor the lump and return to the clinic in 3 months."
ANS: "Because of the change in consistency of the lump, it should be further evaluated by a physician." A lump that has been present for years and is not exhibiting changes may not be serious but still should be explored. Any recent change or new lump should be evaluated. The other responses are not correct.
A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, "What happens to my circulation when the veins are removed?" The nurse should reply: A) "Venous insufficiency is a common problem after this type of surgery." B) "Oh, we have lots of veins—you won't even notice that it has been removed." C) "You will probably experience decreased circulation after the veins are removed." D) "Because the deeper veins in your leg are in good condition, this vein can be removed without harming your circulation."
ANS: "Because the deeper veins in your leg are in good condition, this vein can be removed without harming your circulation." As long as the femoral and popliteal veins remain intact, the superficial veins can be excised without harming the circulation. The other responses are not correct.
A 55-year-old postmenopausal woman is being seen in the clinic for a yearly examination. She is concerned about changes in her breasts that she has noticed over the past 5 years. She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem "flat and flabby." The nurse's best reply would be: a. "This change occurs most often because of long-term use of bras that do not provide enough support to the breast tissues." b. "This is a normal change that occurs as women get older and is due to the increased levels of progesterone during the aging process." c. "Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast and is a normal process of aging." d. "Postural changes in the spine make it appear that your breasts have changed in shape. Exercises to strengthen the muscles of the upper back and chest wall will help prevent the changes in elasticity and size."
ANS: "Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast. This is a normal process of aging." The hormonal changes of menopause cause the breast glandular tissue to atrophy, making the breasts more pendulous, flattened, and sagging.
During a discussion about breast self-examination with a 30-year-old woman, which of these statements by the nurse is most appropriate? a. "The best time to examine your breasts is during ovulation." b. "Examine your breasts every month on the same day of the month." c. "Examine your breasts shortly after your menstrual period each month." d. "The best time to examine your breasts is immediately before menstruation."
ANS: "Examine your breasts shortly after your menstrual period each month." The best time to conduct breast self-examination is shortly after the menstrual period when the breasts are the smallest and least congested.
The nurse is describing a weak, thready pulse on the documentation flow sheet. Which statement is correct? A) "Easily palpable, pounds under the fingertips." B) "Greater than normal force, then collapses suddenly." C) "Hard to palpate, may fade in and out, easily obliterated by pressure." D) "Rhythm is regular, but force varies with alternating beats of large and small amplitude."
ANS: "Hard to palpate, may fade in and out, easily obliterated by pressure." A weak, thready pulse is hard to palpate, may fade in and out, and is easily obliterated by pressure. It is associated with decreased cardiac output and peripheral arterial disease.
A 9-year-old girl is in the clinic for a sports physical. After some initial shyness she finally asks, "Am I normal? I don't seem to need a bra yet, but I have some friends who do. What if I never get breasts?" The nurse's best response would be: a. "Don't worry, you still have plenty of time to develop." b. "I know just how you feel, I was a late bloomer myself. Just be patient, and they will grow." c. "You will probably get your periods before you notice any significant growth in your breasts." d. "I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age."
ANS: "I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age." Adolescent breast development usually begins between 8 and 10 years of age. The nurse should not belittle the girl's feelings by using statements like "don't worry" or by sharing personal experiences. The beginning of breast development precedes menarche by about 2 years.
During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's most appropriate response to this would be: a. "Don't worry about the pain; breast cancer is not painful." b. "I would like some more information about the pain in your left breast." c. "Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct." d. "Breast pain is almost always the result of benign breast disease."
ANS: "I would like some more information about the pain in your left breast." Breast pain occurs with trauma, inflammation, infection, or benign breast disease. The nurse will need to gather more information about the patient's pain rather than make statements that ignore the patient's concerns.
During the history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response? 1. "While sitting up, place a cold compress over your nose." 2. "Sit up with your head tilted forward and pinch your nose." 3. "Just let the bleeding stop on its own, but don't blow your nose." 4. "Lie on your back with your head tilted back and pinch your nose."
ANS: 2 "Sit up with your head tilted forward and pinch your nose." With a nosebleed, the person should sit up with the head tilted forward and pinch the nose between the thumb and forefinger for 5 to 15 minutes.
The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement? A) "Lymph flow is propelled by the contraction of the heart." B) "The flow of lymph is slow compared with that of the blood." C) "One of the functions of the lymph is to absorb lipids from the biliary tract." D) "Lymph vessels have no valves, so there is a free flow of lymph fluid from the tissue spaces into the bloodstream."
ANS: "The flow of lymph is slow compared with that of the blood." The flow of lymph is slow compared with that of the blood. Lymph flow is not propelled by the heart, but rather by contracting skeletal muscles, pressure changes secondary to breathing, and by contraction of the vessel walls. Lymph does not absorb lipids from the biliary tract. The vessels do have valves, so flow is one way from the tissue spaces to the bloodstream.
A woman in her 26th week of pregnancy states that she is "not really short of breath" but feels that she is aware of her breathing and the need to breathe. What is the nurse's best reply? a. "The diaphragm becomes fixed during pregnancy, making it difficult to take in a deep breath." b. "The increase in estrogen levels during pregnancy often causes a decrease in the diameter of the rib cage and makes it difficult to breathe." c. "What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong." d. "This increased awareness of the need to breathe is normal as the fetus grows because of the increased oxygen demand on the mother's body, which results in an increased respiratory rate."
ANS: "What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong." During pregnancy, the woman may develop an increased awareness of the need to breathe. Some women may interpret this as dyspnea, even though structurally nothing is wrong. Estrogen increases relax the chest cage ligaments, causing an increase in transverse diameter. The growing fetus does increase the oxygen demand on the mother's body, but this is met easily by the increasing tidal volume (deeper breathing). Little change occurs in the respiratory rate.
The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct? a. "Your breast milk is immediately present after the delivery of your baby." b. "Breast milk is rich in protein and sugars (lactose) but has very little fat." c. "The colostrum, which is present right after birth, does not contain the same nutrients as breast milk." d. "You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy."
ANS: "You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy." After the fourth month, colostrum may be expressed. This thick yellow fluid is the precursor of milk, and it contains the same amount of protein and lactose but practically no fat. The breasts produce colostrum for the first few days after delivery. It is rich with antibodies that protect the newborn against infection, so breastfeeding is important.
A 14-year-old boy who has been diagnosed with Osgood-Schlatter disease reports painful swelling just below the knee for the past 5 months. Which response by the nurse is appropriate? A) "If these symptoms persist, you may need arthroscopic surgery." B) "You are experiencing degeneration of your knee, which may not resolve." C) "Your disease is due to repeated stress on the patellar tendon. It is usually self-limited, and your symptoms should resolve with rest." D) "Increasing your activity and performing knee-strengthening exercises will help to decrease the inflammation and maintain mobility in the knee."
ANS: "Your disease is due to repeated stress on the patellar tendon. It is usually self-limited, and your symptoms should resolve with rest." Osgood-Schlatter disease is painful swelling of the tibial tubercle just below the knee. It is most likely due to repeated stress on the patellar tendon. It is usually self-limited, occurring during rapid growth and most often in males. The symptoms resolve with rest. The other responses are not appropriate.
The nurse is doing an assessment on a 21-year-old patient and notes that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient? 1. "Are you aware of having any allergies?" 2. "Do you have an elevated temperature?" 3. "Have you had any symptoms of a cold?" 4. "Have you been having frequent nosebleeds?"
ANS: 1 "Are you aware of having any allergies?" With chronic allergy, mucosa looks swollen, boggy, pale, and gray.
The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of: 1. AIDS. 2. measles. 3. leukemia. 4. carcinoma.
ANS: 1 AIDS Oral Kaposi's sarcoma is a bruise-like, dark red or violet, confluent macule that usually occurs on the hard palate. It may appear on the soft palate or gingival margin. Oral lesions may be among the earliest lesions to develop with acquired immunodeficiency syndrome.
The nurse is doing an oral assessment on a 40-year-old black patient and notes the presence of a 1-cm, nontender, grayish-white lesion on the left buccal mucosa. Which of the following is true concerning this lesion? 1. This lesion is leukoedema and is common in blacks. 2. This is the result of hyperpigmentation and is normal. 3. This is torus palatinus and would normally only be found in smokers. 4. This type of lesion is indicative of cancer and should be tested immediately.
ANS: 1 This lesion is leukoedema and is common in blacks. Leukoedema, a grayish-white benign lesion occurring on the buccal mucosa, is present more often in blacks than in whites.
When assessing the tongue of an adult, the nurse knows that an abnormal finding would be: 1. a smooth glossy dorsal surface. 2. a thin white coating over the tongue. 3. raised papillae on the dorsal surface. 4. visible venous patterns on the ventral surface.
ANS: 1 a smooth glossy dorsal surface. The dorsal surface of the tongue is normally roughened from papillae. A thin white coating may be present.
During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notes the following: dry mucosa and deep fissures in the tongue. This finding is reflective of: 1. dehydration. 2. irritation by gastric juices. 3. a normal oral assessment. 4. side effects from nausea medication.
ANS: 1 dehydration Dry mouth occurs with dehydration or fever. The tongue has deep vertical fissures.
The salivary gland that is located in the cheek in front of the ear is the: 1. parotid gland. 2. Stenson's gland. 3. sublingual gland. 4. submandibular gland.
ANS: 1 parotid gland. The mouth contains three pairs of salivary glands. The largest, the parotid gland, lies within the cheeks in front of the ear extending from the zygomatic arch down to the angle of the jaw.
When examining an elderly patient, the nurse recognizes that which finding is due to the aging process? 1. Teeth that appear shorter 2. A tongue that looks smoother in appearance 3. Buccal mucosa that is beefy red in appearance 4. A small, painless lump on the dorsum of the tongue
ANS: 2 A tongue that looks smoother in appearance In the aging adult, the tongue looks smoother because of papillary atrophy. The teeth are slightly yellowed and appear longer because of recession of gingival margins.
When using an otoscope to assess the nasal cavity, which of the following would the nurse need to do? 1. Insert the speculum at least 3 cm into the vestibule. 2. Avoid touching the nasal septum with the speculum. 3. Gently displace the nose to the side that is being examined. 4. Keep the speculum tip medial to avoid touching the floor of the nares.
ANS: 2 Avoid touching the nasal septum with the speculum. Insert the apparatus into the nasal vestibule, again avoiding pressure on the sensitive nasal septum.
The nurse is palpating the sinus areas. If the findings are normal, the patient would report which sensation? 1. No sensation 2. Firm pressure 3. Pain during palpation 4. Pain sensation behind eyes
ANS: 2 Firm pressure The person should feel firm pressure but no pain.
In assessing the tonsils of a 30-year-old, the nurse notes that they are involuted, granular in appearance, and appear to have deep crypts. What is correct response to these findings? 1. Refer the patient to a throat specialist. 2. Nothing, this is the appearance of normal tonsils. 3. Continue with assessment looking for any other abnormal findings. 4. Obtain a throat culture on the patient for possible strep infection.
ANS: 2 Nothing, this is the appearance of normal tonsils. The tonsils are the same color as the surrounding mucous membrane, although they look more granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes.
During an oral examination of a 4-year-old American Indian child, the nurse notices that her uvula is partially split. Which of the following statements is accurate? 1. This is a cleft palate and is common in American Indians. 2. This is a bifid uvula, which occurs in some American Indian groups. 3. This is due to an injury and should be reported to the authorities. 4. This is torus palatinus, which occurs frequently in American Indians.
ANS: 2 This is a bifid uvula, which occurs in some American Indian groups. Bifid uvula, a condition in which the uvula is split either completely or partially, occurs in some American Indian groups.
While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border. It is located on the outer third of the lower lip. What other information would be most important for the nurse to assess? 1. Nutritional status 2. When the patient first noticed the lesion 3. Whether the patient has had a recent cold 4. Whether the patient has had any recent exposure to sick animals
ANS: 2 When the patient first noticed the lesion With carcinoma, the initial lesion is round and indurated, and then it becomes crusted and ulcerated with an elevated border. Most cancers occur between the outer and middle thirds of the lip. Any lesion that is still unhealed after 2 weeks should be referred.
A 40-year-old patient who has just finished chemotherapy for breast cancer tells the nurse that she is concerned about her mouth. During the assessment the nurse finds the following: areas of buccal mucosa that are raw and red with some bleeding as well as other areas that have a white, cheesy coating. The nurse recognizes that this abnormality is: 1. carcinoma. 2. candidiasis. 3. leukoplakia. 4. Koplik's spots.
ANS: 2 candidiasis Candidiasis is a white, cheesy, curd-like patch on the buccal mucosa and tongue. It scrapes off, leaving raw, red surface that bleeds easily. It also occurs after the use of antibiotics or corticosteroids and in immunosuppressed persons.
1. The nurse is teaching a health class to high-school-age boys. When discussing the topic of the use of smokeless tobacco (SLT), which of the following statements are accurate? (Select all that apply. 1. One pinch of SLT in the mouth for 30 minutes delivers the equivalent of one cigarette. 2. The use of SLT has been associated with a greater risk of oral cancer than smoking has. 3. Pain is an early sign of oral cancer. 4. Pain is rarely an early sign of oral cancer. 5. Tooth decay is another risk of SLT because of the use of sugar as a sweetener. 6. SLT is considered a healthy alternative to smoking.
ANS: 2, 4, 5 The use of SLT has been associated with a greater risk of oral cancer than smoking has. Pain is rarely an early sign of oral cancer. Tooth decay is another risk of SLT because of the use of sugar as a sweetener. One pinch of SLT in the mouth for 30 minutes delivers the equivalent of three cigarettes; pain is rarely an early sign of oral cancer. Many brands of SLT are sweetened with sugars, promoting tooth decay. SLT is not considered a healthy alternative to smoking, and the use of SLT has been associated with a greater risk of oral cancer than smoking has.
The nurse is assessing a patient in the hospital who has received numerous antibiotics and notes that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? 1. "We need to get a biopsy and see what the cause is." 2. "This is an overgrowth of hair and will go away in a few days." 3. "This is a fungal infection caused by all the antibiotics you've received." 4. "This is probably caused by the same bacteria you had in your lungs."
ANS: 3 "This is a fungal infection caused by all the antibiotics you've received." A black, hairy tongue is not really hair but the elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue. It occurs after the use of antibiotics, which inhibit normal bacteria and allow proliferation of fungus.
When examining the nares of a 45-year-old patient who has complaints of rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notes the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of the following is most likely the cause? 1. Nasal polyps 2. Acute sinusitis 3. Allergic rhinitis 4. Nasal carcinoma
ANS: 3 Allergic rhinitis With allergic rhinitis, rhinorrhea, itching of the nose and eyes, and sneezing are present. On physical examination, there is serous edema, and the turbinates usually appear pale with a smooth, glistening surface.
A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of the following? 1. Epistaxis 2. Agenesis 3. Dysphagia 4. Xerostomia
ANS: 3 Dysphagia Dysphagia is difficulty with swallowing and may occur with a variety of disorders, including stroke and other neurologic diseases.
The nurse is assessing a 3-year-old who is here for "drainage from the nose." On assessment, it is found that there is a purulent drainage from the left nares that has a very foul odor and no drainage from the right nares. The child is afebrile with no other symptoms. What should the nurse do next? 1. Refer to the physician for an antibiotic order. 2. Have the mother bring the child back in 1 week. 3. Perform an otoscopic examination of the left nares. 4. Tell the mother that this is normal for children of this age.
ANS: 3 Perform an otoscopic examination of the left nares. Children are apt to put an object up the nose, producing unilateral purulent drainage and foul odor. Because some risk for aspiration exists, removal should be prompt.
During an oral assessment of a 30-year-old black patient, the nurse notes bluish lips and a dark line along the gingival margin. What would the nurse do in response to this finding? 1. Check the patient's hemoglobin for anemia. 2. Assess for other signs of insufficient oxygen supply. 3. Proceed with assessment, knowing that this is a normal finding. 4. Ask if he has been exposed to an excessive amount of carbon monoxide.
ANS: 3 Proceed with assessment, knowing that this is a normal finding. Black persons normally may have bluish lips.
Immediately after birth, the nurse is unable to suction the nares of a newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What would be the nurse's best response? 1. Attempt to suction again with a bulb syringe. 2. Wait a few minutes and try again once the infant stops crying. 3. Recognize this is a situation that requires immediate intervention. 4. Contact the physician and request assistance when he gets a chance.
ANS: 3 Recognize this is a situation that requires immediate intervention. It is essential to determine patency of the nares in the immediate newborn period because most newborns are obligate nose breathers. Nares blocked with amniotic fluid are suctioned gently with a bulb syringe. If obstruction is suspected, a small lumen (5F to 10F) catheter is passed down each naris to confirm patency. The inability to pass a catheter through the nasal cavity indicates choanal atresia, which needs immediate intervention.
A patient has been diagnosed with strep throat. The nurse is aware that without treatment which complication may occur? 1. Rubella 2. Leukoplakia 3. Rheumatic fever 4. Scarlet fever
ANS: 3 Rheumatic fever Untreated strep throat may lead to rheumatic fever. When performing a health history, ask whether the patient's sore throats were documented as streptococcal.
During an assessment of a 26-year-old at the clinic for "a spot on my lip I think is cancer" the nurse notes the following findings: a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What would be the most appropriate response by the nurse? 1. Tell the patient she will need to see a skin specialist. 2. Discuss the benefits of having a biopsy done of any unusual lesion. 3. Tell the patient this is herpes simplex I and will heal in 4 to 10 days. 4. Tell the patient that this is most likely the result of a riboflavin deficiency and discuss nutrition.
ANS: 3 Tell the patient this is herpes simplex I and will heal in 4 to 10 days. The cold sores are groups of clear vesicles with a surrounding erythematous base. These evolve into pustules or crusts and heal in 4 to 10 days. The most likely site is the lip-skin junction. Infection often recurs in the same site. It may be precipitated by sunlight, fever, colds, or allergy.
A 10-year-old is at the clinic for "a sore throat lasting 6 days." The nurse is aware that which of the following would be consistent with an acute infection? 1. Tonsils 1+/1-4+ and pink 2. Tonsils 2+/1-4+ with small plugs of white debris 3. Tonsils 3+/1-4+ with large white spots 4. Tonsils 3+/1-4+ with yellowish exudate
ANS: 3 Tonsils 3+/1-4+ with large white spots With an acute infection, tonsils are bright red and swollen and may have exudate or large white spots. Tonsils are enlarged to 2+, 3+, or 4+ with an acute infection.
During an assessment of an 80-year-old patient, the nurse would expect to find: 1. hypertrophy of the gums. 2. an increased production of saliva. 3. a decreased ability to identify odors. 4. finer and less prominent nasal hair.
ANS: 3 a decreased ability to identify odors. The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers.
A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. The nurse recognizes that this patient has: 1. posterior epistaxis. 2. frontal sinusitis. 3. maxillary sinusitis. 4. nasal polyps.
ANS: 3 maxillary sinusitis. Signs include facial pain, after upper respiratory infection, red swollen nasal mucosa, swollen turbinates, and purulent discharge. Person also has fever, chills, and malaise. With maxillary sinusitis, dull throbbing pain occurs in cheeks and teeth on the same side, and pain with palpation is present. With frontal sinusitis, pain is above the supraorbital ridge
The projections in the nasal cavity that increase the surface area are called the: 1. meatus. 2. septum. 3. turbinates. 4. Kiesselbach's plexus.
ANS: 3 turbinates The lateral walls of each nasal cavity contain three parallel bony projections: the superior, middle, and inferior turbinates. They increase the surface area so that more blood vessels and mucous membrane are available to warm, humidify, and filter the inhaled air.
Which of the following is true in relation to a newborn infant? 1. The sphenoid sinuses are full size at birth. 2. The maxillary sinuses reach full size after puberty. 3. The frontal sinuses are fairly well developed at birth. 4. The maxillary and ethmoid sinuses are the only ones present at birth.
ANS: 4 The maxillary and ethmoid sinuses are the only ones present at birth. Only the maxillary and ethmoid sinuses are present at birth.
A 72-year-old patient has a history of hypertension and chronic lung disease. An important question for the nurse to include in the history would be: 1. "Do you use a fluoride supplement?" 2. "Have you had tonsillitis in the last year?" 3. "At what age did you get your first tooth?" 4. "Have you noticed any dryness in your mouth?"
ANS: 4 "Have you noticed any dryness in your mouth?" Xerostomia (dry mouth) is a side effect of many drugs used by older people: antidepressants, anticholinergics, antispasmodics, antihypertensives, antipsychotics, bronchodilators.
While obtaining a history from the mother of a 1-year-old, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, "it makes a great pacifier." The best response by the nurse would be: 1. "You're right, bottles make very good pacifiers." 2. "Use of a bottle is better for the teeth than thumb sucking." 3. "It's okay to do this as long as the bottle contains milk and not juice." 4. "Prolonged use of a bottle can increase the risk for tooth decay and ear infections."
ANS: 4 "Prolonged use of a bottle can increase the risk for tooth decay and ear infections." Prolonged use of a bottle during the day or when going to sleep places the infant at risk for tooth decay and middle ear infections.
A 32-year-old woman is at the clinic for "little white bumps in my mouth." During the assessment, the nurse notes that she has a 0.5 cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient? 1. "These spots are seen with infections such as strep throat." 2. "These could be indicative of a serious lesion, so I will refer you to a specialist." 3. "This is called leukoplakia and can be caused by chronic irritation such as smoking." 4. "These bumps are Fordyce's granules, which are sebaceous cysts and not a serious condition."
ANS: 4 "These bumps are Fordyce's granules, which are sebaceous cysts and not a serious condition." Fordyce's granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and not significant.
A mother brings her 4-month-old to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notes a 0.5-cm, fleshy, elevated area in the middle of the upper lip. There is no evidence of inflammation or drainage. What would the nurse tell this mother? 1. "This is an area of irritation caused from teething and is nothing to worry about." 2. "This is an abnormal finding and should be evaluated by another health care provider." 3. "This is the result of chronic drooling and should resolve within the next month or two." 4. "This is a sucking tubercle caused from the friction of breast- or bottle-feeding and is normal."
ANS: 4 "This is a sucking tubercle caused from the friction of breast- or bottle-feeding and is normal." A normal finding in infants is the sucking tubercle, a small pad in the middle of the upper lip from the friction of breast- or bottle-feeding.
During a check-up, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also notes that it does not work as well as it used to when she started using it. The best response by the nurse would be: 1. "You should never use over-the-counter nasal sprays because of the risk of addiction." 2. "You should try switching to another brand of medication to prevent this problem." 3. "It is important to keep using this spray to keep your allergies under control." 4. "Using these nasal medications irritates the lining of the nose and may cause rebound swelling."
ANS: 4 "Using these nasal medications irritates the lining of the nose and may cause rebound swelling." Misuse of over-the-counter nasal medications irritates the mucosa, causing rebound swelling, a common problem.
When assessing the tongue of an adult, the nurse knows that an abnormal finding would be: 1. A painful vesicle inside the cheek for 2 days 2. The presence of moist, nontender Stenson's ducts 3. Stippled gingival margins that adhere snugly to the teeth 4. An ulceration on the side of the tongue with rolled edges.
ANS: 4 An ulceration on the side of the tongue with rolled edges. An ulceration on the side, base, or under the tongue raises the suspicion of cancer and must be investigated. Risk of early metastasis is present because of rich lymphatic drainage.
Which of the following best describes the test the nurse should use to assess the function of cranial nerve X? 1. Observe the patient's ability to articulate specific words. 2. Assess movement of the hard palate and uvula with the gag reflex. 3. Have the patient stick out the tongue and observe for tremors or pulling to one side. 4. Ask the patient to say "ahhh" and watch for movement of the soft palate and uvula.
ANS: 4 Ask the patient to say "ahhh" and watch for movement of the soft palate and uvula. Ask the person to say "ahhh" and note that the soft palate and uvula rise in the midline. This tests one function of CN X, the vagus nerve.
The tissue that connects the tongue to the floor of the mouth is the: 1. uvula. 2. palate. 3. papillae. 4. frenulum.
ANS: 4 frenulum. The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth.
When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale? A) 2 B) 3 C) 4 D) 5
ANS: 5 Complete range of motion against gravity is normal muscle strength and is recorded as Grade 5 muscle strength.
Of the 33 vertebrae in the spinal column, there are: A) 5 lumbar. B) 5 thoracic. C) 7 sacral. D) 12 cervical.
ANS: 5 lumbar. There are 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 3 to 4 coccygeal vertebrae.
What is the pulse pressure for a patient whose blood pressure is 158/96 mm Hg and whose pulse rate is 72 beats per minute?
ANS: 62
The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place them at a higher risk for breast cancer? a. 37 year old who is slightly overweight b. 42 year old who has had ovarian cancer c. 45 year old who has never been pregnant d. 65 year old whose mother had breast cancer
ANS: 65 year old whose mother had breast cancer Risk factors for breast cancer include having a first-degree relative with breast cancer (mother, sister, or daughter) and being older than 50 years. Refer to Table 17- 2 for other risk factors.
23. A patient is at the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should: a. Collect a follow-up data base and then check her blood pressure. b. Ask her to read her health record and indicate any changes since her last visit. c. Check only her blood pressure because her complete health history was documented 2 months ago. d. Obtain a complete health history before checking her blood pressure because much of her history information may have changed.
ANS: A A follow-up data base is used in all settings to follow up short-term or chronic health problems. The other responses are not appropriate for the situation.
24. The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal? a. High-tone frequency loss b. Increased elasticity of the pinna c. Thin, translucent membrane d. Shiny, pink tympanic membrane
ANS: A A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging. The pinna loses elasticity, causing earlobes to be pendulous. The eardrum may be whiter in color and more opaque and duller in the older person than in the younger adult.
11. The nurse knows that developing appropriate nursing interventions for a patient relies on the appropriateness of the __________ diagnosis. a. Nursing b. Medical c. Admission d. Collaborative
ANS: A An accurate nursing diagnosis provides the basis for the selection of nursing interventions to achieve outcomes for which the nurse is accountable. The other items do not contribute to the development of appropriate nursing interventions.
29. When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. The preliminary analysis based on this information is that the child:a. Most likely has serous otitis media. b. Has an acute purulent otitis media. c. Has evidence of a resolving cholesteatoma. d. Is experiencing the early stages of perforation.
ANS: A An amber-yellow color to the tympanic membrane suggests serum or pus in the middle ear. Air or fluid or bubbles behind the tympanic membrane are often visible. The patient may have feelings of fullness, transient hearing loss, and a popping sound with swallowing. These findings most likely suggest that the child has serous otitis media. The other responses are not correct.
15. Barriers to incorporating EBP include: a. Nurses lack of research skills in evaluating the quality of research studies. b. Lack of significant research studies. c. Insufficient clinical skills of nurses. d. Inadequate physical assessment skills.
ANS: A As individuals, nurses lack research skills in evaluating the quality of research studies, are isolated from other colleagues who are knowledgeable in research, and often lack the time to visit the library to read research. The other responses are not considered barriers.
11. A woman who has lived in the United States for a year after moving from Europe has learned to speak English and is almost finished with her college studies. She now dresses like her peers and says that her family in Europe would hardly recognize her. This nurse recognizes that this situation illustrates which concept? a. Assimilation b. Heritage consistency c. Biculturalism d. Acculturation
ANS: A Assimilation is the process by which a person develops a new cultural identity and becomes like members of the dominant culture. This concept does not reflect heritage consistency. Biculturalism is a dual pattern of identification; acculturation is the process of adapting to and acquiring another culture.
17. While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would the nurse want to include in the history? a. Does your baby seem to startle with loud noises? b. Has your baby had any surgeries on her ears? c. Have you noticed any drainage from her ears? d. How many ear infections has your baby had since birth?
ANS: A Children at risk for a hearing deficit include those exposed in utero to a variety of conditions, such as maternal rubella or to maternal ototoxic drugs.
26. A 30-year-old woman has recently moved to the United States with her husband. They are living with the womans sister until they can get a home of their own. When company arrives to visit with the womans sister, the woman feels suddenly shy and retreats to the back bedroom to hide until the company leaves. She explains that her reaction to guests is simply because she does not know how to speak perfect English. This woman could be experiencing: a. Culture shock. b. Cultural taboos. c. Cultural unfamiliarity. d. Culture disorientation.
ANS: A Culture shock is a term used to describe the state of disorientation or inability to respond to the behavior of a different cultural group because of its sudden strangeness, unfamiliarity, and incompatibility with the individuals perceptions and expectations. The other terms are not correct.
11. A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for complaints of burning and pain during urination. He is experiencing: a. Dysuria. b. Nocturia. c. Polyuria. d. Hematuria.
ANS: A Dysuria (burning with urination) is common with acute cystitis, prostatitis, and urethritis. Nocturia is voiding during the night. Polyuria is voiding in excessive quantities. Hematuria is voiding with blood in the urine.
13. A newly admitted patient is in acute pain, has not been sleeping well lately, and is having difficulty breathing. How should the nurse prioritize these problems? a. Breathing, pain, and sleep b. Breathing, sleep, and pain c. Sleep, breathing, and pain d. Sleep, pain, and breathing
ANS: A First-level priority problems are immediate priorities, remembering the ABCs (airway, breathing, and circulation), followed by second-level problems, and then third-level problems.
33. The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which one of these reflects the correct procedure? a. Pulling the pinna down b. Pulling the pinna up and back c. Slightly tilting the childs head toward the examiner d. Instructing the child to touch his chin to his chest
ANS: A For an otoscopic examination on an infant or on a child under 3 years of age, the pinna is pulled down. The other responses are not part of the correct procedure.
5. When reviewing the demographics of ethnic groups in the United States, the nurse recalls that the largest and fastest growing population is: a. Hispanic. b. Black. c. Asian. d. American Indian.
ANS: A Hispanics are the largest and fastest growing population in the United States, followed by Asians, Blacks, American Indians and Alaska natives, and other groups.
The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. On examination, the nurse expects to find: a. Lesions that run together. b. Annular lesions that have grown together. c. Lesions arranged in a line along a nerve route. d. Lesions that are grouped or clustered together.
ANS: A Confluent lesions (as with urticaria [hives]) run together. Grouped lesions are clustered together. Annular lesions are circular in nature. Zosteriform lesions are arranged along a nerve route.
25. The nurse recognizes that working with children with a different cultural perspective may be especially difficult because: a. Children have spiritual needs that are influenced by their stages of development. b. Children have spiritual needs that are direct reflections of what is occurring in their homes. c. Religious beliefs rarely affect the parents perceptions of the illness. d. Parents are often the decision makers, and they have no knowledge of their childrens spiritual needs.
ANS: A Illness during childhood may be an especially difficult clinical situation. Children, as well as adults, have spiritual needs that vary according to the childs developmental level and the religious climate that exists in the family. The other statements are not correct.
10. An older man is concerned about his sexual performance. The nurse knows that in the absence of disease, a withdrawal from sexual activity later in life may be attributable to: a. Side effects of medications. b. Decreased libido with aging. c. Decreased sperm production. d. Decreased pleasure from sexual intercourse.
ANS: A In the absence of disease, a withdrawal from sexual activity may be attributable to side effects of medications such as antihypertensives, antidepressants, sedatives, psychotropics, antispasmotics, tranquilizers or narcotics, and estrogens. The other options are not correct.
6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as: a. Intuition. b. The nursing process. c. Clinical knowledge. d. Diagnostic reasoning.
ANS: A Intuition is characterized by pattern recognitionexpert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. The other options are not correct.
17. When performing a genitourinary assessment, the nurse notices that the urethral meatus is ventrally positioned. This finding is: a. Called hypospadias. b. A result of phimosis. c. Probably due to a stricture. d. Often associated with aging.
ANS: A Normally, the urethral meatus is positioned just about centrally. Hypospadias is the ventral location of the urethral meatus. The position of the meatus does not change with aging. Phimosis is the inability to retract the foreskin. A stricture is a narrow opening of the meatus.
1. After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be: a. Objective. b. Reflective. c. Subjective. d. Introspective.
ANS: A Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. Subjective data is what the person says about him or herself during history taking. The terms reflective and introspective are not used to describe data.
12. A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of a television or radio. The most likely cause of his hearing loss is: a. Otosclerosis. b. Presbycusis. c. Trauma to the bones. d. Frequent ear infections.
ANS: A Otosclerosis is a common cause of conductive hearing loss in young adults between the ages of 20 and 40 years. Presbycusis is a type of hearing loss that occurs with aging. Trauma and frequent ear infections are not a likely cause of his hearing loss.
32. The nurse is inspecting the scrotum and testes of a 43-year-old man. Which finding would require additional follow-up and evaluation? a. Skin on the scrotum is taut. b. Left testicle hangs lower than the right testicle. c. Scrotal skin has yellowish 1-cm nodules that are firm and nontender. d. Testes move closer to the body in response to cold temperatures.
ANS: A Scrotal swelling may cause the skin to be taut and to display pitting edema. Normal scrotal skin is rugae, and asymmetry is normal with the left scrotal half usually lower than the right. The testes may move closer to the body in response to cold temperatures.
6. A male patient with possible fertility problems asks the nurse where sperm is produced. The nurse knows that sperm production occurs in the: a. Testes. b. Prostate. c. Epididymis. d. Vas deferens.
ANS: A Sperm production occurs in the testes, not in the other structures listed.
1. The nurse needs to pull the portion of the ear that consists of movable cartilage and skin down and back when administering eardrops. This portion of the ear is called the: a. Auricle. b. Concha. c. Outer meatus. d. Mastoid process.
ANS: A The external ear is called the auricle or pinna and consists of movable cartilage and skin.
17. Illness is considered part of lifes rhythmic course and is an outward sign of disharmony within. This statement most accurately reflects the views about illness from which theory? a. Naturalistic b. Biomedical c. Reductionist d. Magicoreligious
ANS: A The naturalistic perspective states that the laws of nature create imbalances, chaos, and disease. From the perspective of the Chinese, for example, illness is not considered an introducing agent; rather, illness is considered a part of lifes rhythmic course and an outward sign of disharmony within. The other options are not correct.
7. The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction? a. Air conduction is the normal pathway for hearing. b. Vibrations of the bones in the skull cause air conduction. c. Amplitude of sound determines the pitch that is heard. d. Loss of air conduction is called a conductive hearing loss.
ANS: A The normal pathway of hearing is air conduction, which starts when sound waves produce vibrations on the tympanic membrane. Conductive hearing loss results from a mechanical dysfunction of the external or middle ear. The other statements are not true concerning air conduction.
6. During an assessment, the nurse notices that a patient is handling a small charm that is tied to a leather strip around his neck. Which action by the nurse is appropriate? a. Ask the patient about the item and its significance. b. Ask the patient to lock the item with other valuables in the hospitals safe. c. Tell the patient that a family member should take valuables home. d. No action is necessary.
ANS: A The nurse should inquire about the amulets meaning. Amulets, such as charms, are often considered an important means of protection from evil spirits by some cultures
During inspection of a patient's face, the nurse notices that the facial features are symmetric. This finding indicates that which cranial nerve is intact? A) VII B) IX C) XI D)XII
ANS: A Cranial nerve VII is responsible for facial symmetry. Page: 766
14. Which of these statements is most appropriate when the nurse is obtaining a genitourinary history from an older man? a. Do you need to get up at night to urinate? b. Do you experience nocturnal emissions, or wet dreams? c. Do you know how to perform a testicular self-examination? d. Has anyone ever touched your genitals when you did not want them to?
ANS: A The older male patient should be asked about the presence of nocturia. Awaking at night to urinate may be attributable to a diuretic medication, fluid retention from mild heart failure or varicose veins, or fluid ingestion 3 hours before bedtime, especially coffee and alcohol. The other questions are more appropriate for younger men.
3. The patients record, laboratory studies, objective data, and subjective data combine to form the: a. Data base. b. Admitting data. c. Financial statement. d. Discharge summary.
ANS: A Together with the patients record and laboratory studies, the objective and subjective data form the data base. The other items are not part of the patients record, laboratory studies, or data.
23. The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? The infant: a. Turns his or her head to localize the sound. b. Shows no obvious response to the noise. c. Shows a startle and acoustic blink reflex. d. Stops any movement, and appears to listen for the sound.
ANS: A With a loud sudden noise, the nurse should notice the infant turning his or her head to localize the sound and to respond to his or her own name. A startle reflex and acoustic blink reflex is expected in newborns; at age 3 to 4 months, the infant stops any movement and appears to listen.
38. During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, It feels like the room is spinning! The nurse notices that the patient is experiencing: a. Objective vertigo. b. Subjective vertigo. c. Tinnitus. d. Dizziness.
ANS: A With objective vertigo, the patient feels like the room spins; with subjective vertigo, the person feels like he or she is spinning. Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders. Dizziness is not the same as true vertigo; the person who is dizzy may feel unsteady and lightheaded.
39. During a physical examination, the nurse finds that a male patients foreskin is fixed and tight and will not retract over the glans. The nurse recognizes that this condition is: a. Phimosis. b. Epispadias. c. Urethral stricture. d. Peyronie disease.
ANS: A With phimosis, the foreskin is nonretractable, forming a pointy tip of the penis with a tiny orifice at the end of the glans. The foreskin is advanced and so tight that it is impossible to retract over the glans. This condition may be congenital or acquired from adhesions related to infection. (See Table 24-3 for information on urethral stricture. See Table 24-4 for information on epispadias and Peyronie disease.)
15. An Asian-American woman is experiencing diarrhea, which is believed to be cold or yin. The nurse expects that the woman is likely to try to treat it with: a. Foods that are hot or yang. b. Readings and Eastern medicine meditations. c. High doses of medicines believed to be cold. d. No treatment is tried because diarrhea is an expected part of life.
ANS: A Yin foods are cold and yang foods are hot. Cold foods are eaten with a hot illness, and hot foods are eaten with a cold illness. The other explanations do not reflect the yin/yang theory.
A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because: a. The woman could be at increased risk for infection and lesions because of her chronic disease. b. With her diabetes, she has increased circulation to her foot, and it could cause severe bleeding. c. She is 75 years old and is unable to see; consequently, she places herself at greater risk for self-injury with the scissors. d. With her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely.
ANS: A A personal history of diabetes and peripheral vascular disease increases a person's risk for skin lesions in the feet or ankles. The patient needs to seek a professional for assistance with corn removal.
34. The nurse is reviewing statistics for lactose intolerance. In the United States, the incidence of lactose intolerance is higher in adults of which ethnic group? A) African-Americans B) Hispanics C) Whites D) Asians
ANS: A A recent study found lactose-intolerance prevalence estimates as follows: 19.5% for African-Americans, 10% for Hispanics, and 7.72% for whites
A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding? a. Color variation b. Border regularity c. Symmetry of lesions d. Diameter of less than 6 mm
ANS: A Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.
19. A nurse notices that a patient has ascites, which indicates the presence of: A) fluid. B) feces. C) flatus. D) fibroid tumors.
ANS: A Ascites is free fluid in the peritoneal cavity, and occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.
During a speculum inspection of the vagina, the nurse would expect to see what at the end of the vaginal canal? A) Cervix B) Uterus C) Ovaries D) Fallopian tubes
ANS: A At the end of the canal, the uterine cervix projects into the vagina
While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition? a. Heart failure b. Venous thrombosis c. Local inflammation d. Blockage of lymphatic drainage
ANS: A Bilateral edema or edema that is generalized over the entire body is caused by a central problem such as heart failure or kidney failure. Unilateral edema usually has a local or peripheral cause.
When assessing a newborn infant's genitalia, the nurse notices that the genitalia are somewhat engorged. The labia majora are swollen, the clitoris looks large, and the hymen is thick. The vaginal opening is difficult to visualize. The infant's mother states that she is worried about the labia being swollen. The nurse should reply: A) "This is a normal finding in newborns and should resolve within a few weeks." B) "This could indicate an abnormality and may need to be evaluated by a physician." C) "We will need to have estrogen levels evaluated to make sure that they are within normal limits." D) "We will need to keep close watch over the next few days to see if the genitalia decrease in size."
ANS: A It is normal for a newborn's genitalia to be somewhat engorged. A sanguineous vaginal discharge or leukorrhea is normal during the first few weeks because of the maternal estrogen effect. During the early weeks, the genital engorgement resolves, and the labia minora atrophy and remain small until puberty.
During an examination, which tests will the nurse collect to screen for cervical cancer? A) Endocervical specimen, cervical scrape, and vaginal pool B) Endocervical specimen, vaginal pool, and acetic acid wash C) Endocervical specimen, KOH preparation, and acetic acid wash D) Cervical scrape, acetic acid wash, saline mount ("wet prep")
ANS: A Laboratories may vary in method, but usually the test consists of three specimens: endocervical specimen, cervical scrape, and vaginal pool. The other tests (acetic acid wash, KOH preparation, and saline mount) are used to test for sexually transmitted infections
A woman is in the clinic for an annual gynecologic examination. The nurse should plan to begin the interview with the: A) menstrual history because it is generally nonthreatening. B) obstetric history because it is the most important information. C) urinary system history because there may be problems in this area as well. D) sexual history because it will build rapport to discuss this first.
ANS: A Menstrual history is usually nonthreatening; thus it is a good place to start. Obstetric, urinary, and sexual histories are also part of the interview but not necessarily the best topics with which to start.
The nurse is preparing to interview a postmenopausal woman. Which of these statements is true with regard to the history of a postmenopausal woman? A) The nurse should ask a postmenopausal woman if she ever has vaginal bleeding. B) Once a woman reaches menopause, the nurse does not need to ask any further history questions. C) The nurse should screen for monthly breast tenderness. D) Postmenopausal women are not at risk for contracting sexually transmitted infections and thus these questions can be omitted.
ANS: A Postmenopausal bleeding warrants further workup and referral. The other statements are not true.
When performing an external genitalia examination of a 10-year-old girl, the nurse notices that there is no pubic hair, and the mons and the labia are covered with fine vellus hair. These findings are consistent with stage _____ of sexual maturity, according to the Sexual Maturity Rating scale. A) 1 B) 2 C) 3 D) 4
ANS: A Sexual Maturity Rating stage 1 is the preadolescent stage. There is no pubic hair. The mons and labia are covered with fine, vellus hair as on the abdomen. See Table 26-1.
An 11-year-old girl is in the clinic for a sports physical. The nurse notices that she has begun to develop breasts, and during the conversation the girl reveals that she is worried about her development. The nurse should use which of these techniques to best assist the young girl in understanding the expected sequence for development? The nurse should: A) use the Tanner's table on the five stages of sexual development. B) describe her development and compare it with that of other girls her age. C) use Jacobsen's table on expected development on the basis of height and weight data. D) reassure her that her development is within normal limits and should tell her not to worry about the next step.
ANS: A Tanner's table on the five stages of pubic hair development is helpful in teaching girls the expected sequence of sexual development (see Table 26-1). The other responses are not appropriate.
The nurse is examining a patient who tells the nurse, "I sure sweat a lot, especially on my face and feet but it doesn't have an odor." The nurse knows that this condition could be related to: a. Eccrine glands. b. Apocrine glands. c. Disorder of the stratum corneum. d. Disorder of the stratum germinativum.
ANS: A The eccrine glands are coiled tubules that directly open onto the skin surface and produce a dilute saline solution called sweat. Apocrine glands are primarily located in the axillae, anogenital area, nipples, and naval area and mix with bacterial flora to produce the characteristic musky body odor. The patient's statement is not related to disorders of the stratum corneum or the stratum germinativum.
During an examination the nurse observes a female patient's vestibule and expects to see the: A) urethral meatus and vaginal orifice. B) vaginal orifice and vestibular (Bartholin) glands. C) urethral meatus and paraurethral (Skene) glands. D) paraurethral (Skene) and vestibular (Bartholin) glands.
ANS: A The labial structures encircle a boat-shaped space, or cleft, termed the vestibule. Within it are numerous openings. The urethral meatus and vaginal orifice are visible. The ducts of the paraurethral (Skene) glands and the vestibular (Bartholin) glands are present but not visible.
1. The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? A) Dullness B) Tympany C) Resonance D) Hyperresonance
ANS: A The liver is located in the right upper quadrant and would elicit a dull percussion note
30. Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites? A) Dullness across the abdomen B) Flatness in the right upper quadrant C) Hyperresonance in the left upper quadrant D) Tympany in the right and left lower quadrants
ANS: A The presence of fluid causes a dull sound to percussion. A large amount of ascitic fluid would produce a dull sound to percussion
33. When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved? A) Spleen B) Sigmoid colon C) Appendix D) Gallbladder
ANS: A The spleen is located in the left upper quadrant of the abdomen. The gallbladder is in the right upper quadrant, the sigmoid colon is in the left lower quadrant, and the appendix is in the right lower quadrant
36. During report, the student nurse hears that a patient has "hepatomegaly" and recognizes that this term refers to: A) an enlarged liver. B) an enlarged spleen. C) distended bowel. D) excessive diarrhea.
ANS: A The term hepatomegaly refers to an enlarged liver. The term splenomegaly refers to an enlarged spleen. The other responses are not correct.
The nurse is reviewing the changes that occur with menopause. Which of these are changes associated with menopause? A) Uterine and ovarian atrophy along with thinning vaginal epithelium B) Ovarian atrophy, increased vaginal secretions, and increasing clitoral size C) Cervical hypertrophy, ovarian atrophy, and increased acidity of vaginal secretions D) Vaginal mucosa fragility, increased acidity of vaginal secretions, and uterine hypertrophy
ANS: A The uterus shrinks because of its decreased myometrium. The ovaries atrophy to 1 to 2 cm and are not palpable after menopause. The sacral ligaments relax, and the pelvic musculature weakens, so the uterus droops. The cervix shrinks and looks paler with a thick glistening epithelium. The vaginal epithelium atrophies, becoming thinner, drier, and itchy. The vaginal pH becomes more alkaline, and secretions are decreased. This results in a fragile mucosal surface that is at risk for bleeding and vaginitis.
During a vaginal examination of a 38-year-old woman, the nurse notices that the vulva and vagina are erythematous and edematous with thick, white, curdlike discharge adhering to the vaginal walls. The woman reports intense pruritus and thick white discharge from her vagina. The nurse knows that these history and physical examination findings are most consistent with which of these conditions? A) Candidiasis B) Trichomoniasis C) Atrophic vaginitis D) Bacterial vaginosis
ANS: A The woman with candidiasis often reports intense pruritus and thick white discharge. The vulva and vagina are erythematous and edematous. The discharge is usually thick, white, and curdlike. Infection with trichomoniasis causes a profuse, watery, gray-green, and frothy discharge. Bacterial vaginosis causes a profuse discharge that has a "foul, fishy, rotten" odor. Atrophic vaginitis may have a mucoid discharge. See Table 26-5 for complete descriptions of each option.
A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. The nurse begins the examination suspecting: a. Tinea capitis. b. Folliculitis. c. Toxic alopecia. d. Seborrheic dermatitis.
ANS: A Tinea capitis is rounded patchy hair loss on the scalp, leaving broken-off hairs, pustules, and scales on the skin, and is caused by a fungal infection. Lesions are fluorescent under a Wood light and are usually observed in children and farmers; tinea capitis is highly contagious. (See Table 12-12, Abnormal Conditions of Hair, for descriptions of the other terms.)
During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is: a. Xerosis. b. Pruritus. c. Alopecia. d. Seborrhea.
ANS: A Xerosis is the term used to describe skin that is excessively dry. Pruritus refers to itching, alopecia refers to hair loss, and seborrhea refers to oily skin.
A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe? A) A unilateral cool foot B) Thin, shiny, atrophic skin C) Pallor of the toes and cyanosis of the nail beds D) A brownish discoloration to the skin of the lower leg
ANS: A brownish discoloration to the skin of the lower leg A brown discoloration occurs with chronic venous stasis as a result of hemosiderin deposits (a by-product of red blood cell degradation). Pallor, cyanosis, atrophic skin, and unilateral coolness are all signs associated with arterial problems.
The nurse is preparing to perform a manual compression test on a patient. Which of these statements is true about this procedure? A) Rapid filling of the veins indicates incompetent veins. B) Competent valves in the veins will transmit a wave to the distal fingers. C) A palpable wave transmission occurs when the valves are incompetent. D) The test assesses whether the valves of varicosity are competent when the person is in the supine position.
ANS: A palpable wave transmission occurs when the valves are incompetent. With the manual compression test, a palpable wave transmission occurs when the valves are incompetent. Competent veins will prevent a wave transmission and the nurse's distal (lower) fingers will feel no change. The test is performed while the patient is standing.
Which of these clinical situations would the nurse consider to be outside normal limits? a. A patient has had one pregnancy and states that she believes she may be entering menopause. Her breast examination reveals breasts that are soft and slightly sagging. b. A patient has never been pregnant. Her breast examination reveals large pendulous breasts that have a firm, transverse ridge along the lower quadrant in both breasts. c. A patient has never been pregnant and reports that she should begin her period tomorrow. Her breast examination reveals breast tissue that is nodular and somewhat engorged. She states that the examination was slightly painful. d. A patient has had two pregnancies, and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipples.
ANS: A patient has had two pregnancies and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft and she has a small amount of thick yellow discharge from both nipples. In nulliparous women, normal breast tissue feels firm, smooth, and elastic; after pregnancy, the tissue feels softer and looser. If any discharge appears, the nurse should note its color and consistency. Except in pregnancy and lactation, discharge is abnormal. Premenstrual engorgement is normal, and consists of a slight enlargement, tenderness to palpation, and a generalized nodularity. A firm, transverse ridge of compressed tissue in the lower quadrants, known as the inframammary ridge, is especially noticeable in large breasts.
A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings? Select all that apply. A) The patient has a history of diabetes and cigarette smoking. B) The patient's skin is pale and cool. C) The patient's ankles have two small, weeping ulcers. D) The patient works long hours sitting at a computer desk. E) The patient states that the pain gets worse when walking. F) The patient states that the pain is worse at the end of the day.
ANS: A, B, E The patient has a history of diabetes and cigarette smoking. The patient's skin is pale and cool. The patient states that the pain gets worse when walking. See Table 20-3. Patients with chronic arterial symptoms often have a history of smoking and diabetes (among other risk factors). The pain has a gradual onset, with exertion, and is relieved with rest or dangling. The skin appears cool and pale. The other responses reflect chronic venous problems.
A female patient tells the nurse that she has had six pregnancies, with four live births at term and two spontaneous abortions. Her four children are still living. How would the nurse record this information? a.P-6, B-4, (S)Ab-2 b.Grav 6, Term 4, (S)Ab-2, Living 4 c.Patient has had four living babies. d.Patient has been pregnant six times.
B
1. The nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply. a. Inspiratory wheezes noted in left lower lobes b. Hypoactive bowel sounds c. Nonproductive cough d. Edema, +2, noted on left hand e. Patient reports dyspnea upon exertion f. Rate of respirations 16 breaths per minute
ANS: A, C, E, F Clustering related cues help the nurse recognize relationships among the data. The cues related to the patients respiratory status (e.g., wheezes, cough, report of dyspnea, respiration rate and rhythm) are all related. Cues related to bowels and peripheral edema are not related to the respiratory cues.
2. A 16-year-old boy is brought to the clinic for a problem that he refused to let his mother see. The nurse examines him, and finds that he has scrotal swelling on the left side. He had the mumps the previous week, and the nurse suspects that he has orchitis. Which of the following assessment findings support this diagnosis? Select all that apply. a. Swollen testis b. Mass that transilluminates c. Mass that does not transilluminate d. Scrotum that is nontender upon palpation e. Scrotum that is tender upon palpation f. Scrotal skin that is reddened
ANS: A, C, E, F With orchitis, the testis is swollen, with a feeling of weight, and is tender or painful. The mass does not transilluminate, and the scrotal skin is reddened. Transillumination of a mass occurs with a hydrocele, not orchitis.
1. A 55-year-old man is in the clinic for a yearly checkup. He is worried because his father died of prostate cancer. The nurse knows which tests should be performed at this time? Select all that apply. a. Blood test for prostate-specific antigen (PSA) b. Urinalysis c. Transrectal ultrasound d. Digital rectal examination (DRE) e. Prostate biopsy
ANS: A, D Prostate cancer is typically detected by testing the blood for PSA or by a DRE. It is recommended that both PSA and DRE be offered to men annually, beginning at age 50 years. If the PSA is elevated, then further laboratory work or a transrectal ultrasound (TRUS) and biopsy may be recommended.
The nurse is preparing for a certification course in skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct? Select all that apply. a. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color b. Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus) c. Papule: Hypertrophic scar d. Vesicle: Known as a friction blister e. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm
ANS: A, D, E A pustule is an elevated, circumscribed lesion filled with turbid fluid (pus). A hypertrophic scar is a keloid. A bulla is larger than 1 cm and contains clear fluid. A papule is solid and elevated but measures less than 1 cm.
A patient is recovering from several hours of orthopedic surgery. During an assessment of the patient's lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? Select all that apply. A) Intense, sharp pain, with the deep muscle tender to touch B) Aching, tired pain, with a feeling of fullness C) Pain is worse at the end of the day D) Sudden onset E) Warm, red, and swollen calf F) Pain that is relieved with elevation of leg
ANS: A, D, E Intense, sharp pain, with the deep muscle tender to touch Sudden onset Warm, red, and swollen calf Signs and symptoms of acute venous problems include pain in the calf that has a sudden onset and that is intense and sharp with tenderness in the deep muscle when touched. The calf is warm, red, and swollen. The other options are symptoms of chronic venous problems.
The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? Select all that apply. a. Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. b. As the patient repeatedly says "ninety-nine," the examiner clearly hears the words "ninety-nine." c. When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said. d. As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. e. As the patient says a long "ee-ee-ee" sound, the examiner hears a long "aaaaaa" sound.
ANS: A. Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. C. When the patient speaks in a normal voice, the examiner can hear a sound but cannot distinguish exactly what is being said. D. As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. As a patient says "ninety-nine" repeatedly, normally, the examiner hears sound but cannot distinguish what is being said. If a clear "ninety-nine" is auscultated, then it could indicate increased lung density, which enhances transmission of voice sounds. This is a measure of bronchophony. When a patient says a long "ee-ee-ee" sound, normally the examiner also hears a long "ee-ee-ee" sound through auscultation. This is a measure of egophony. If the examiner hears a long "aaaaaa" sound instead, this could indicate areas of consolidation or compression. With whispered pectoriloquy, as when a patient whispers a phrase such as "one-two-three," the normal response when auscultating voice sounds is to hear sounds that are faint, muffled, and almost inaudible. If the examiners hears the whispered voice clearly, as if the patient is speaking through the stethoscope, then consolidation of the lung fields may exist.
The nurse is reviewing statistics regarding breast cancer. Which woman, aged 40 years in the United States, has the highest risk for development of breast cancer? a. Black b. White c. Asian d. American Indian
ANS: African-American The incidence of breast cancer varies with different cultural groups. White women have a higher incidence of breast cancer than African-American women starting at age 45 years; but African-American women have a higher incidence before age 45 years. Asian, Hispanic, and American Indian women have a lower risk for development of breast cancer (American Cancer Society, 2009-2010).
The nurse is preparing for a class in early detection of breast cancer. Which statement is true with regard to breast cancer in African-American women in the United States? a. Breast cancer is not a threat to black women. b. Black women have a lower incidence of regional or distant breast cancer than white women. c. Black women are more likely to die of breast cancer at any age. d. Breast cancer incidence in black women is higher than that of white women after age 45.
ANS: African-American women are more likely to die of breast cancer at any age. African-American women have a higher incidence of breast cancer before age 45 years than white women, and are more likely to die of their disease. In addition, African-American women are significantly more likely to be diagnosed with regional or distant breast cancer than are white women. This racial difference in mortality rates may be related to insufficient use of screening measures and lack of access to health care.
An 85-year-old man has come in for a physical examination, and the nurse notices that he uses a cane. When documenting general appearance, the nurse should document this information under the section that covers: A) posture. B) mobility & general appearance C) mood and affect. D) physical deformity.
B
A 65-year-old patient remarks that she just can't believe that her breasts sag so much. She states it must be from lack of exercise. What explanation should the nurse offer her? a. Only women with large breasts experience sagging. b. Sagging is usually due to decreased muscle mass within the breast. c. A diet that is high in protein will help maintain muscle mass, which keeps the breasts from sagging. d. The glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag.
ANS: After menopause, the glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag. After menopause, the glandular tissue atrophies and is replaced with connective tissue. The fat envelope atrophies also, beginning in the middle years and becoming marked in the eighth and ninth decades. These changes decrease breast size and elasticity, so the breasts droop and sag, looking flattened and flabby.
The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about the ABI is true? A) Normal ABI indices are from 0.50 to 1.0. B) The normal ankle pressure is slightly lower than the brachial pressure. C) The ABI is a reliable measurement of peripheral vascular disease in diabetic individuals. D) An ABI of 0.90 to 0.70 indicates the presence of peripheral vascular disease and mild claudication.
ANS: An ABI of 0.90 to 0.70 indicates the presence of peripheral vascular disease and mild claudication. Use of the Doppler stethoscope is a noninvasive way to determine the extent of peripheral vascular disease. The normal ankle pressure is slightly greater than or equal to the brachial pressure. An ABI of 0.90 to 0.70 indicates the presence of peripheral vascular disease and mild claudication. The ABI is less reliable in patients with diabetes mellitus because of claudication, which makes the arteries noncompressible and may give a falsely high ankle pressure.
A patient has a long history of chronic obstructive pulmonary disease. During the assessment, the nurse is most likely to observe which of these? a. Unequal chest expansion b. Increased tactile fremitus c. Atrophied neck and trapezius muscles d. Anteroposterior-to-transverse diameter ratio of 1:1
ANS: An anteroposterior-to-transverse diameter ratio of 1:1 An anteroposterior-to-transverse diameter of 1:1 or "barrel chest" is seen in individuals with chronic obstructive pulmonary disease because of hyperinflation of the lungs. The ribs are more horizontal, and the chest appears as if held in continuous inspiration. Neck muscles are hypertrophied from aiding in forced respiration. Chest expansion may be decreased but symmetric. Decreased tactile fremitus occurs from decreased transmission of vibrations.
During a history interview, a female patient states that she has noticed a few drops of clear discharge from her right nipple. What should the nurse do next? a. Immediately contact the physician to report the discharge. b. Ask her if she is possibly pregnant. c. Ask the patient some additional questions about the medications she is taking. d. Immediately obtain a sample for culture and sensitivity testing.
ANS: Ask her some additional questions about the medications she is taking. The use of some medications, such as oral contraceptives, phenothiazines, diuretics, digitalis, steroids, methyldopa, and calcium channel blockers, may cause clear nipple discharge. Bloody or blood-tinged discharge from the nipple, not clear, is significant, especially if a lump is also present. In the pregnant female, colostrum would be a thick, yellowish liquid, and it would be expressed after the fourth month of pregnancy.
The nurse is attempting to assess the femoral pulse in an obese patient. Which of these actions would be most appropriate? A) Have the patient assume a prone position. B) Ask the patient to bend his or her knees to the side in a froglike position. C) Press firmly against the bone with the patient in a semi-Fowler position. D) Listen with a stethoscope for pulsations because it is very difficult to palpate the pulse in an obese person.
ANS: Ask the patient to bend his or her knees to the side in a froglike position. To help expose the femoral area, particularly in obese people, the nurse should ask the person to bend his or her knees to the side in a froglike position.
A 65-year-old patient with a history of heart failure comes to the clinic with complaints of "being awakened from sleep with shortness of breath." Which action by the nurse is most appropriate? a. Obtaining a detailed health history of the patient's allergies and a history of asthma b. Telling the patient to sleep on his or her right side to facilitate ease of respirations c. Assessing for other signs and symptoms of paroxysmal nocturnal dyspnea d. Assuring the patient that paroxysmal nocturnal dyspnea is normal and will probably resolve within the next week
ANS: Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. The patient is experiencing paroxysmal nocturnal dyspnea: being awakened from sleep with shortness of breath and the need to be upright to achieve comfort.
During an examination of a 7-year-old girl, the nurse notices that the girl is showing breast budding. What should the nurse do next? a. Ask the young girl if her periods have started. b. Assess the girl's weight and body mass index (BMI). c. Ask the girl's mother at what age she started to develop breasts. d. Nothing; breast budding is a normal finding.
ANS: Assess the girl's weight and body mass index (BMI). Research has shown that girls with overweight or obese BMI levels have a higher occurrence of early onset of breast budding (before age 8 years for African-American girls and age 10 years for white girls) and early menarche.
The nurse is assessing the joints of a woman who has stated, "I have a long family history of arthritis, and my joints hurt." The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? Select all that apply.
ANS: Asymmetric joint involvement Pain with motion of affected joints Affected joints are swollen with hard, bony protuberances In osteoarthritis, asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. Affected joints have stiffness, swelling with hard bony protuberances, pain with motion, and limitation of motion. The other options reflect signs of rheumatoid arthritis.
When assessing a patient the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next? A) Document the finding. B) Auscultate the site for a bruit. C) Check for calf pain. D) Check capillary refill in the toes.
ANS: Auscultate the site for a bruit. If a pulse is weak or diminished at the femoral site, the nurse should auscultate for a bruit. Presence of a bruit, or turbulent blood flow, indicates partial occlusion. The other responses are not correct.
26. While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. The nurse interprets these findings to indicate a(n): a. Fungal infection. b. Acute otitis media. c. Perforation of the eardrum. d. Cholesteatoma.
ANS: B Absent or distorted light reflex and a bright red color of the eardrum are indicative of acute otitis media. (See Table 15-5 for descriptions of the other conditions.)
4. When performing a genital examination on a 25-year-old man, the nurse notices deeply pigmented, wrinkled scrotal skin with large sebaceous follicles. On the basis of this information, the nurse would: a. Squeeze the glans to check for the presence of discharge. b. Consider this finding as normal, and proceed with the examination. c. Assess the testicles for the presence of masses or painless lumps. d. Obtain a more detailed history, focusing on any scrotal abnormalities the patient has noticed.
ANS: B After adolescence, the scrotal skin is deeply pigmented and has large sebaceous follicles and appears corrugated.
14. The nurse is reviewing theories of illness. The germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions, is a basic belief of which theory of illness? a. Holistic b. Biomedical c. Naturalistic d. Magicoreligious
ANS: B Among the biomedical explanations for disease is the germ theory, which states that microscopic organisms such as bacteria and viruses are responsible for specific disease conditions. The naturalistic, or holistic, perspective holds that the forces of nature must be kept in natural balance. The magicoreligious perspective holds that supernatural forces dominate and cause illness or health.
31. The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane? a. Red and bulging b. Hypomobility c. Retraction with landmarks clearly visible d. Flat, slightly pulled in at the center, and moves with insufflation
ANS: B An early sign of otitis media is hypomobility of the tympanic membrane. As pressure increases, the tympanic membrane begins to bulge.
12. The nurse is conducting a heritage assessment. Which question is most appropriate for this assessment? a. What is your religion? b. Do you mostly participate in the religious traditions of your family? c. Do you smoke? d. Do you have a history of heart disease?
ANS: B Asking questions about participation in the religious traditions of family enables the nurse to assess a persons heritage. Simply asking about ones religion, smoking history, or health history does not reflect heritage.
10. Which critical thinking skill helps the nurse see relationships among the data? a. Validation b. Clustering related cues c. Identifying gaps in data d. Distinguishing relevant from irrelevant
ANS: B Clustering related cues helps the nurse see relationships among the data.
1. The nurse is reviewing the development of culture. Which statement is correct regarding the development of ones culture? Culture is: a. Genetically determined on the basis of racial background. b. Learned through language acquisition and socialization. c. A nonspecific phenomenon and is adaptive but unnecessary. d. Biologically determined on the basis of physical characteristics.
ANS: B Culture is learned from birth through language acquisition and socialization. It is not biologically or genetically determined and is learned by the individual.
32. The nurse is performing a middle ear assessment on a 15-year-old patient who has had a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 oclock and landmarks visible. The nurse should: a. Refer the patient for the possibility of a fungal infection. b. Know that these are scars caused from frequent ear infections. c. Consider that these findings may represent the presence of blood in the middle ear. d. Be concerned about the ability to hear because of this abnormality on the tympanic membrane.
ANS: B Dense white patches on the tympanic membrane are sequelae of repeated ear infections. They do not necessarily affect hearing.
33. A 55-year-old man is experiencing severe pain of sudden onset in the scrotal area. It is somewhat relieved by elevation. On examination the nurse notices an enlarged, red scrotum that is very tender to palpation. Distinguishing the epididymis from the testis is difficult, and the scrotal skin is thick and edematous. This description is consistent with which of these? a. Varicocele b. Epididymitis c. Spermatocele d. Testicular torsion
ANS: B Epididymitis presents as severe pain of sudden onset in the scrotum that is somewhat relieved by elevation. On examination, the scrotum is enlarged, reddened, and exquisitely tender. The epididymis is enlarged and indurated and may be hard to distinguish from the testis. The overlying scrotal skin may be thick and edematous. (See Table 24-6 for more information and for the descriptions of the other terms.)
19. The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal? a. If the drum has ruptured, then purulent drainage will result. b. Bloody or clear watery drainage can indicate a basal skull fracture. c. The auditory canal many be occluded from increased cerumen. d. Foreign bodies from the accident may cause occlusion of the canal.
ANS: B Frank blood or clear watery drainage (cerebrospinal leak) after a trauma suggests a basal skull fracture and warrants immediate referral. Purulent drainage indicates otitis externa or otitis media.
10. A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correct regarding the significance of this in relation to the infants hearing? a. Rubella may affect the mothers hearing but not the infants. b. Rubella can damage the infants organ of Corti, which will impair hearing. c. Rubella is only dangerous to the infant in the second trimester of pregnancy. d. Rubella can impair the development of CN VIII and thus affect hearing.
ANS: B If maternal rubella infection occurs during the first trimester, then it can damage the organ of Corti and impair hearing.
23. The nurse is describing how to perform a testicular self-examination to a patient. Which statement is most appropriate? a. A good time to examine your testicles is just before you take a shower. b. If you notice an enlarged testicle or a painless lump, call your health care provider. c. The testicle is egg shaped and movable. It feels firm and has a lumpy consistency. d. Perform a testicular examination at least once a week to detect the early stages of testicular cancer.
ANS: B If the patient notices a firm painless lump, a hard area, or an overall enlarged testicle, then he should call his health care provider for further evaluation. The testicle normally feels rubbery with a smooth surface. A good time to examine the testicles is during the shower or bath, when ones hands are warm and soapy and the scrotum is warm. Testicular self-examination should be performed once a month.
23. The nurse is reviewing concepts of cultural aspects of pain. Which statement is true regarding pain? a. All patients will behave the same way when in pain. b. Just as patients vary in their perceptions of pain, so will they vary in their expressions of pain. c. Cultural norms have very little to do with pain tolerance, because pain tolerance is always biologically determined. d. A patients expression of pain is largely dependent on the amount of tissue injury associated with the pain.
ANS: B In addition to expecting variations in pain perception and tolerance, the nurse should expect variations in the expression of pain. It is well known that individuals turn to their social environment for validation and comparison. The other statements are incorrect.
20. When performing a scrotal assessment, the nurse notices that the scrotal contents show a red glow with transillumination. On the basis of this finding the nurse would: a. Assess the patient for the presence of a hernia. b. Suspect the presence of serous fluid in the scrotum. c. Consider this finding normal, and proceed with the examination. d. Refer the patient for evaluation of a mass in the scrotum.
ANS: B Normal scrotal contents do not allow light to pass through the scrotum. However, serous fluid does transilluminate and shows as a red glow. Neither a mass nor a hernia would transilluminate.
5. The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using: a. Intuition. b. A set of rules. c. Articles in journals. d. Advice from supervisors.
ANS: B Novice nurses operate from a set of defined, structured rules. The expert practitioner uses intuitive links.
8. The mother of a 10-year-old boy asks the nurse to discuss the recognition of puberty. The nurse should reply by saying: a. Puberty usually begins around 15 years of age. b. The first sign of puberty is an enlargement of the testes. c. The penis size does not increase until about 16 years of age. d. The development of pubic hair precedes testicular or penis enlargement.
ANS: B Puberty begins sometime between age 9 for African Americans and age 10 for Caucasians and Hispanics. The first sign is an enlargement of the testes. Pubic hair appears next, and then penis size increases.
16. A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. The nurse knows that this finding: a. Is normal for people of his age. b. Is a characteristic of recruitment. c. May indicate a middle ear infection. d. Indicates that the patient has a cerumen impaction.
ANS: B Recruitment is significant hearing loss occurring when speech is at low intensity, but sound actually becomes painful when the speaker repeats at a louder volume. The other responses are not correct.
33. The nurse is reviewing concepts related to ones heritage and beliefs. The belief in divine or superhuman power(s) to be obeyed and worshipped as the creator(s) and ruler(s) of the universe is known as: a. Culture. b. Religion. c. Ethnicity. d. Spirituality.
ANS: B Religion is defined as an organized system of beliefs concerning the cause, nature, and purpose of the universe, especially belief in or the worship of God or gods. Spirituality is born out of each persons unique life experiences and his or her personal efforts to find purpose and meaning in life. Ethnicity pertains to a social group within the social system that claims to possess variable traits, such as a common geographic origin, religion, race, and others.
19. When assessing the scrotum of a male patient, the nurse notices the presence of multiple firm, nontender, yellow 1-cm nodules. The nurse knows that these nodules are most likely: a. From urethritis. b. Sebaceous cysts. c. Subcutaneous plaques. d. From an inflammation of the epididymis.
ANS: B Sebaceous cysts are commonly found on the scrotum. These yellowish 1-cm nodules are firm, nontender, and often multiple. The other options are not correct.
22. Symptoms, such as pain, are often influenced by a persons cultural heritage. Which of the following is a true statement regarding pain? a. Nurses attitudes toward their patients pain are unrelated to their own experiences with pain. b. Nurses need to recognize that many cultures practice silent suffering as a response to pain. c. A nurses area of clinical practice will most likely determine his or her assessment of a patients pain. d. A nurses years of clinical experience and current position are strong indicators of his or her response to patient pain.
ANS: B Silent suffering is a potential response to pain in many cultures. The nurses assessment of pain needs to be embedded in a cultural context. The other responses are not correct.
8. The nurse recognizes that an example of a person who is heritage consistent would be a: a. Woman who has adapted her clothing to the clothing style of her new country. b. Woman who follows the traditions that her mother followed regarding meals. c. Man who is not sure of his ancestors country of origin. d. Child who is not able to speak his parents native language.
ANS: B Someone who is heritage consistent lives a lifestyle that reflects his or her traditional heritage, not the norms and customs of the new country.
18. An individual who takes the magicoreligious perspective of illness and disease is likely to believe that his or her illness was caused by: a. Germs and viruses. b. Supernatural forces. c. Eating imbalanced foods. d. An imbalance within his or her spiritual nature.
ANS: B The basic premise of the magicoreligious perspective is that the world is seen as an arena in which supernatural forces dominate. The fate of the world and those in it depends on the actions of supernatural forces for good or evil. The other answers do not reflect the magicoreligious perspective.
24. A patient is brought by ambulance to the emergency department with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection? a. Collect history information first, then perform the physical examination and institute life-saving measures. b. Simultaneously ask history questions while performing the examination and initiating life-saving measures. c. Collect all information on the history form, including social support patterns, strengths, and coping patterns. d. Perform life-saving measures and delay asking any history questions until the patient is transferred to the intensive care unit.
ANS: B The emergency data base calls for a rapid collection of the data base, often concurrently compiled with life-saving measures. The other responses are not appropriate for the situation.
1. The external male genital structures include the: a. Testis. b. Scrotum. c. Epididymis. d. Vas deferens.
ANS: B The external male genital structures include the penis and scrotum. The testis, epididymis, and vas deferens are internal structures.
13. In the majority culture of America, coughing, sweating, and diarrhea are symptoms of an illness. For some individuals of Mexican-American origin, however, these symptoms are a normal part of living. The nurse recognizes that this difference is true, probably because Mexican-Americans: a. Have less efficient immune systems and are often ill. b. Consider these symptoms part of normal living, not symptoms of ill health. c. Come from Mexico, and coughing is normal and healthy there. d. Are usually in a lower socioeconomic group and are more likely to be sick.
ANS: B The nurse needs to identify the meaning of health to the patient, remembering that concepts are derived, in part, from the way in which members of the cultural group define health.
3. When examining the ear with an otoscope, the nurse notes that the tympanic membrane should appear: a. Light pink with a slight bulge. b. Pearly gray and slightly concave. c. Pulled in at the base of the cone of light. d. Whitish with a small fleck of light in the superior portion.
ANS: B The tympanic membrane is a translucent membrane with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The tympanic membrane is oval and slightly concave, pulled in at its center by the malleus, which is one of the middle ear ossicles.
27. During an examination of an aging man, the nurse recognizes that normal changes to expect would be: a. Change in scrotal color. b. Decrease in the size of the penis. c. Enlargement of the testes and scrotum. d. Increase in the number of rugae over the scrotal sac.
ANS: B When assessing the genitals of an older man, the nurse may notice thinner, graying pubic hair and a decrease in the size of the penis. The size of the testes may be decreased, they may feel less firm, and the scrotal sac is pendulous with less rugae. No change in scrotal color is observed.
36. A 17-year-old student is a swimmer on her high schools swim team. She has had three bouts of otitis externa this season and wants to know what to do to prevent it. The nurse instructs her to: a. Use a cotton-tipped swab to dry the ear canals thoroughly after each swim. b. Use rubbing alcohol or 2% acetic acid eardrops after every swim. c. Irrigate the ears with warm water and a bulb syringe after each swim. d. Rinse the ears with a warmed solution of mineral oil and hydrogen peroxide.
ANS: B With otitis externa (swimmers ear), swimming causes the external canal to become waterlogged and swell; skinfolds are set up for infection. Otitis externa can be prevented by using rubbing alcohol or 2% acetic acid eardrops after every swim.
20. In performing a voice test to assess hearing, which of these actions would the nurse perform? a. Shield the lips so that the sound is muffled. b. Whisper a set of random numbers and letters, and then ask the patient to repeat them. c. Ask the patient to place his finger in his ear to occlude outside noise. d. Stand approximately 4 feet away to ensure that the patient can really hear at this distance.
ANS: B With the head 30 to 60 cm (1 to 2 feet) from the patients ear, the examiner exhales and slowly whispers a set of random numbers and letters, such as 5, B, 6. Normally, the patient is asked to repeat each number and letter correctly after hearing the examiner say them.
A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. The nurse suspects that this coloring is due to: a. Polycythemia. b. Carbon monoxide poisoning. c. Carotenemia. d. Uremia.
ANS: B A bright cherry-red coloring in the face, upper torso, nail beds, lips, and oral mucosa appears in cases of carbon monoxide poisoning.
27. During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least: A) 1 minute. B) 5 minutes. C) 10 minutes. D) 2 minutes in each quadrant.
ANS: B Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding bowel sounds are completely absent.
11. The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? A) "We need to determine areas of tenderness before using percussion and palpation." B) "It prevents distortion of bowel sounds that might occur after percussion and palpation." C) "It allows the patient more time to relax and therefore be more comfortable with the physical examination." D) "This prevents distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation."
ANS: B Auscultation is performed first (after inspection) because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.
A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition? a. Acne b. Basal cell carcinoma c. Melanoma d. Squamous cell carcinoma
ANS: B Basal cell carcinoma usually starts as a skin-colored papule that develops rounded, pearly borders with a central red ulcer. It is the most common form of skin cancer and grows slowly. This description does not fit acne lesions. (See Table 12-11 for descriptions of melanoma and squamous cell carcinoma.)
12. The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? A) They are usually loud, high-pitched, rushing, tinkling sounds. B) They are usually high-pitched, gurgling, irregular sounds. C) They sound like two pieces of leather being rubbed together. D) They originate from the movement of air and fluid through the large intestine.
ANS: B Bowel sounds are high-pitched, gurgling, cascading sounds that occur irregularly from 5 to 30 times per minute. They originate from the movement of air and fluid through the small intestine.
A 54-year-old woman who has just completed menopause is in the clinic today for a yearly physical examination. Which of these statements should the nurse include in patient education? "A postmenopausal woman: A) is not at any greater risk for heart disease than a younger woman is." B) should be aware that she is at increased risk for dyspareunia because of decreased vaginal secretions." C) has only stopped menstruating; there really are no other significant changes with which she should be concerned." D) is likely to have difficulty with sexual pleasure as a result of drastic changes in the female sexual response cycle."
ANS: B Decreased vaginal secretions leave the vagina dry and at risk for irritation and pain with intercourse (dyspareunia). The other statements are incorrect.
10. A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: A) diarrhea. B) peritonitis. C) laxative use. D) gastroenteritis.
ANS: B Diminished or absent bowel sounds signal decreased motility from inflammation as seen with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction
A 22-year-old woman comes to the clinic because of severe sunburn and states, "I was out in the sun for just a couple of minutes." The nurse begins a medication review with her, paying special attention to which medication class? a. Nonsteroidal antiinflammatory drugs for pain b. Tetracyclines for acne c. Proton pump inhibitors for heartburn d. Thyroid replacement hormone for hypothyroidism
ANS: B Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.
The nurse is preparing to examine the external genitalia of a school-age girl. Which of these positions would be most appropriate in this situation? A) In the parent's lap B) In a frog-leg position on the examining table C) In the lithotomy position with the feet in stirrups D) Lying flat on the examining table with legs extended
ANS: B For school-age children it is best to place them on the examining table in a frog-leg position. With toddlers and preschoolers, it is best to have the child on the parent's lap in a frog-leg position.
17. An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to: A) increased gastric acid secretion. B) decreased gastric acid secretion. C) delayed gastrointestinal emptying time. D) increased gastrointestinal emptying time.
ANS: B Gastric acid secretion decreases with aging, and this may cause pernicious anemia (because it interferes with vitamin B12 absorption), iron deficiency anemia, and malabsorption of calcium.
A woman has just been diagnosed with HPV, or genital warts. The nurse should counsel her to receive regular examinations because this virus makes her at a higher risk for _____ cancer. A) uterine B) cervical C) ovarian D) endometrial
ANS: B HPV is the virus responsible for most cases of cervical cancer, not the other options.
A mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects: a. Eczema. b. Impetigo. c. Herpes zoster. d. Diaper dermatitis.
ANS: B Impetigo is moist, thin-roofed vesicles with a thin erythematous base and is a contagious bacterial infection of the skin and most common in infants and children. Eczema is characterized by erythematous papules and vesicles with weeping, oozing, and crusts. Herpes zoster (i.e., chickenpox or varicella) is characterized by small, tight vesicles that are shiny with an erythematous base. Diaper dermatitis is characterized by red, moist maculopapular patches with poorly defined borders.
A nurse is assessing a patient's risk of contracting a sexually transmitted infection (STI). An appropriate question to ask would be: A) "You know that it's important to use condoms for protection, right?" B) "Do you use a condom with each episode of sexual intercourse?" C) "Do you have a sexually transmitted infection?" D) "You are aware of the dangers of unprotected sex, aren't you?"
ANS: B In reviewing a patient's risk for sexually transmitted infections, the nurse should ask, in a nonconfrontational manner, whether condoms are used at each episode of sexual intercourse. Asking a person whether he or she has an infection does not address the risk.
23. The nurse is assessing the abdomen of an aging adult. Which of these statements regarding the aging adult and abdominal assessment is true? A) The abdominal tone is increased. B) The abdominal musculature is thinner. C) Abdominal rigidity with acute abdominal conditions is more common. D) The aging person complains of more pain with an acute abdominal condition than a younger person would.
ANS: B In the aging person, the abdominal musculature is thinner and has less tone than that of the younger adult, and abdominal rigidity with acute abdominal conditions is less common in aging. The aging person often complains less of pain than a younger person would with an acute abdominal condition.
During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient's scleras are not yellow. From this finding, the nurse could probably rule out: a. Pallor b. Jaundice c. Cyanosis d. Iron deficiency
ANS: B Jaundice is exhibited by a yellow color, which indicates rising levels of bilirubin in the blood. Jaundice is first noticed in the junction of the hard and soft palate in the mouth and in the scleras.
During an internal examination, the nurse notices that the cervix bulges outside the introitus when the patient is asked to strain. The nurse will document this as: A) uterine prolapse, graded first degree. B) uterine prolapse, graded second degree. C) uterine prolapse, graded third degree. D) a normal finding.
ANS: B The cervix should not be found to bulge into the vagina. Uterine prolapse is graded as follows: first degree—cervix appears at introitus with straining; second degree—cervix bulges outside introitus with straining; and third degree—whole uterus protrudes, even without straining (essentially, uterus is inside out).
The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS) and notices multiple patchlike lesions on the temple and beard area that are faint pink in color. The nurse recognizes these lesions as: a. Measles (rubeola). b. Kaposi's sarcoma. c. Angiomas. d. Herpes zoster.
ANS: B Kaposi's sarcoma is a vascular tumor that, in the early stages, appears as multiple, patchlike, faint pink lesions over the patient's temple and beard areas. Measles is characterized by a red-purple maculopapular blotchy rash that appears on the third or fourth day of illness. The rash is first observed behind the ears, spreads over the face, and then spreads over the neck, trunk, arms, and legs. Cherry (senile) angiomas are small (1 to 5 mm), smooth, slightly raised bright red dots that commonly appear on the trunk in all adults over 30 years old. Herpes zoster causes vesicles up to 1 cm in size that are elevated with a cavity containing clear fluid.
A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. The nurse suspects: a. Rubeola. b. Lyme disease. c. Allergy to mosquito bites. d. Rocky Mountain spotted fever.
ANS: B Lyme disease occurs in people who spend time outdoors in May through September. The first disease state exhibits the distinctive bull's eye and a red macular or papular rash that radiates from the site of the tick bite with some central clearing. The rash spreads 5 cm or larger, and is usually in the axilla, midriff, inguinal, or behind the knee, with regional lymphadenopathy.
The nurse is palpating a female patient's adnexa. The findings include a firm, smooth uterine wall; the ovaries are palpable and feel smooth and firm. The fallopian tube is firm and pulsating. The nurse's most appropriate course of action would be to: A) tell the patient that her examination was normal. B) give her an immediate referral to a gynecologist. C) suggest that she return in a month for a recheck to verify the findings. D) tell the patient that she may have an ovarian cyst that should be evaluated further.
ANS: B Normally the uterine wall feels firm and smooth, with the contour of the fundus rounded. Ovaries are not often palpable, but when they are, they normally feel smooth, firm, and almond shaped and are highly movable, sliding through the fingers. The fallopian tube is not palpable normally. No other mass or pulsation should be felt. Pulsation or palpable fallopian tube suggests ectopic pregnancy, which warrants immediate referral
28. A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? A) Obturator test B) Test for Murphy's sign C) Assess for rebound tenderness D) Iliopsoas muscle test
ANS: B Normally, palpating the liver causes no pain. In a person with inflammation of the gallbladder, orcholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration (Murphy's test). The person feels sharp pain and abruptly stops inspiration midway.
A 50-year-old woman calls the clinic because she has noticed some changes in her body and breasts and wonders if they could be due to the hormone replacement therapy (HRT) she started 3 months ago. The nurse should tell her: A) "Hormone replacement therapy is at such a low dose that side effects are very unusual." B) "Hormone replacement therapy has several side effects, including fluid retention, breast tenderness, and vaginal bleeding." C) "It would be very unusual to have vaginal bleeding with hormone replacement therapy, and I suggest you come in to the clinic immediately to have this evaluated." D) "It sounds as if your dose of estrogen is too high; I think you may need to decrease the amount you are taking and then call back in a week."
ANS: B Side effects of hormone replacement therapy include fluid retention, breast pain, and vaginal bleeding. The other responses are not correct.
When the nurse is discussing sexuality and sexual issues with adolescents, a permission statement helps to convey that it is normal to think or feel a certain way. Which of these is the best example of a permission statement? A) "It is okay that you have become sexually active." B) "Often girls your age have questions about sexual activity. Have you any questions?" C) "If it is okay with you, I'd like to ask you some questions about your sexual history." D) "Often girls your age engage in sexual activity. It is okay to tell me if you have had intercourse."
ANS: B Start with a permission statement, "Often girls your age experience . . . ." This conveys that it is normal to think or feel a certain way, and it is important to relay that the topic is normal and unexceptional.
A 52-year-old patient states that when she sneezes or coughs she "wets herself a little." She is very concerned that something may be wrong with her. The nurse suspects that the problem is: A) dysuria. B) stress incontinence. C) hematuria. D) urge incontinence.
ANS: B Stress incontinence is involuntary urine loss with physical strain, sneezing, or coughing. Dysuria is pain or burning with urination. Hematuria is bleeding with urination. Urge incontinence is involuntary urine loss but it occurs due to an overactive detrusor muscle in the bladder that contracts and causes an urgent need to void
A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would: a. Tell the patient to watch the lesion and report back in 2 months. b. Refer the patient because of the suggestion of melanoma on the basis of her symptoms. c. Ask additional questions regarding environmental irritants that may have caused this condition. d. Tell the patient that these signs suggest a compound nevus, which is very common in young to middle-aged adults.
ANS: B The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, the development of itching, burning, and bleeding, or a new-pigmented lesion. Any one of these signs raises the suggestion of melanoma and warrants immediate referral.
During an examination, the nurse would expect the cervical os of a woman who has never had children to appear: A) stellate. B) small and round. C) as a horizontal irregular slit. D) everted.
ANS: B The cervical os in a nulliparous woman is small and round. In the parous woman, it is a horizontal, irregular slit that also may show healed lacerations on the sides. See Figure 26-13.
During the examination portion of a patient's visit, she will be in lithotomy position. Which statement below reflects some things that the nurse can do to make this more comfortable for her? A) Ask her to place her hands and arms behind her head. B) Elevate her head and shoulders to maintain eye contact. C) Allow her to choose to have her feet in the stirrups or have them resting side by side on the edge of the table. D) Allow her to keep her buttocks about 6 inches from the edge of the table to prevent her from feeling as if she will fall off.
ANS: B The nurse should elevate her head and shoulders to maintain eye contact. The patient's arms should be placed at her sides or across the chest, not behind the head, because this position only tightens the abdominal muscles. The feet should be placed into the stirrups, knees apart, and buttocks at the edge of the examining table. Place the stirrups so the legs are not abducted too far
31. A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate? A) "No need to worry. Most men your age develop hernias." B) "A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles." C) "This hernia is a result of prenatal growth abnormalities that are just now causing problems." D) "I'll have to have your physician explain this to you."
ANS: B The nurse should explain that a hernia is a protrusion of the abdominal viscera through an abnormal opening in the muscle wall
39. The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should: A) examine the tender area first. B) examine the tender area last. C) avoid palpating the tender area. D) palpate the tender area first and then auscultate for bowel sounds.
ANS: B The nurse should save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination. Auscultation is done before percussion and palpation because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds
The nurse keeps in mind that a thorough skin assessment is extremely important because the skin holds information about a person's: a. Support systems. b. Circulatory status. c. Socioeconomic status. d. Psychological wellness.
ANS: B The skin holds information about the body's circulation, nutritional status, and signs of systemic diseases, as well as topical data on the integumentary system itself.
The nurse is assessing a patient who has liver disease for jaundice. Which of these assessment findings is indicative of true jaundice? a. Yellow patches in the outer sclera b. Yellow color of the sclera that extends up to the iris c. Skin that appears yellow when examined under low light d. Yellow deposits on the palms and soles of the feet where jaundice first appears
ANS: B The yellow sclera of jaundice extends up to the edge of the iris. Calluses on the palms and soles of the feet often appear yellow but are not classified as jaundice. Scleral jaundice should not be confused with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned persons.
The nurse has just completed an inspection of a nulliparous woman's external genitalia. Which of these would be a description of a finding within normal limits? A) Redness of the labia majora B) Multiple nontender sebaceous cysts C) Discharge that is sticky and yellow-green D) Gaping and slightly shriveled labia majora
ANS: B There should be no lesions, except for occasional sebaceous cysts. These are yellowish 1-cm nodules that are firm, nontender, and often multiple. The labia majora are dark pink, moist, and symmetrical; redness indicates inflammation or lesions. Discharge that is sticky and yellow-green may indicate infection. In the nulliparous woman, the labia majora meet in the midline, are symmetric and plump.
14. During an abdominal assessment, the nurse would consider which of these findings as normal? A) The presence of a bruit in the femoral area B) A tympanic percussion note in the umbilical region C) A palpable spleen between the ninth and eleventh ribs in the left midaxillary line D) A dull percussion note in the left upper quadrant at the midclavicular line
ANS: B Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not usually present. Normally the spleen is not palpable. Dullness would not be found in the area of lung resonance (left upper quadrant at the midclavicular line)
A patient calls the clinic for instructions before having a Papanicolaou (Pap) smear. The most appropriate instructions from the nurse are: A) "If you are menstruating, please use pads to avoid placing anything into the vagina." B) "Avoid intercourse, inserting anything into the vagina, or douching within 24 hours of your appointment." C) "If you suspect that you have a vaginal infection, please gather a sample of the discharge to bring with you." D) "We would like you to use a mild saline douche before your examination. You may pick this up in our office."
ANS: B When instructing a patient before a Papanicolaou (Pap) smear is obtained, the nurse should follow these guidelines: Do not obtain during the woman's menses or if a heavy infectious discharge is present. Instruct the woman not to douche, have intercourse, or put anything into the vagina within 24 hours before collecting the specimens. Any specimens will be obtained during the visit, not beforehand.
20. The nurse knows that during an abdominal assessment, deep palpation is used to determine: A) bowel motility. B) enlarged organs. C) superficial tenderness. D) overall impression of skin surface and superficial musculature.
ANS: B With deep palpation, the nurse should notice the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses.
An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination? a. Smooth mucous membranes and lips b. Dry mucous membranes and cracked lips c. Pale mucous membranes d. White patches on the mucous membranes
ANS: B With dehydration, mucous membranes appear dry and the lips look parched and cracked. The other responses are not found in dehydration.
41. The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply. A. Test for Murphy's sign. B. Test for Blumberg's sign. C. Test for shifting dullness. D. Perform iliopsoas muscle test. E. Test for fluid wave.
ANS: B, D Testing for Blumberg's sign (rebound tenderness) and performing the iliopsoas muscle test should be used to assess for appendicitis. Murphy's sign is used to assess for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is done to assess for ascites
1. The nurse is reviewing aspects of cultural care. Which statements illustrate proper cultural care? Select all that apply. a. Examine the patient within the context of ones own cultural health and illness practices. b. Select questions that are not complex. c. Ask questions rapidly. d. Touch patients within the cultural boundaries of their heritage. e. Pace questions throughout the physical examination.
ANS: B, D, E Patients should be examined within the context of their own cultural health and illness practices. Questions should be simply stated and not rapidly asked.
1. The nurse is testing the hearing of a 78-year-old man and is reminded of the changes in hearing that occur with aging that include which of the following? Select all that apply. a. Hearing loss related to aging begins in the mid 40s. b. Progression of hearing loss is slow. c. The aging person has low-frequency tone loss. d. The aging person may find it harder to hear consonants than vowels. e. Sounds may be garbled and difficult to localize. f. Hearing loss reflects nerve degeneration of the middle ear.
ANS: B, D, E Presbycusis is a type of hearing loss that occurs with aging and is found in 60% of those older than 65 years. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve, and it slowly progresses after the age of 50 years. The person first notices a high-frequency tone loss; it is harder to hear consonants (high-pitched components of speech) than vowels, which makes words sound garbled. The ability to localize sound is also impaired.
The nurse is palpating an ovarian mass during an internal examination of a 63-year-old woman. Which findings of the mass's characteristics would suggest the presence of an ovarian cyst? Select all that apply. A) Heavy and solid B) Mobile and fluctuant C) Mobile and solid D) Fixed E) Smooth and round F) Poorly defined
ANS: B, E An ovarian cyst (fluctuant ovarian mass) is usually asymptomatic, and would feel like a smooth, round, fluctuant, mobile, nontender mass on the ovary. A mass that is heavy, solid, fixed, and poorly defined suggests malignancy. A benign mass may feel mobile and solid.
A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer? Select all that apply. a. Intact skin appears red but is not broken. b. Partial thickness skin erosion is observed with a loss of epidermis or dermis. c. Ulcer extends into the subcutaneous tissue. d. Localized redness in light skin will blanch with fingertip pressure. e. Open blister areas have a red-pink wound bed. f. Patches of eschar cover parts of the wound.
ANS: B, E Stage I pressure ulcers have intact skin that appears red but is not broken, and localized redness in intact skin will blanche with fingertip pressure. Stage II pressure ulcers have partial thickness skin erosion with a loss of epidermis or also the dermis; open blisters have a red-pink wound bed. Stage III pressure ulcers are full thickness, extending into the subcutaneous tissue; subcutaneous fat may be seen but not muscle, bone, or tendon. Stage IV pressure ulcers involve all skin layers and extend into supporting tissue, exposing muscle, bone, and tendon. Slough (stringy matter attached to the wound bed) or eschar (black or brown necrotic tissue) may be present.
During an annual physical exam, a 43-year-old patient states that she doesn't perform monthly breast self-examinations (BSE). She tells the nurse that she believes that mammograms "do a much better job than I ever could to find a lump." The nurse should explain to her that: a. BSEs may detect lumps that appear between mammograms. b. BSEs are unnecessary until the age of 50 years. c. She is correct—mammography is a good replacement for BSE. d. She does not need to perform BSEs as long as a physician checks her breasts annually.
ANS: BSEs may detect lumps that appear between mammograms. The monthly practice of breast self-examination, along with clinical breast examination and mammograms are complementary screening measures. Mammography can reveal cancers too small to be detected by the woman or by the most experienced examiner. However, interval lumps may become palpable between mammograms.
When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? a. Between the scapulae b. Third intercostal space, MCL c. Fifth intercostal space, midaxillary line (MAL) d. Over the lower lobes, posterior side
ANS: Between the scapulae Normally, fremitus is most prominent between the scapulae and around the sternum. These are sites where the major bronchi are closest to the chest wall. Fremitus normally decreases as one progress down the chest because more tissue impedes sound transmission.
8. A patient has been shown to have a sensorineural hearing loss. During the assessment, it would be important for the nurse to: a. Speak loudly so the patient can hear the questions. b. Assess for middle ear infection as a possible cause. c. Ask the patient what medications he is currently taking. d. Look for the source of the obstruction in the external ear.
ANS: C A simple increase in amplitude may not enable the person to understand spoken words. Sensorineural hearing loss may be caused by presbycusis, which is a gradual nerve degeneration that occurs with aging and by ototoxic drugs, which affect the hair cells in the cochlea.
5. A patient with a middle ear infection asks the nurse, What does the middle ear do? The nurse responds by telling the patient that the middle ear functions to: a. Maintain balance. b. Interpret sounds as they enter the ear. c. Conduct vibrations of sounds to the inner ear. d. Increase amplitude of sound for the inner ear to function.
ANS: C Among its other functions, the middle ear conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear. The other responses are not functions of the middle ear.
A patient comes in for a physical examination and complains of "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool and attributes this finding to: a. Venous pooling. b. Peripheral vasodilation. c. Peripheral vasoconstriction. d. Decreased arterial perfusion.
ANS: C A chilly or air-conditioned environment causes vasoconstriction, which results in false pallor and coolness (see Table 12-1).
30. The nurse is performing an assessment on a 65-year-old man. He reports a crusty nodule behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. The preliminary analysis in this situation is that this: a. Is most likely a benign sebaceous cyst. b. Is most likely a keloid. c. Could be a potential carcinoma, and the patient should be referred for a biopsy. d. Is a tophus, which is common in the older adult and is a sign of gout.
ANS: C An ulcerated crusted nodule with an indurated base that fails to heal is characteristic of a carcinoma. These lesions fail to heal and intermittently bleed. Individuals with such symptoms should be referred for a biopsy (see Table 15-2). The other responses are not correct.
39. A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, I dont know what the matter is. All of a sudden, I cant hear you out of my left ear! What should the nurse do next? a. Make note of this finding for the report to the next shift. b. Prepare to remove cerumen from the patients ear. c. Notify the patients health care provider. d. Irrigate the ear with rubbing alcohol.
ANS: C Any sudden loss of hearing in one or both ears that is not associated with an upper respiratory infection needs to be reported at once to the patients health care provider. Hearing loss associated with trauma is often sudden. Irrigating the ear or removing cerumen is not appropriate at this time.
14. During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky cerumen in his canal. What is the significance of this finding? This finding: a. Is probably the result of lesions from eczema in his ear. b. Represents poor hygiene. c. Is a normal finding, and no further follow-up is necessary. d. Could be indicative of change in cilia; the nurse should assess for hearing loss.
ANS: C Asians and Native Americans are more likely to have dry cerumen, whereas Blacks and Whites usually have wet cerumen.
31. During a class on cultural practices, the nurse hears the term cultural taboo. Which statement illustrates the concept of a cultural taboo? a. Believing that illness is a punishment of sin b. Trying prayer before seeking medical help c. Refusing to accept blood products as part of treatment d. Stating that a childs birth defect is the result of the parents sins
ANS: C Cultural taboos are practices that are to be avoided, such as receiving blood products, eating pork, and consuming caffeine. The other answers do not reflect cultural taboos.
14. Which of these would be formulated by a nurse using diagnostic reasoning? a. Nursing diagnosis b. Medical diagnosis c. Diagnostic hypothesis d. Diagnostic assessment
ANS: C Diagnostic reasoning calls for the nurse to formulate a diagnostic hypothesis; the nursing process calls for a nursing diagnosis.
34. The nurse is performing a genitourinary assessment on a 50-year-old obese male laborer. On examination, the nurse notices a painless round swelling close to the pubis in the area of the internal inguinal ring that is easily reduced when the individual is supine. These findings are most consistent with a(n) ______ hernia. a. Scrotal b. Femoral c. Direct inguinal d. Indirect inguinal
ANS: C Direct inguinal hernias occur most often in men over the age of 40 years. It is an acquired weakness brought on by heavy lifting, obesity, chronic cough, or ascites. The direct inguinal hernia is usually a painless, round swelling close to the pubis in the area of the internal inguinal ring that is easily reduced when the individual is supine. (See Table 24-6 for a description of scrotal hernia. See Table 24-7 for the descriptions of femoral hernias and indirect inguinal hernias.)
22. The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement is true regarding this examination? a. Immobility of the drum is a normal finding. b. An injected membrane would indicate an infection. c. The normal membrane may appear thick and opaque. d. The appearance of the membrane is identical to that of an adult.
ANS: C During the first few days after the birth, the tympanic membrane of a newborn often appears thickened and opaque. It may look injected and have a mild redness from increased vascularity. The other statements are not correct.
7. The nurse is reviewing information about evidence-based practice (EBP). Which statement best reflects EBP? a. EBP relies on tradition for support of best practices. b. EBP is simply the use of best practice techniques for the treatment of patients. c. EBP emphasizes the use of best evidence with the clinicians experience. d. The patients own preferences are not important with EBP.
ANS: C EBP is a systematic approach to practice that emphasizes the use of best evidence in combination with the clinicians experience, as well as patient preferences and values, when making decisions about care and treatment. EBP is more than simply using the best practice techniques to treat patients, and questioning tradition is important when no compelling and supportive research evidence exists.
9. After a class on culture and ethnicity, the new graduate nurse reflects a correct understanding of the concept of ethnicity with which statement? a. Ethnicity is dynamic and ever changing. b. Ethnicity is the belief in a higher power. c. Ethnicity pertains to a social group within the social system that claims shared values and traditions. d. Ethnicity is learned from birth through the processes of language acquisition and socialization.
ANS: C Ethnicity pertains to a social group within the social system that claims to have variable traits, such as a common geographic origin, migratory status, religion, race, language, values, traditions, symbols, or food preferences.Culture is dynamic, ever changing, and learned from birth through the processes of language acquisition and socialization. Religion is the belief in a higher power.
27. The nurse has implemented several planned interventions to address the nursing diagnosis of acute pain. Which would be the next appropriate action? a. Establish priorities. b. Identify expected outcomes. c. Evaluate the individuals condition, and compare actual outcomes with expected outcomes. d. Interpret data, and then identify clusters of cues and make inferences.
ANS: C Evaluation is the next step after the implementation phase of the nursing process. During this step, the nurse evaluates the individuals condition and compares the actual outcomes with expected outcomes (See Figure 1-2).
38. During a genital examination, the nurse notices that a male patient has clusters of small vesicles on the glans, surrounded by erythema. The nurse recognizes that these lesions are: a. Peyronie disease. b. Genital warts. c. Genital herpes. d. Syphilitic cancer.
ANS: C Genital herpes, or herpes simplex virus 2 (HSV-2), infections are indicated with clusters of small vesicles with surrounding erythema, which are often painful and erupt on the glans or foreskin. (See Table 24-4 for the descriptions of the other options.)
2. An accessory glandular structure for the male genital organs is the: a. Testis. b. Scrotum. c. Prostate. d. Vas deferens.
ANS: C Glandular structures accessory to the male genital organs are the prostate, seminal vesicles, and bulbourethral glands.
24. A 2-month-old uncircumcised infant has been brought to the clinic for a well-baby checkup. How would the nurse proceed with the genital examination? a. Eliciting the cremasteric reflex is recommended. b. The glans is assessed for redness or lesions. c. Retracting the foreskin should be avoided until the infant is 3 months old. d. Any dirt or smegma that has collected under the foreskin should be noted.
ANS: C If uncircumcised, then the foreskin is normally tight during the first 3 months and should not be retracted because of the risk of tearing the membrane attaching the foreskin to the shaft. The other options are not correct.
20. An older Mexican-American woman with traditional beliefs has been admitted to an inpatient care unit. A culturally sensitive nurse would: a. Contact the hospital administrator about the best course of action. b. Automatically get a curandero for her, because requesting one herself is not culturally appropriate. c. Further assess the patients cultural beliefs and offer the patient assistance in contacting a curandero or priest if she desires. d. Ask the family what they would like to do because Mexican-Americans traditionally give control of decision making to their families.
ANS: C In addition to seeking help from the biomedical or scientific health care provider, patients may also seek help from folk or religious healers. Some people, such as those of Mexican-American or American-Indian origins, may believe that the cure is incomplete unless the body, mind, and spirit are also healed (although the division of the person into parts is a Western concept).
9. During an examination of an aging man, the nurse recognizes that normal changes to expect would be: a. Enlarged scrotal sac. b. Increased pubic hair. c. Decreased penis size. d. Increased rugae over the scrotum.
ANS: C In the aging man, the amount of pubic hair decreases, the penis size decreases, and the rugae over the scrotal sac decreases. The scrotal sac does not enlarge.
16. Many Asians believe in the yin/yang theory, which is rooted in the ancient Chinese philosophy of Tao. Which statement most accurately reflects health in an Asian with this belief? a. A person is able to work and produce. b. A person is happy, stable, and feels good. c. All aspects of the person are in perfect balance. d. A person is able to care for others and function socially.
ANS: C Many Asians believe in the yin/yang theory, in which health is believed to exist when all aspects of the person are in perfect balance. The other statements do not describe this theory.
22. The nurse is aware of which statement to be true regarding the incidence of testicular cancer? a. Testicular cancer is the most common cancer in men aged 30 to 50 years. b. The early symptoms of testicular cancer are pain and induration. c. Men with a history of cryptorchidism are at the greatest risk for the development of testicular cancer. d. The cure rate for testicular cancer is low.
ANS: C Men with undescended testicles (cryptorchidism) are at the greatest risk for the development of testicular cancer. The overall incidence of testicular cancer is rare. Although testicular cancer has no early symptoms, when detected early and treated before metastasizing, the cure rate is almost 100%.
25. A 2-year-old boy has been diagnosed with physiologic cryptorchidism. Considering this diagnosis, during assessment the nurse will most likely observe: a. Testes that are hard and painful to palpation. b. Atrophic scrotum and a bilateral absence of the testis. c. Absence of the testis in the scrotum, but the testis can be milked down. d. Testes that migrate into the abdomen when the child squats or sits cross-legged.
ANS: C Migratory testes (physiologic cryptorchidism) are common because of the strength of the cremasteric reflex and the small mass of the prepubertal testes. The affected side has a normally developed scrotum and the testis can be milked down. The other responses are not correct.
13. A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says that he cant always tell where the sound is coming from and the words often sound mixed up. What might the nurse suspect as the cause for this change? a. Atrophy of the apocrine glands b. Cilia becoming coarse and stiff c. Nerve degeneration in the inner ear d. Scarring of the tympanic membrane
ANS: C Presbycusis is a type of hearing loss that occurs in 60% of those older than 65 years of age, even in those living in a quiet environment. This sensorineural loss is gradual and caused by nerve degeneration in the inner ear. Words sound garbled, and the ability to localize sound is also impaired. This communication dysfunction is accentuated when background noise is present.
9. When considering priority setting of problems, the nurse keeps in mind that second-level priority problems include which of these aspects? a. Low self-esteem b. Lack of knowledge c. Abnormal laboratory values d. Severely abnormal vital signs
ANS: C Second-level priority problems are those that require prompt intervention to forestall further deterioration (e.g., mental status change, acute pain, abnormal laboratory values, risks to safety or security) (see Table 1-1).
10. The nurse is comparing the concepts of religion and spirituality. Which of the following is an appropriate component of ones spirituality? a. Belief in and the worship of God or gods b. Attendance at a specific church or place of worship c. Personal effort made to find purpose and meaning in life d. Being closely tied to ones ethnic background
ANS: C Spirituality refers to each persons unique life experiences and his or her personal effort to find purpose and meaning in life. The other responses apply to religion.
12. A 45-year-old mother of two children is seen at the clinic for complaints of losing my urine when I sneeze. The nurse documents that she is experiencing: a. Urinary frequency. b. Enuresis. c. Stress incontinence. d. Urge incontinence.
ANS: C Stress incontinence is involuntary urine loss with physical strain, sneezing, or coughing that occurs as a result to weakness of the pelvic floor. Urinary frequency is urinating more times than usual (more than five to six times per day). Enuresis is involuntary passage of urine at night after age 5 to 6 years (bed wetting). Urge incontinence is involuntary urine loss from overactive detrusor muscle in the bladder. It contracts, causing an urgent need to void.
2. A patient tells the nurse that he is very nervous, is nauseated, and feels hot. These types of data would be: a. Objective. b. Reflective. c. Subjective. d. Introspective.
ANS: C Subjective data are what the person says about him or herself during history taking. Objective data are what the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The terms reflective and introspective are not used to describe data.
31. When the nurse is performing a testicular examination on a 25-year-old man, which finding is considered normal? a. Nontender subcutaneous plaques b. Scrotal area that is dry, scaly, and nodular c. Testes that feel oval and movable and are slightly sensitive to compression d. Single, hard, circumscribed, movable mass, less than 1 cm under the surface of the testes
ANS: C Testes normally feel oval, firm and rubbery, smooth, and bilaterally equal and are freely movable and slightly tender to moderate pressure. The scrotal skin should not be dry, scaly, or nodular or contain subcutaneous plaques. Any mass would be an abnormal finding.
21. A visiting nurse is making an initial home visit for a patient who has many chronic medical problems. Which type of data base is most appropriate to collect in this setting? a. A follow-up data base to evaluate changes at appropriate intervals b. An episodic data base because of the continuing, complex medical problems of this patient c. A complete health data base because of the nurses primary responsibility for monitoring the patients health d. An emergency data base because of the need to collect information and make accurate diagnoses rapidly
ANS: C The complete data base is collected in a primary care setting, such as a pediatric or family practice clinic, independent or group private practice, college health service, womens health care agency, visiting nurse agency, or community health agency. In these settings, the nurse is the first health professional to see the patient and has the primary responsibility for monitoring the persons health care.
3. During a seminar on cultural aspects of nursing, the nurse recognizes that the definition stating the specific and distinct knowledge, beliefs, skills, and customs acquired by members of a society reflects which term? a. Mores b. Norms c. Culture d. Social learning
ANS: C The culture that develops in any given society is always specific and distinctive, encompassing all of the knowledge, beliefs, customs, and skills acquired by members of the society. The other terms do not fit the given definition.
2. The nurse is examining a patients ears and notices cerumen in the external canal. Which of these statements about cerumen is correct? a. Sticky honey-colored cerumen is a sign of infection. b. The presence of cerumen is indicative of poor hygiene. c. The purpose of cerumen is to protect and lubricate the ear. d. Cerumen is necessary for transmitting sound through the auditory canal.
ANS: C The ear is lined with glands that secrete cerumen, which is a yellow waxy material that lubricates and protects the ear.
6. The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti? a. I b. III c. VIII d. XI
ANS: C The nerve impulses are conducted by the auditory portion of CN VIII to the brain.
18. The nurse is performing an otoscopic examination on an adult. Which of these actions is correct? a. Tilting the persons head forward during the examination b. Once the speculum is in the ear, releasing the traction c. Pulling the pinna up and back before inserting the speculum d. Using the smallest speculum to decrease the amount of discomfort
ANS: C The pinna is pulled up and back on an adult or older child, which helps straighten the S-shape of the canal. Traction should not be released on the ear until the examination is completed and the otoscope is removed.
36. During an examination, the nurse notices that a male patient has a red, round, superficial ulcer with a yellowish serous discharge on his penis. On palpation, the nurse finds a nontender base that feels like a small button between the thumb and fingers. At this point the nurse suspects that this patient has: a. Genital warts. b. Herpes infection. c. Syphilitic chancre. d. Carcinoma lesion.
ANS: C This lesion indicates syphilitic chancre, which begins within 2 to 4 weeks of infection. (See Table 24-4 for the descriptions of the other options.)
37. During an examination, the patient states he is hearing a buzzing sound and says that it is driving me crazy! The nurse recognizes that this symptom indicates: a. Vertigo. b. Pruritus. c. Tinnitus. d. Cholesteatoma.
ANS: C Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders.
19. If an American Indian woman has come to the clinic to seek help with regulating her diabetes, then the nurse can expect that she: a. Will comply with the treatment prescribed. b. Has obviously given up her belief in naturalistic causes of disease. c. May also be seeking the assistance of a shaman or medicine man. d. Will need extra help in dealing with her illness and may be experiencing a crisis of faith.
ANS: C When self-treatment is unsuccessful, the individual may turn to the lay or folk healing systems, to spiritual or religious healing, or to scientific biomedicine. In addition to seeking help from a biomedical or scientific health care provider, patients may also seek help from folk or religious healers.
4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to: a. Immediately notify the patients physician. b. Document the sound exactly as it was heard. c. Validate the data by asking a coworker to listen to the breath sounds. d. Assess again in 20 minutes to note whether the sound is still present.
ANS: C When unsure of a sound heard while listening to a patients breath sounds, the nurse validates the data to ensure accuracy. If the nurse has less experience in an area, then he or she asks an expert to listen.
A 13-year-old girl is interested in obtaining information about the cause of her acne. The nurse should share with her that acne: a. Is contagious. b. Has no known cause. c. Is caused by increased sebum production. d. Has been found to be related to poor hygiene.
ANS: C Approximately 90% of males and 80% of females will develop acne; causes are increased sebum production and epithelial cells that do not desquamate normally.
During the interview a patient reveals that she has some vaginal discharge. She is worried that it may be a sexually transmitted infection. The nurse's most appropriate response to this would be: A) "Oh, don't worry. Some cyclic vaginal discharge is normal." B) "Have you been engaging in unprotected sexual intercourse?" C) "I'd like some information about the discharge. What color is it?" D) "Have you had any urinary incontinence associated with the discharge?"
ANS: C Ask questions that help the patient reveal more information about her symptoms in a nonthreatening manner. Assess vaginal discharge further by asking about the amount, color, and odor. Normal vaginal discharge is small, clear or cloudy, and always nonirritating.
The changes normally associated with menopause occur generally because the cells in the reproductive tract are: A) aging. B) becoming fibrous. C) estrogen dependent. D) able to respond to estrogen.
ANS: C Because cells in the reproductive tract are estrogen dependent, decreased estrogen levels during menopause bring dramatic physical changes. The other options are not correct.
The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best? a. Assessing the skin for cyanosis and swelling b. Assessing the oral mucosa for generalized erythema c. Palpating the skin for edema and increased warmth d. Palpating for tenderness and local areas of ecchymosis
ANS: C Because inflammation cannot be seen in dark-skinned persons, palpating the skin for increased warmth, for taut or tightly pulled surfaces that may be indicative of edema, and for a hardening of deep tissues or blood vessels is often necessary.
21. The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be: A) gallbladder disease. B) overuse of laxatives. C) gastrointestinal bleeding. D) localized bleeding around the anus.
ANS: C Black stools may be tarry as a result of occult blood (melena) from gastrointestinal bleeding. Redblood in stools occurs with localized bleeding around the anus
A 42-year-old woman complains that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse expects that the spots are probably: a. Anasarca. b. Scleroderma. c. Senile angiomas. d. Latent myeloma.
ANS: C Cherry (senile) angiomas are small, smooth, slightly raised bright red dots that commonly appear on the trunk of adults over 30 years old.
The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition? a. Severe obesity b. Childhood growth spurts c. Severe dehydration d. Connective tissue disorders such as scleroderma
ANS: C Decreased skin turgor is associated with severe dehydration or extreme weight loss.
3. A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has: A) aphasia. B) dysphasia. C) dysphagia. D) anorexia.
ANS: C Dysphagia is a condition that occurs with disorders of the throat or esophagus and results in difficulty swallowing. Aphasia and dysphasia are speech disorders. Anorexia is a loss of appetite
The nurse should wear gloves for which of these examinations? A) Measuring vital signs B) Palpation of the sinuses C) Palpation of the mouth and tongue D) Inspection of the eye with an ophthalmoscope
ANS: C Gloves should be worn when the examiner is exposed to the patient's body fluids. Page: 766
During an external genitalia examination of a woman, the nurse notices several lesions around the vulva. The lesions are pink, moist, soft, and pointed papules. The patient states that she is not aware of any problems in that area. The nurse recognizes that these lesions may be: A) syphilitic chancre. B) herpes simplex virus type 2 (herpes genitalis). C) human papillomavirus (HPV), or genital warts. D) pediculosis pubis (crab lice).
ANS: C HPV lesions are painless, warty growths that the woman may not notice. Lesions are pink or flesh colored, soft, pointed, moist, warty papules that occur in single or multiple cauliflower-like patches around the vulva, introitus, anus, vagina, or cervix. Herpetic lesions are painful clusters of small, shallow vesicles with surrounding erythema. Syphilitic chancres begin as a solitary silvery papule that erodes to a red, round or oval, superficial ulcer with a yellowish discharge. Pediculosis pubis causes severe perineal itching and excoriations and erythematous areas. See Table 26-2.
During the interview with a female patient, the nurse gathers data that indicate that the patient is perimenopausal. Which of these statements made by this patient leads to this conclusion? A) "I have noticed that my muscles ache at night when I go to bed." B) "I will be very happy when I can stop worrying about having a period." C) "I have been noticing that I sweat a lot more than I used to, especially at night." D) "I have only been pregnant twice, but both times I had breast tenderness as my first symptom."
ANS: C Hormone shifts occur during the perimenopausal period, and associated symptoms of menopause may occur, such as hot flashes, night sweats, numbness and tingling, headache, palpitations, drenching sweats, mood swings, vaginal dryness, and itching. The other responses are not correct.
A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. During the assessment, the nurse might expect to find: a. Pallor b. Coolness c. Distended veins d. Prolonged capillary filling time
ANS: C Keeping the feet in a dependent position causes venous pooling, resulting in redness, warmth, and distended veins. Prolonged elevation would cause pallor and coolness. Immobilization or prolonged inactivity would cause prolonged capillary filling time (see Table 12-1).
A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?" The nurse tells her, "They are: a. "Signs of decreased hematocrit related to anemia." b. "Due to the destruction of melanin in your skin from exposure to the sun." c. "Clusters of melanocytes that appear after extensive sun exposure." d. "Areas of hyperpigmentation related to decreased perfusion and vasoconstriction."
ANS: C Liver spots, or senile lentigines, are clusters of melanocytes that appear on the forearms and dorsa of the hands after extensive sun exposure. The other responses are not correct.
26. The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm? A) A bruit is absent. B) Femoral pulses are increased. C) A pulsating mass is usually present. D) Most are located below the umbilicus.
ANS: C Most aortic aneurysms are palpable during routine examination and feel like a pulsating mass. A bruit will be audible, and femoral pulses are present but decreased. Such aneurysms are located in the upper abdomen just to the left of midline
The nurse is examining a 35-year-old female patient. During the history, the nurse notices that she has had two term pregnancies, and both babies were delivered vaginally. During the internal examination the nurse observes that the cervical os is a horizontal slit with some healed lacerations and that the cervix has some nabothian cysts that are small, smooth, and yellow. In addition, the nurse notices that the cervical surface is granular and red, especially around the os. Finally, the nurse notices the presence of stringy, opaque, odorless secretions. Which of these findings are abnormal? A) Nabothian cysts are present. B) The cervical os is a horizontal slit. C) The cervical surface is granular and red. D) Stringy and opaque secretions are present.
ANS: C Normal findings: Nabothian cysts may be present on the cervix after childbirth. The cervical os is a horizontal, irregular slit in the parous woman. Secretions vary according to the day of the menstrual cycle, and may be clear and thin or thick, opaque, and stringy. The surface is normally smooth, but cervical eversion, or ectropion may occur where the endocervical canal is "rolled out." Abnormal finding: The cervical surface should not be reddened or granular, which may indicate a lesion.
When performing the bimanual examination, the nurse notices that the cervix feels smooth and firm, is round, and is fixed in place (does not move). When cervical palpation is performed, the patient complains of some pain. The nurse's interpretation of these results should be which of these? A) These findings are all within normal limits. B) The cervical consistency should be soft and velvety—not firm. C) The cervix should move when palpated; an immobile cervix may indicate malignancy. D) Pain may occur during palpation of the cervix.
ANS: C Normally the cervix feels smooth and firm, as the consistency of the tip of the nose. It softens and feels velvety at 5 to 6 weeks of pregnancy (Goodell's sign). The cervix should be evenly rounded. With a finger on either side, the examiner should be able to move the cervix gently from side to side, and doing so should produce no pain for the patient. Hardness of the cervix may occur with malignancy. Immobility may occur with malignancy, and pain may occur with inflammation or ectopic pregnancy.
9. While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are: A) pulsations of the renal arteries. B) pulsations of the inferior vena cava. C) normal abdominal aortic pulsations. D) increased peristalsis from a bowel obstruction.
ANS: C Normally, one may see the pulsations from the aorta beneath the skin in the epigastric area, particularly in thin persons with good muscle wall relaxation.
During a bimanual examination, the nurse detects a solid tumor on the ovary that is heavy and fixed, with a poorly defined mass. This finding is suggestive of: A) an ovarian cyst. B) endometriosis. C) ovarian cancer. D) an ectopic pregnancy.
ANS: C Ovarian tumors that are solid, heavy, and fixed, with poorly defined mass are suggestive of malignancy. Benign masses may feel mobile and solid. An ovarian cyst may feel smooth, round, fluctuant, mobile, and nontender. With an ectopic pregnancy, the examiner may feel a palpable, tender pelvic mass that is solid, mobile, and unilateral. Endometriosis may have masses (in various locations in the pelvic area) that are small, firm, nodular and tender to palpation, with enlarged ovaries.
40. During a health history, the patient tells the nurse, "I have pain all the time in my stomach. It's worse two hours after I eat, but it gets better if I eat again!" The nurse suspects that the patient has which condition, based on these symptoms? A) Appendicitis B) Gastric ulcer C) Duodenal ulcer D) Cholecystitis
ANS: C Pain associated with duodenal ulcers occurs 2 to 3 hours after a meal, yet it is relieved by more food. Chronic pain associated with gastric ulcers occurs usually on an empty stomach. Severe, acute pain would occur with appendicitis and cholecystitis
A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patient's skin? a. Ruddy blue. b. Generalized pallor. c. Ashen, gray, or dull. d. Patchy areas of pallor.
ANS: C Pallor attributable to shock, with decreased perfusion and vasoconstriction, in black-skinned people will cause the skin to appear ashen, gray, or dull (see Table 12-2).
16. The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include: A) flatness, resonance, and dullness. B) resonance, dullness, and tympany. C) tympany, hyperresonance, and dullness. D) resonance, hyperresonance, and flatness.
ANS: C Percussion notes normally heard during the abdominal assessment may include tympany, which should predominate because air in the intestines rises to the surface when the person is supine; hyperresonance, which may be present with gaseous distention; and dullness, which may be found over a distended bladder, adipose tissue, fluid, or a mass.
A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say, "The physician is referring to the: a. "Blue dilation of blood vessels in a star-shaped linear pattern on the legs." b. "Fiery red, star-shaped marking on the cheek that has a solid circular center." c. "Confluent and extensive patch of petechiae and ecchymoses on the feet." d. "Tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color."
ANS: C Purpura is a confluent and extensive patch of petechiae and ecchymoses and a flat macular hemorrhage observed in generalized disorders such as thrombocytopenia and scurvy. The blue dilation of blood vessels in a star-shaped linear pattern on the legs describes a venous lake. The fiery red, star-shaped marking on the cheek that has a solid circular center describes a spider or star angioma. The tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color describes petechiae.
A woman states that 2 weeks ago she had a urinary tract infection that was treated with an antibiotic. As a part of the interview, the nurse should ask, "Have you noticed: A) a change in your urination patterns?" B) any excessive vaginal bleeding?" C) any unusual vaginal discharge or itching?" D) any changes in your desire for intercourse?"
ANS: C Several medications may increase the risk of vaginitis. Broad-spectrum antibiotics alter the balance of normal flora, which may lead to the development of vaginitis. The other questions are not correct
18. A patient is complaining of a sharp pain along the costovertebral angles. The nurse knows that this symptom is most often indicative of: A) ovary infection. B) liver enlargement. C) kidney inflammation. D) spleen enlargement.
ANS: C Sharp pain along the costovertebral angles occurs with inflammation of the kidney or paranephric area. The other options are not correct
A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patient's fingernails? a. Splinter hemorrhages b. Paronychia c. Pitting d. Beau lines
ANS: C Sharply defined pitting and crumbling of the nails, each with distal detachment characterize pitting nails and are associated with psoriasis. (See Table 12-13 for descriptions of the other terms.)
22. During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures? A) Spleen B) Sigmoid C) Appendix D) Gallbladder
ANS: C The appendix is located in the right lower quadrant, and when the iliopsoas muscle is inflamed (which occurs with an inflamed or perforated appendix), pain is felt in the right lower quadrant
The nurse is preparing for an internal genitalia examination of a woman. Which order of the examination is correct? A) Bimanual, speculum, rectovaginal B) Speculum, rectovaginal, bimanual C) Speculum, bimanual, rectovaginal D) Rectovaginal, bimanual, speculum
ANS: C The correct sequence is speculum examination, then bimanual examination after removing the speculum, and then rectovaginal examination. The examiner should change gloves before performing the rectovaginal examination to avoid spreading any possible infection
During an internal examination of a woman's genitalia, the nurse will use which technique for proper insertion of the speculum? A) Instruct the woman to bear down, open the speculum blades, and apply in a swift, upward movement. B) Insert the blades of the speculum on a horizontal plane, turning them to a 30-degree angle while continuing to insert them. Ask the woman to bear down after the speculum is inserted. C) Instruct the woman to bear down, turn the width of the blades horizontally, and insert the speculum at a 45-degree angle downward toward the small of the woman's back. D) Lock the blades open by turning the thumbscrew. Once the blades are open, apply pressure to the introitus and insert the blades at a 45-degree angle downward to bring the cervix into view.
ANS: C The examiner should instruct the woman to bear down, turn the width of the blades horizontally, and insert the speculum at a 45-degree angle downward toward the small of the woman's back. See the text under "Speculum Examination" for more detail.
Which statement would be most appropriate when the nurse is introducing the topic of sexual relationships during an interview? A) "Now it is time to talk about your sexual history. When did you first have intercourse?" B) "Women often feel dissatisfied with their sexual relationships. Would it be okay to discuss this now?" C) "Often women have questions about their sexual relationship and how it affects their health. Do you have any questions?" D) "Most women your age have had more than one sexual partner. How many would you say you have had?"
ANS: C The nurse should begin with an open-ended question to assess individual needs. The nurse should include appropriate questions as a routine part of the history, because doing so communicates that the nurse accepts the individual's sexual activity and believes it is important. The nurse's comfort with discussion prompts the patient's interest and possibly relief that the topic has been introduced. This establishes a database for comparison with any future sexual activities and provides an opportunity to screen sexual problems.
37. During an assessment the nurse notices that a patient's umbilicus is enlarged and everted. It is midline, and there is no change in skin color. The nurse recognizes that the patient may have which condition? A) Intra-abdominal bleeding B) Constipation C) Umbilical hernia D) An abdominal tumor
ANS: C The umbilicus is normally midline and inverted, with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect.
When the nurse is interviewing a preadolescent girl, which opening statement would be least threatening? A) "Do you have any questions about growing up?" B) "What has your mother told you about growing up?" C) "When did you notice that your body was changing?" D) "I remember being very scared when I got my period. How do you think you'll feel?"
ANS: C Try the open-ended, "When did you ... ?" rather than "Do you ... ?" This is less threatening because it implies that the topic is normal and unexceptional.
An 18-year-old patient is having her first pelvic examination. Which action by the nurse is appropriate? A) Invite her mother to be present during the examination. B) Avoid the lithotomy position this first time because it can be uncomfortable and embarrassing. C) Raise the head of the examination table and give her a mirror so that she can view the exam. D) Drape her fully, leaving the drape between her legs elevated to avoid embarrassing her with eye contact.
ANS: C Use the techniques of the educational or mirror pelvic examination. This is a routine examination with some modifications in attitude, position, and communication. First, the woman is considered an active participant, one who is interested in learning and in sharing decisions about her own health care. The woman props herself up on one elbow, or the head of the table is raised. Her other hand holds a mirror between her legs, above the examiner's hands. The woman can see all that the examiner is doing and has a full view of her genitalia. The mirror works well for teaching normal anatomy and its relationship to sexual behavior. You can ask her if she would like to have a family member, friend, or chaperone present for the examination. The drape should be pushed down between the woman's legs so that the nurse can see her face.
A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is: a. Caused by an excess of melanin pigment b. Caused by an excess of apocrine glands in her feet c. Caused by the complete absence of melanin pigment d. Related to impetigo and can be treated with an ointment
ANS: C Vitiligo is the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices—otherwise, the depigmented skin is normal.
A 46-year-old woman is in the clinic for her annual gynecologic examination. She voices a concern about ovarian cancer because her mother and sister died of it. The nurse knows that which of these statements is correct regarding ovarian cancer? A) Ovarian cancer rarely has any symptoms. B) The Pap smear detects the presence of ovarian cancer. C) Women at high risk for ovarian cancer should have annual transvaginal ultrasonography for screening. D) Women over age 40 years should have a thorough pelvic examination every 3 years.
ANS: C With ovarian cancer, the patient may have abdominal pain, pelvic pain, increased abdominal size, bloating, and nonspecific gastrointestinal symptoms, or she may be asymptomatic. The Pap smear does not detect the presence of ovarian cancer. Annual transvaginal ultrasonography may detect ovarian cancer at an earlier stage in women who are at high risk for it.
In performing an assessment of a woman's axillary lymph system, the nurse should assess which of these nodes? a. Central, axillary, lateral, and sternal b. Pectoral, lateral, anterior, and sternal c. Central, lateral, pectoral, and subscapular d. Lateral, pectoral, axillary, and suprascapular
ANS: Central, lateral, pectoral, and subscapular nodes The breast has extensive lymphatic drainage. Four groups of axillary nodes are present: (1) central, (2) pectoral (anterior), (3) subscapular (posterior), and (4) lateral.
A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition? a. Absent or decreased breath sounds b. Productive cough with thin, frothy sputum c. Chest pain that is worse on deep inspiration and dyspnea d. Diffuse infiltrates with areas of dullness upon percussion
ANS: Chest pain that is worse on deep inspiration, dyspnea Findings for pulmonary embolism include chest pain that is worse on deep inspiration, dyspnea, apprehension, anxiety, restlessness, PaO2 less than 80, diaphoresis, hypotension, crackles, and wheezes.
The nurse is performing an assessment on an adult. The adult's vital signs are normal and capillary refill time is 5 seconds. What should the nurse do next? A) Ask the patient about a past history of frostbite. B) Suspect that the patient has a venous insufficiency problem. C) Consider this a delayed capillary refill time and investigate further. D) Consider this a normal capillary refill time that requires no further assessment.
ANS: Consider this a delayed capillary refill time and investigate further. Normal capillary refill time is less than 1 to 2 seconds. The following conditions can skew the findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia.
A patient states, "I can hear a crunching or grating sound when I kneel." She also states that "it is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problem? A) Crepitation B) A bone spur C) A loose tendon D) Fluid in the knee joint
ANS: Crepitation Crepitation is an audible and palpable crunching or grating that accompanies movement and occurs when articular surfaces in the joints are roughened, as with rheumatoid arthritis. The other options are not correct.
35. During an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and the ear canal wall. What does this finding suggest? a. Malignancy b. Viral infection c. Blood in the middle ear d. Yeast or fungal infection
ANS: D A colony of black or white dots on the drum or canal wall suggests a yeast or fungal infection (otomycosis).
26. The nurse knows that a common assessment finding in a boy younger than 2 years old is: a. Inflamed and tender spermatic cord. b. Presence of a hernia in the scrotum. c. Penis that looks large in relation to the scrotum. d. Presence of a hydrocele, or fluid in the scrotum.
ANS: D A common scrotal finding in boys younger than 2 years of age is a hydrocele, or fluid in the scrotum. The other options are not correct.
7. A 62-year-old man states that his physician told him that he has an inguinal hernia. He asks the nurse to explain what a hernia is. The nurse should: a. Tell him not to worry and that most men his age develop hernias. b. Explain that a hernia is often the result of prenatal growth abnormalities. c. Refer him to his physician for additional consultation because the physician made the initial diagnosis. d. Explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.
ANS: D A hernia is a loop of bowel protruding through a weak spot in the musculature. The other options are not correct responses to the patients question.
29. A 15-year-old boy is seen in the clinic for complaints of dull pain and pulling in the scrotal area. On examination, the nurse palpates a soft, irregular mass posterior to and above the testis on the left. This mass collapses when the patient is supine and refills when he is upright. This description is consistent with: a. Epididymitis. b. Spermatocele. c. Testicular torsion. d. Varicocele.
ANS: D A varicocele consists of dilated, tortuous varicose veins in the spermatic cord caused by incompetent valves within the vein. Symptoms include dull pain or a constant pulling or dragging feeling, or the individual may be asymptomatic. When palpating the mass, the examiner will feel a soft, irregular mass posterior to and above the testis that collapses when the individual is supine and refills when the individual is upright. (See Table 24-6 for more information and for the descriptions of the other options.)
27. After a symptom is recognized, the first effort at treatment is often self-care. Which of the following statements about self-care is true? Self-care is: a. Not recognized as valuable by most health care providers. b. Usually ineffective and may delay more effective treatment. c. Always less expensive than biomedical alternatives. d. Influenced by the accessibility of over-the-counter medicines.
ANS: D After a symptom is identified, the first effort at treatment is often self-care. The availability of over-the-counter medications, the relatively high literacy level of Americans, and the influence of the mass media in communicating health-related information to the general population have contributed to the high percentage of cases of self-treatment.
3. Which of these statements is true regarding the penis? a. The urethral meatus is located on the ventral side of the penis. b. The prepuce is the fold of foreskin covering the shaft of the penis. c. The penis is made up of two cylindrical columns of erectile tissue. d. The corpus spongiosum expands into a cone of erectile tissue called the glans.
ANS: D At the distal end of the shaft, the corpus spongiosum expands into a cone of erectile tissue, the glans. The penis is made up of three cylindrical columns of erectile tissue. The skin that covers the glans of the penis is the prepuce. The urethral meatus forms at the tip of the glans.
18. When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these? a. Disease originates from the external environment. b. The individual human is a closed system. c. Nurses are responsible for a patients health state. d. Holistic health views the mind, body, and spirit as interdependent.
ANS: D Consideration of the whole person is the essence of holistic health, which views the mind, body, and spirit as interdependent. The basis of disease originates from both the external environment and from within the person. Both the individual human and the external environment are open systems, continually changing and adapting, and each person is responsible for his or her own personal health state.
7. The nurse manager is explaining culturally competent care during a staff meeting. Which statement accurately describes the concept of culturally competent care? The caregiver: a. Is able to speak the patients native language. b. Possesses some basic knowledge of the patients cultural background. c. Applies the proper background knowledge of a patients cultural background to provide the best possible health care. d. Understands and attends to the total context of the patients situation.
ANS: D Culturally competent implies that the caregiver understands and attends to the total context of the individuals situation. This competency includes awareness of immigration status, stress factors, other social factors, and cultural similarities and differences. It does not require the caregiver to speak the patients native language.
2. During a class on the aspects of culture, the nurse shares that culture has four basic characteristics. Which statement correctly reflects one of these characteristics? a. Cultures are static and unchanging, despite changes around them. b. Cultures are never specific, which makes them hard to identify. c. Culture is most clearly reflected in a persons language and behavior. d. Culture adapts to specific environmental factors and available natural resources.
ANS: D Culture has four basic characteristics. Culture adapts to specific conditions related to environmental and technical factors and to the availability of natural resources, and it is dynamic and ever changing. Culture is learned from birth through the process of language acquisition and socialization, but it is not most clearly reflected in ones language and behavior.
16. What step of the nursing process includes data collection by health history, physical examination, and interview? a. Planning b. Diagnosis c. Evaluation d. Assessment
ANS: D Data collection, including performing the health history, physical examination, and interview, is the assessment step of the nursing process (see Figure 1-2).
34. The nurse is conducting a child safety class for new mothers. Which factor places young children at risk for ear infections? a. Family history b. Air conditioning c. Excessive cerumen d. Passive cigarette smoke
ANS: D Exposure to passive and gestational smoke is a risk factor for ear infections in infants and children.
17. During a staff meeting, nurses discuss the problems with accessing research studies to incorporate evidence-based clinical decision making into their practice. Which suggestion by the nurse manager would best help these problems? a. Form a committee to conduct research studies. b. Post published research studies on the units bulletin boards. c. Encourage the nurses to visit the library to review studies. d. Teach the nurses how to conduct electronic searches for research studies.
ANS: D Facilitating support for EBP would include teaching the nurses how to conduct electronic searches; time to visit the library may not be available for many nurses. Actually conducting research studies may be helpful in the long-run but not an immediate solution to reviewing existing research.
8. The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem? a. Patient with postoperative pain b. Newly diagnosed patient with diabetes who needs diabetic teaching c. Individual with a small laceration on the sole of the foot d. Individual with shortness of breath and respiratory distress
ANS: D First-level priority problems are those that are emergent, life threatening, and immediate (e.g., establishing an airway, supporting breathing, maintaining circulation, monitoring abnormal vital signs) (see Table 1-1).
25. An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. The nurse would need to know additional information that includes which of these? a. Any change in the ability to hear b. Any recent drainage from the ear c. Recent history of trauma to the ear d. Any prolonged exposure to extreme col
ANS: D Frostbite causes reddish-blue discoloration and swelling of the auricle after exposure to extreme cold. Vesicles or bullae may develop, and the person feels pain and tenderness.
34. When planning a cultural assessment, the nurse should include which component? a. Family history b. Chief complaint c. Medical history d. Health-related beliefs
ANS: D Health-related beliefs and practices are one component of a cultural assessment. The other items reflect other aspects of the patients history.
37. During a health history, a patient tells the nurse that he has trouble in starting his urine stream. This problem is known as: a. Urgency. b. Dribbling. c. Frequency. d. Hesitancy.
ANS: D Hesitancy is trouble in starting the urine stream. Urgency is the feeling that one cannot wait to urinate. Dribbling is the last of the urine before or after the main act of urination. Frequency is urinating more often than usual.
9. During an interview, the patient states he has the sensation that everything around him is spinning. The nurse recognizes that the portion of the ear responsible for this sensation is the: a. Cochlea. b. CN VIII. c. Organ of Corti. d. Labyrinth.
ANS: D If the labyrinth ever becomes inflamed, then it feeds the wrong information to the brain, creating a staggering gait and a strong, spinning, whirling sensation called vertigo.
18. The nurse is performing a genital examination on a male patient and notices urethral drainage. When collecting urethral discharge for microscopic examination and culture, the nurse should: a. Ask the patient to urinate into a sterile cup. b. Ask the patient to obtain a specimen of semen. c. Insert a cotton-tipped applicator into the urethra. d. Compress the glans between the examiners thumb and forefinger, and collect any discharge.
ANS: D If urethral discharge is noticed, then the examiner should collect a smear for microscopic examination and culture by compressing the glans anteroposteriorly between the thumb and forefinger. The other options are not correct actions.
29. In the hot/cold theory, illnesses are believed to be caused by hot or cold entering the body. Which of these patient conditions is most consistent with a cold condition? a. Patient with diabetes and renal failure b. Teenager with an abscessed tooth c. Child with symptoms of itching and a rash d. Older man with gastrointestinal discomfort
ANS: D Illnesses believed to be caused by cold entering the body include earache, chest cramps, gastrointestinal discomfort, rheumatism, and tuberculosis. Those illnesses believed to be caused by heat, or overheating, include sore throats, abscessed teeth, rashes, and kidney disorders.
22. Which situation is most appropriate during which the nurse performs a focused or problem-centered history? a. Patient is admitted to a long-term care facility. b. Patient has a sudden and severe shortness of breath. c. Patient is admitted to the hospital for surgery the following day. d. Patient in an outpatient clinic has cold and influenza-like symptoms.
ANS: D In a focused or problem-centered data base, the nurse collects a mini data base, which is smaller in scope than the completed data base. This mini data base primarily concerns one problem, one cue complex, or one body system.
21. In performing an examination of a 3-year-old child with a suspected ear infection, the nurse would: a. Omit the otoscopic examination if the child has a fever. b. Pull the ear up and back before inserting the speculum. c. Ask the mother to leave the room while examining the child. d. Perform the otoscopic examination at the end of the assessment.
ANS: D In addition to its place in the complete examination, eardrum assessment is mandatory for any infant or child requiring care for an illness or fever. For the infant or young child, the timing of the otoscopic examination is best toward the end of the complete examination.
26. In the health promotion model, the focus of the health professional includes: a. Changing the patients perceptions of disease. b. Identifying biomedical model interventions. c. Identifying negative health acts of the consumer. d. Helping the consumer choose a healthier lifestyle.
ANS: D In the health promotion model, the focus of the health professional is on helping the consumer choose a healthier lifestyle.
20. The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the: a. Patients history of allergies. b. Patients use of medications at home. c. Last menstrual period 1 month ago. d. 2 5 cm scar on the right lower forearm.
ANS: D Objective data are the patients record, laboratory studies, and condition that the health professional observes by inspecting, percussing, palpating, and auscultating during the physical examination. The other responses reflect subjective data.
27. The mother of a 2-year-old toddler is concerned about the upcoming placement of tympanostomy tubes in her sons ears. The nurse would include which of these statements in the teaching plan? a. The tubes are placed in the inner ear. b. The tubes are used in children with sensorineural loss. c. The tubes are permanently inserted during a surgical procedure. d. The purpose of the tubes is to decrease the pressure and allow for drainage.
ANS: D Polyethylene tubes are surgically inserted into the eardrum to relieve middle ear pressure and to promote drainage of chronic or recurrent middle ear infections. Tubes spontaneously extrude in 6 months to 1 year.
35. The nurse is providing patient teaching about an erectile dysfunction drug. One of the drugs potential side effects is prolonged, painful erection of the penis without sexual stimulation, which is known as: a. Orchitis. b. Stricture. c. Phimosis. d. Priapism.
ANS: D Priapism is prolonged, painful erection of the penis without sexual desire. Orchitis is inflammation of the testes. Stricture is a narrowing of the opening of the urethral meatus. Phimosis is the inability to retract the foreskin.
24. During a class on religion and spirituality, the nurse is asked to define spirituality. Which answer is correct? Spirituality: a. Is a personal search to discover a supreme being. b. Is an organized system of beliefs concerning the cause, nature, and purpose of the universe. c. Is a belief that each person exists forever in some form, such as a belief in reincarnation or the afterlife. d. Arises out of each persons unique life experience and his or her personal effort to find purpose in life.
ANS: D Spirituality arises out of each persons unique life experience and his or her personal effort to find purpose and meaning in life. The other definitions reflect the concept of religion.
35. Which of the following reflects the traditional health and illness beliefs and practices of those of African heritage? Health is: a. Being rewarded for good behavior. b. The balance of the body and spirit. c. Maintained by wearing jade amulets. d. Being in harmony with nature.
ANS: D The belief that health is being in harmony with nature reflects the health beliefs of those of African heritages. The other examples represent Iberian and Central and South American heritages, American-Indian heritages, and Asian heritages (See Table 2-3).
4. The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true? a. The eustachian tube is responsible for the production of cerumen. b. It remains open except when swallowing or yawning. c. The eustachian tube allows passage of air between the middle and outer ear. d. It helps equalize air pressure on both sides of the tympanic membrane.
ANS: D The eustachian tube allows an equalization of air pressure on each side of the tympanic membrane so that the membrane does not rupture during, for example, altitude changes in an airplane. The tube is normally closed, but it opens with swallowing or yawning.
16. The nurse is examining the glans and knows which finding is normal for this area? a. The meatus may have a slight discharge when the glans is compressed. b. Hair is without pest inhabitants. c. The skin is wrinkled and without lesions. d. Smegma may be present under the foreskin of an uncircumcised male.
ANS: D The glans looks smooth and without lesions and does not have hair. The meatus should not have any discharge when the glans is compressed. Some cheesy smegma may have collected under the foreskin of an uncircumcised male.
28. The nurse is reviewing the hot/cold theory of health and illness. Which statement best describes the basic tenets of this theory? a. The causation of illness is based on supernatural forces that influence the humors of the body. b. Herbs and medicines are classified on their physical characteristics of hot and cold and the humors of the body. c. The four humors of the body consist of blood, yellow bile, spiritual connectedness, and social aspects of the individual. d. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors of the body.
ANS: D The hot/cold theory of health and illness is based on the four humors of the body: blood, phlegm, black bile, and yellow bile. These humors regulate the basic bodily functions, described in terms of temperature, dryness, and moisture. The treatment of disease consists of adding or subtracting cold, heat, dryness, or wetness to restore the balance of the humors. The other statements are not correct.
25. A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurse knows that including cultural information in his health assessment is important to: a. Identify the cause of his illness. b. Make accurate disease diagnoses. c. Provide cultural health rights for the individual. d. Provide culturally sensitive and appropriate care.
ANS: D The inclusion of cultural considerations in the health assessment is of paramount importance to gathering data that are accurate and meaningful and to intervening with culturally sensitive and appropriate care.
11. The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse? a. It is unusual for a small child to have frequent ear infections unless something else is wrong. b. We need to check the immune system of your son to determine why he is having so many ear infections. c. Ear infections are not uncommon in infants and toddlers because they tend to have more cerumen in the external ear. d. Your sons eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily.
ANS: D The infants eustachian tube is relatively shorter and wider than the adults eustachian tube, and its position is more horizontal; consequently, pathogens from the nasopharynx can more easily migrate through to the middle ear. The other responses are not appropriate.
13. When the nurse is conducting sexual history from a male adolescent, which statement would be most appropriate to use at the beginning of the interview? a. Do you use condoms? b. You dont masturbate, do you? c. Have you had sex in the last 6 months? d. Often adolescents your age have questions about sexual activity.
ANS: D The interview should begin with a permission statement, which conveys that it is normal and acceptable to think or feel a certain way. Sounding judgmental should be avoided.
28. When performing a genital assessment on a middle-aged man, the nurse notices multiple soft, moist, painless papules in the shape of cauliflower-like patches scattered across the shaft of the penis. These lesions are characteristic of: a. Carcinoma. b. Syphilitic chancres. c. Genital herpes. d. Genital warts.
ANS: D The lesions of genital warts are soft, pointed, moist, fleshy, painless papules that may be single or multiple in a cauliflower-like patch. They occur on the shaft of the penis, behind the corona, or around the anus, where they may grow into large grapelike clusters. (See Table 24-4 for more information and for the descriptions of the other options.)
During an assessment of a patient's family history, the nurse constructs a genogram. Which statement best describes a genogram? a.List of diseases present in a person's near relatives b.Graphic family tree that uses symbols to depict the gender, relationship, and age of immediate family members c.Drawing that depicts the patient's family members up to five generations back d.Description of the health of a person's children and grandchildren
B
28. In an individual with otitis externa, which of these signs would the nurse expect to find on assessment? a. Rhinorrhea b. Periorbital edema c. Pain over the maxillary sinuses d. Enlarged superficial cervical nodes
ANS: D The lymphatic drainage of the external ear flows to the parotid, mastoid, and superficial cervical nodes. The signs are severe swelling of the canal, inflammation, and tenderness. Rhinorrhea, periorbital edema, and pain over the maxillary sinuses do not occur with otitis externa.
30. When providing culturally competent care, nurses must incorporate cultural assessments into their health assessments. Which statement is most appropriate to use when initiating an assessment of cultural beliefs with an older American-Indian patient? a. Are you of the Christian faith? b. Do you want to see a medicine man? c. How often do you seek help from medical providers? d. What cultural or spiritual beliefs are important to you?
ANS: D The nurse needs to assess the cultural beliefs and practices of the patient. American Indians may seek assistance from a medicine man or shaman, but the nurse should not assume this. An open-ended question regarding cultural and spiritual beliefs is best used initially when performing a cultural assessment.
12. The nursing process is a sequential method of problem solving that nurses use and includes which steps? a. Assessment, treatment, planning, evaluation, discharge, and follow-up b. Admission, assessment, diagnosis, treatment, and discharge planning c. Admission, diagnosis, treatment, evaluation, and discharge planning d. Assessment, diagnosis, outcome identification, planning, implementation, and evaluation
ANS: D The nursing process is a method of problem solving that includes assessment, diagnosis, outcome identification, planning, implementation, and evaluation.
28. Which statement best describes a proficient nurse? A proficient nurse is one who: a. Has little experience with a specified population and uses rules to guide performance. b. Has an intuitive grasp of a clinical situation and quickly identifies the accurate solution. c. Sees actions in the context of daily plans for patients. d. Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient.
ANS: D The proficient nurse, with more time and experience than the novice nurse, is able to understand a patient situation as a whole rather than as a list of tasks. The proficient nurse is able to see how todays nursing actions can apply to the point the nurse wants the patient to reach at a future time.
15. The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? a. Do you ever notice ringing or crackling in your ears? b. When was the last time you had your hearing checked? c. Have you ever been told that you have any type of hearing loss? d. Is there any relationship between the ear pain and the discharge you mentioned?
ANS: D Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs
5. Which statement concerning the testes is true? a. The lymphatic vessels of the testes drain into the abdominal lymph nodes. b. The vas deferens is located along the inferior portion of each testis. c. The right testis is lower than the left because the right spermatic cord is longer. d. The cremaster muscle contracts in response to cold and draws the testicles closer to the body.
ANS: D When it is cold, the cremaster muscle contracts, which raises the scrotal sac and brings the testes closer to the body to absorb heat necessary for sperm viability. The lymphatic vessels of the testes drain into the inguinal lymph nodes. The vas deferens is located along the upper portion of each testis. The left testis is lower than the right because the left spermatic cord is longer.
21. When the nurse is performing a genital examination on a male patient, which action is correct? a. Auscultating for the presence of a bruit over the scrotum b. Palpating for the vertical chain of lymph nodes along the groin, inferior to the inguinal ligament c. Palpating the inguinal canal only if a bulge is present in the inguinal region during inspection d. Having the patient shift his weight onto the left (unexamined) leg when palpating for a hernia on the right side
ANS: D When palpating for the presence of a hernia on the right side, the male patient is asked to shift his weight onto the left (unexamined) leg. Auscultating for a bruit over the scrotum is not appropriate. When palpating for lymph nodes, the horizontal chain is palpated. The inguinal canal should be palpated whether a bulge is present or not.
15. When the nurse is performing a genital examination on a male patient, the patient has an erection. The nurses most appropriate action or response is to: a. Ask the patient if he would like someone else to examine him. b. Continue with the examination as though nothing has happened. c. Stop the examination, leave the room while stating that the examination will resume at a later time. d. Reassure the patient that this is a normal response and continue with the examination.
ANS: D When the male patient has an erection, the nurse should reassure the patient that this is a normal physiologic response to touch and proceed with the rest of the examination. The other responses are not correct and may be perceived as judgmental.
21. A 63-year-old Chinese-American man enters the hospital with complaints of chest pain, shortness of breath, and palpitations. Which statement most accurately reflects the nurses best course of action? a. The nurse should focus on performing a full cardiac assessment. b. The nurse should focus on psychosomatic complaints because the patient has just learned that his wife has cancer. c. This patient is not in any danger at present; therefore, the nurse should send him home with instructions to contact his physician. d. It is unclear what is happening with this patient; consequently, the nurse should perform an assessment in both the physical and the psychosocial realms.
ANS: D Wide cultural variations exist in the manner in which certain symptoms and disease conditions are perceived, diagnosed, labeled, and treated. Chinese-Americans sometimes convert mental experiences or states into bodily symptoms (e.g., complaining of cardiac symptoms because the center of emotion in the Chinese culture is the heart).
25. To detect diastasis recti, the nurse should have the patient perform which of these maneuvers? A) Relax in the supine position. B) Raise the arms in the left lateral position. C) Raise the arms over the head while supine. D) Raise the head while remaining supine.
ANS: D Diastasis recti is a separation of the abdominal rectus muscles, which can occur congenitally, as a result of pregnancy, or from marked obesity. This is assessed by having the patient raise the head while remaining supine.
30. When performing a genitourinary assessment on a 16-year-old male adolescent, the nurse notices a swelling in the scrotum that increases with increased intra-abdominal pressure and decreases when he is lying down. The patient complains of pain when straining. The nurse knows that this description is most consistent with a(n) ______ hernia. a. Femoral b. Incisional c. Direct inguinal d. Indirect inguinal
ANS: D With indirect inguinal hernias, pain occurs with straining and a soft swelling increases with increased intra-abdominal pressure, which may decrease when the patient lies down. These findings do not describe the other hernias. (See Table 24-7 for the descriptions of femoral, direct inguinal, and indirect inguinal hernias.)
32. The nurse recognizes that categories such as ethnicity, gender, and religion illustrate the concept of: a. Family. b. Cultures. c. Spirituality. d. Subcultures.
ANS: D Within cultures, groups of people share different beliefs, values, and attitudes. Differences occur because of ethnicity, religion, education, occupation, age, and gender. When such groups function within a large culture, they are referred to as subcultural groups.
4. When discussing the use of the term subculture, the nurse recognizes that it is best described as: a. Fitting as many people into the majority culture as possible. b. Defining small groups of people who do not want to be identified with the larger culture. c. Singling out groups of people who suffer differential and unequal treatment as a result of cultural variations. d. Identifying fairly large groups of people with shared characteristics that are not common to all members of a culture.
ANS: D Within cultures, groups of people share different beliefs, values, and attitudes. Differences occur because of ethnicity, religion, education, occupation, age, and gender. When such groups function within a large culture, they are referred to as subcultural groups.
The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse reports this as a: a. Bulla. b. Wheal. c. Nodule. d. Papule.
ANS: D A papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm in diameter, and is due to superficial thickening in the epidermis. A bulla is larger than 1 cm, superficial, and thin walled. A wheal is superficial, raised, transient, erythematous, and irregular in shape attributable to edema. A nodule is solid, elevated, hard or soft, and larger than 1 cm.
7. A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as: A) obese. B) herniated. C) scaphoid. D) protuberant.
ANS: D A protuberant abdomen is rounded, bulging, and stretched. See Figure 21-7. A scaphoid abdomencaves inward
The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor in the older adult? a. Increased vascularity of the skin b. Increased numbers of sweat and sebaceous glands c. An increase in elastin and a decrease in subcutaneous fat d. An increased loss of elastin and a decrease in subcutaneous fat
ANS: D An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, a decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging, a increasingly sedentary lifestyle, and the chance of immobility.
13. The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: A) a loud continuous hum. B) a peritoneal friction rub. C) hypoactive bowel sounds. D) hyperactive bowel sounds.
ANS: D Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling.
A 35-year-old woman is at the clinic for a gynecologic examination. During the examination, she asks the nurse, "How often do I need to have this Pap test done?" Which reply by the nurse is correct? A) "It depends. Do you smoke?" B) "This will need to be done annually until you are 65." C) "If you have 2 consecutive normal Pap tests, then you can wait 5 years between tests." D) "After age 30, if you have 3 consecutive normal Pap tests, then you may be screened every 2 to 3 years."
ANS: D Cervical cancer screening with the Pap test continues annually until age 30. After age 30, if the woman has 3 consecutive normal Pap tests, then women may be screened every 2 to 3 years.
The nurse documents that a patient has coarse, thickened skin and brown discoloration over the lower legs. Pulses are present. This finding is probably the result of: A) lymphedema. B) Raynaud's disease. C) chronic arterial insufficiency. D) chronic venous insufficiency.
ANS: D Chronic venous insufficiency would present as firm brawny edema, coarse thickened skin, normal pulses, and brown discoloration. See Chapter 20. Pages: 499-525
A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding? a. Anasarca b. Scleroderma c. Pedal erythema d. Clubbing of the nails
ANS: D Clubbing of the nails occurs with congenital cyanotic heart disease and neoplastic and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases.
8. The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a _____ profile. A) flat B) convex C) bulging D) concave
ANS: D Contour describes the profile of the abdomen from the rib margin to the pubic bone; a scaphoid contour is one that is concave from a horizontal plane. See Figure 21-7.
A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and takes oral hypoglycemic agents. The patient needs to be concerned about which possible effect of her medications? a. Increased possibility of bruising b. Skin sensitivity as a result of exposure to salt water c. Lack of availability of glucose-monitoring supplies d. Importance of sunscreen and avoiding direct sunlight
ANS: D Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline.
4. The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? A) Percuss and palpate in the lumbar region. B) Inspect and palpate in the epigastric region. C) Auscultate and percuss in the inguinal region. D) Percuss and palpate the midline area above the suprapubic bone.
ANS: D Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation.
A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is due to hyperemia and knows that it can be caused by: a. Decreased amounts of bilirubin in the blood b. Excess blood in the underlying blood vessels c. Decreased perfusion to the surrounding tissues d. Excess blood in the dilated superficial capillaries
ANS: D Erythema is an intense redness of the skin caused by excess blood (hyperemia) in the dilated superficial capillaries.
5. The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: A) increased salivation. B) increased liver size. C) increased esophageal emptying. D) decreased gastric acid secretion.
ANS: D Gastric acid secretion decreases with aging. As one ages, salivation decreases, esophageal emptying is delayed, and liver size decreases
A 22-year-old woman is being seen at the clinic for problems with vulvar pain, dysuria, and fever. On physical examination, the nurse notices clusters of small, shallow vesicles with surrounding erythema on the labia. There is also inguinal lymphadenopathy present. The most likely cause of these lesions is: A) pediculosis pubis. B) contact dermatitis. C) human papillomavirus. D) herpes simplex virus type 2.
ANS: D Herpes simplex virus type 2 presents with clusters of small, shallow vesicles with surrounding erythema that erupt on the genital areas. There is also the presence of inguinal lymphadenopathy. The individual reports local pain, dysuria, and fever. See Table 26-2 for more information and descriptions of the other conditions.
6. A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation? A) The spleen can be enlarged as a result of trauma. B) The spleen is normally felt upon routine palpation. C) If an enlarged spleen is noticed, then the nurse should palpate thoroughly to determine size. D) An enlarged spleen should not be palpated because it can rupture easily.
ANS: D If an enlarged spleen is felt, then the nurse should refer the person but should not continue to palpate it. An enlarged spleen is friable and can rupture easily with overpalpation
38. During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with: A) splenomegaly. B) distended bladder. C) constipation. D) ascites.
ANS: D If ascites (fluid in the abdomen) is present, then the examiner will feel a fluid wave when assessing the abdomen. A fluid wave is not present with splenomegaly, a distended bladder, or constipation
A 65-year-old woman is in the office for routine gynecologic care. She had a complete hysterectomy 3 months ago after cervical cancer was detected. The nurse knows that which of these statements is true with regard to this visit? A) Her cervical mucosa will be red and dry looking. B) She will not need to have a Pap smear done. C) The nurse can expect to find that her uterus will be somewhat enlarged and her ovaries small and hard. D) The nurse should plan to lubricate the instruments and the examining hand well to avoid a painful examination.
ANS: D In the aging adult woman, natural lubrication is decreased; to avoid a painful examination, the nurse should take care to lubricate instruments and the examining hand adequately. Menopause, with the resulting decrease in estrogen production, shows numerous physical changes. The cervix shrinks and looks pale and glistening. With the bimanual examination, the uterus feels smaller and firmer and the ovaries are not palpable normally. Women should continue cervical cancer screening up to age 70 years if they have an intact cervix and are in good health. Women who have had a total hysterectomy for benign gynecologic disease do not need cervical cancer screening, but if the hysterectomy was done for cervical cancer, then Pap tests should continue until the patient has a 10-year history of no abnormal results.
During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning: a. Metrocytes. b. Fungacytes. c. Phagocytes. d. Melanocytes.
ANS: D In the aging hair matrix, the number of functioning melanocytes decreases; as a result, the hair looks gray or white and feels thin and fine. The other options are not correct.
A patient has had a "terrible itch" for several months that he has been continuously scratching. On examination, the nurse might expect to find: a. A keloid. b. A fissure. c. Keratosis. d. Lichenification.
ANS: D Lichenification results from prolonged, intense scratching that eventually thickens the skin and produces tightly packed sets of papules. A keloid is a hypertrophic scar. A fissure is a linear crack with abrupt edges, which extends into the dermis; it can be dry or moist. Keratoses are lesions that are raised, thickened areas of pigmentation that appear crusted, scaly, and warty.
A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration. The nurse should test skin mobility and turgor over the infant's: a. Sternum. b. Forehead. c. Forearms. d. Abdomen.
ANS: D Mobility and turgor are tested over the abdomen in an infant. Poor turgor, or tenting, indicates dehydration or malnutrition. The other sites are not appropriate for checking skin turgor in an infant.
During examination, the nurse finds that a patient is unable to distinguish objects placed in his hand. The nurse would document: A) stereognosis. B) astereognosis. C) graphesthesia. D) agraphesthesia.
B
A 22-year-old woman has been considering using oral contraceptives. As a part of her history, the nurse should ask: A) "Do you have a history of heart murmurs?" B) "Will you be in a monogamous relationship?" C) "Have you thought this choice through carefully?" D) "If you smoke, how many cigarettes do you smoke per day?"
ANS: D Oral contraceptives, together with cigarette smoking, increase the risk for cardiovascular side effects. If cigarettes are used, then the nurse should assess smoking history. The other questions are not appropriate.
35. The nurse is assessing a patient for possible peptic ulcer disease and knows that which condition often causes this problem? A) Hypertension B) Streptococcus infections C) History of constipation and frequent laxative use D) Frequent use of nonsteroidal antiinflammatory drugs
ANS: D Peptic ulcer disease occurs with frequent use of nonsteroidal antiinflammatory drugs, alcohol use, smoking, and Helicobacter pylori infection.
A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cool temperature in the examination room. The infant's mother also notices the mottling and asks what it is. The nurse knows that this mottling is called: a. Café au lait. b. Carotenemia. c. Acrocyanosis. d. Cutis marmorata.
ANS: D Persistent or pronounced cutis marmorata occurs with infants born with Down syndrome or those born prematurely and is a transient mottling in the trunk and extremities in response to cool room temperatures. A café au lait spot is a large round or oval patch of light-brown pigmentation. Carotenemia produces a yellow-orange color in light-skinned persons. Acrocyanosis is a bluish color around the lips, hands and fingernails, and feet and toenails.
A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on" his skin. Which is the best prediction? a. Senile lentigines, which do not become cancerous b. Actinic keratoses, which are precursors to basal cell carcinoma c. Acrochordons, which are precursors to squamous cell carcinoma d. Seborrheic keratoses, which do not become cancerous
ANS: D Seborrheic keratoses appear like dark, greasy, "stuck-on" lesions that primarily develop on the trunk. These lesions do not become cancerous. Senile lentigines are commonly called liver spots and are not precancerous. Actinic (senile or solar) keratoses are lesions that are red-tan scaly plaques that increase over the years to become raised and roughened. They may have a silvery-white scale adherent to the plaque. They occur on sun-exposed surfaces and are directly related to sun exposure. They are premalignant and may develop into squamous cell carcinoma. Acrochordons are skin tags and are not precancerous.
During a health history, a 22-year old woman asks, "Can I get that vaccine for HPV? I have genital warts and I'd like them to go away!" What is the nurse's best response? A) "The HPV vaccine is for girls and women ages 9 to 26, so we can start that today." B) "This vaccine is only for girls who have not started to have intercourse yet." C) "Let's check with the physician to see if you are a candidate for this vaccine." D) "The vaccine cannot protect you if you already have an HPV infection."
ANS: D The HPV (human papillomavirus) vaccine is appropriate for girls and women age 9 to 26 and is given to prevent cervical cancer by preventing HPV infections before girls become sexually active. However, it cannot protect the woman if an HPV infection is already present.
32. A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of about 10 cm. The nurse should: A) document the presence of hepatomegaly. B) ask additional history questions regarding his alcohol intake. C) describe this as an enlarged liver and refer him to a physician. D) consider this a normal finding and proceed with the examination.
ANS: D The average liver span in the midclavicular line is 6 to 12 cm. Men and taller individuals are at the upper end of this range. Women and shorter individuals are at the lower end of this range. A liver span of 10 cm is within normal limits for this individual
The nurse educator is preparing an education module for the nursing staff on the dermis layer of skin. Which of these statements would be included in the module? The dermis: a. Contains mostly fat cells. b. Consists mostly of keratin. c. Is replaced every 4 weeks. d. Contains sensory receptors.
ANS: D The dermis consists mostly of collagen, has resilient elastic tissue that allows the skin to stretch, and contains nerves, sensory receptors, blood vessels, and lymphatic vessels. It is not replaced every 4 weeks.
The nurse educator is preparing an education module for the nursing staff on the epidermal layer of skin. Which of these statements would be included in the module? The epidermis is: a. Highly vascular. b. Thick and tough. c. Thin and nonstratified. d. Replaced every 4 weeks.
ANS: D The epidermis is thin yet tough, replaced every 4 weeks, avascular, and stratified into several zones.
The nurse is assessing for clubbing of the fingernails and expects to find: a. Nail bases that are firm and slightly tender. b. Curved nails with a convex profile and ridges across the nails. c. Nail bases that feel spongy with an angle of the nail base of 150 degrees. d. Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy.
ANS: D The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy.
2. Which structure is located in the left lower quadrant of the abdomen? A) Liver B) Duodenum C) Gallbladder D) Sigmoid colon
ANS: D The sigmoid colon is located in the left lower quadrant of the abdomen.
A 25-year-old woman comes to the emergency department with a sudden fever of 101° F and abdominal pain. Upon examination, the nurse notices that she has rigid, boardlike lower abdominal musculature. When the nurse tries to perform a vaginal examination, the patient has severe pain when the uterus and cervix are moved. The nurse knows that these signs and symptoms are suggestive of: A) endometriosis. B) uterine fibroids. C) ectopic pregnancy. D) pelvic inflammatory disease.
ANS: D These signs and symptoms are suggestive of acute pelvic inflammatory disease, also known as acute salpingitis. See Table 26-7. For description of endometriosis and uterine fibroids, see Table 26-6; for description of ectopic pregnancy, see Table 26-7.
During inspection of the posterior chest, the nurse should assess for: A) symmetric expansion. B) symmetry of shoulders and muscles. C) tactile fremitus. D) diaphragmatic excursion.
B
A mother brings her child into the clinic for an examination of the scalp and hair. She states that the child has developed irregularly shaped patches with broken-off, stublike hair in some places; she is worried that this condition could be some form of premature baldness. The nurse tells her that it is: a. Folliculitis that can be treated with an antibiotic. b. Traumatic alopecia that can be treated with antifungal medications. c. Tinea capitis that is highly contagious and needs immediate attention. d. Trichotillomania; her child probably has a habit of absentmindedly twirling her hair.
ANS: D Trichotillomania, self-induced hair loss, is usually due to habit. It forms irregularly shaped patches with broken-off, stublike hairs of varying lengths. A person is never completely bald. It occurs as a child absentmindedly rubs or twirls the area while falling asleep, reading, or watching television. (See Table 12-12, Abnormal Conditions of Hair, for descriptions of the other terms.)
The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth that are elevated approximately 1 to 3 mm. What other signs would the nurse expect to find in this patient? a. Pink, papular rash on the face and neck b. Pruritic vesicles over her trunk and neck c. Hyperpigmentation on the chest, abdomen, and back of the arms d. Red-purple, maculopapular, blotchy rash behind the ears and on the face
ANS: D With measles (rubeola), the examiner assesses a red-purple, blotchy rash on the third or fourth day of illness that appears first behind the ears, spreads over the face, and then over the neck, trunk, arms, and legs. The rash appears coppery and does not blanch. The bluish-white, red-based spots in the mouth are known as Koplik spots.
A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient? A) Hard and fixed cervical nodes B) Enlarged and tender inguinal nodes C) Bilateral enlargement of the popliteal nodes D) "Pellet-like" nodes in the supraclavicular region
ANS: Enlarged and tender inguinal nodes The inguinal nodes in the groin drain most of the lymph of the lower extremities. With local inflammation, the nodes in that area become swollen and tender.
The nurse is explaining the mechanism of the growth of long bones to a mother of a toddler. Where does lengthening of the bones occur? A) Bursa B) Calcaneus C) Epiphyses D) Tuberosities
ANS: Epiphyses Lengthening occurs at the epiphyses, or growth plates. The other options are not correct.
When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next? A) Assess the patient's abdomen, and notice any tenderness. B) Carefully assess the cervical lymph nodes, and check for any enlargement. C) Ask additional history questions regarding any recent ear infections or sore throats. D) Examine the patient's lower arm and hand, and check for the presence of infection or lesions.
ANS: Examine the patient's lower arm and hand, and check for the presence of infection or lesions. The epitrochlear nodes are located in the antecubital fossa and drain the hand and lower arm. The other actions are not correct for this assessment finding.
In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse's best course of action? a. Recommend that he make an appointment with his physician for a mammogram. b. Ignore it. Benign breast enlargement in men is not unusual. c. Explain that this condition may be the result of hormonal changes, and recommend that he see his physician. d. Explain that gynecomastia in men is usually associated with prostate enlargement and recommend that he be thoroughly screened.
ANS: Explain that this condition may be the result of hormonal changes and recommend that he see his physician. Gynecomastia may reappear in the aging male and may be due to testosterone deficiency.
The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)? A) Flexion and extension B) Supination and pronation C) Circumduction D) Inversion and eversion
ANS: Flexion and extension The knee is a hinge joint, permitting flexion and extension of the lower leg on a single plane. The knee is not capable of the other movements listed.
A patient with pleuritis has been admitted to the hospital and complains of pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation? a. Stridor b. Friction rub c. Crackles d. Wheezing
ANS: Friction rub A patient with pleuritis will exhibit a pleural friction rub upon auscultation. This is the sound made when pleurae become inflamed and rub together during respiration. The sound is superficial, coarse, and low-pitched, as if two pieces of leather are being rubbed together. Stridor is associated with croup, acute epiglottitis in children, and foreign body inhalation. Crackles are associated with several diseases, such as pneumonia, heart failure, chronic bronchitis, and others (see Table 18-6). Wheezes are associated with diffuse airway obstruction caused by acute asthma or chronic emphysema.
The nurse is examining a 2-month-old infant and notices asymmetry of the infant's gluteal folds. The nurse should assess for other signs of what disorder? A) Fractured clavicle B) Down syndrome C) Spina bifida D) Hip dislocation
ANS: Hip dislocation Unequal gluteal folds may accompany hip dislocation after 2 to 3 months of age, but some asymmetry may occur in healthy children. Further assessment is needed. The other responses are not correct.
A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, with a rate of 12 per minute. The nurse interprets this respiration pattern as which of the following? a. Bradypnea b. Cheyne-Stokes respirations c. Hypoventilation d. Chronic obstructive breathing
ANS: Hypoventilation Hypoventilation is characterized by an irregular, shallow pattern, and can be caused by an overdose of narcotics or anesthetics. Bradypnea is slow breathing, with a rate less than 10 respirations per minute. See Table 18-4 for descriptions of Cheyne-Stokes respirations and chronic obstructive breathing.
A 54-year-old man comes to the clinic with a "horrible problem." He tells the nurse that he has just discovered a lump on his breast and is fearful of cancer. The nurse knows that which statement about breast cancer in males is true? a. Breast masses in men are difficult to detect because of minimal breast tissue. b. Breast cancer in men rarely spreads to the lymph nodes. c. One percent of all breast cancers occurs in men. d. Most breast masses in men are diagnosed as gynecomastia.
ANS: One percent of all breast cancer occurs in men. One percent of all breast cancer occurs in men. Early spread to axillary lymph nodes occurs due to minimal breast tissue.
The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? A) Intraluminal valves ensure unidirectional flow toward the heart. B) Contracting skeletal muscles milk blood distally toward the veins. C) The high-pressure system of the heart helps to facilitate venous return. D) Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.
ANS: Intraluminal valves ensure unidirectional flow toward the heart. Blood moves through the veins by (1) contracting skeletal muscles that milk the blood proximally; (2) pressure gradients caused by breathing, in which inspiration makes the thoracic pressure decrease and the abdominal pressure increase; and (3) the intraluminal valves, which ensure unidirectional flow toward the heart.
During an examination, the nurse notes a supernumerary nipple just under the patient's left breast. The patient tells the nurse that she always thought it was a mole. Which statement about this finding is correct? a. This variation is normal and not a significant finding. b. This finding is significant and needs further investigation. c. A supernumerary nipple also contains glandular tissue and may leak milk during pregnancy and lactation. d. The patient is correct—a supernumerary nipple is actually a mole that happens to be located under the breast.
ANS: It is a normal variation and not a significant finding. A supernumerary nipple looks like a mole, but close examination reveals a tiny nipple and areola. It is not a significant finding.
During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate? a. Normal nipple inversion is usually bilateral. b. Unilateral inversion of a nipple is always a serious sign. c. Whether the inversion is a recent change should be determined. d. Nipple inversion is not significant unless accompanied by an underlying palpable mass.
ANS: It should be determined whether the inversion is a recent change. The nurse should distinguish a recently retracted nipple from one that has been inverted for many years or since puberty. Normal nipple inversion may be unilateral or bilateral and usually can be pulled out (i.e., it is not fixed). Recent nipple retraction signifies acquired disease. See Table 17-3.
The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation? A) Behind the knee B) Over the lateral malleolus C) In the groove behind the medial malleolus D) Lateral to the extensor tendon of the great toe
ANS: Lateral to the extensor tendon of the great toe The dorsalis pedis artery is located on the dorsum of the foot. The nurse should palpate just lateral to and parallel with the extensor tendon of the big toe. The popliteal artery is palpated behind the knee. The posterior tibial pulse is palpated in the groove between the malleolus and the Achilles tendon. There is no pulse palpated at the lateral malleolus.
During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways? a. Listening to at least one full respiration in each location b. Listening as the patient inhales and then going to the next site during exhalation c. Instructing the patient to breathe in and out rapidly while listening to the breath sounds d. If the patient is modest, listening to sounds over his or her clothing or hospital gown
ANS: Listen to at least one full respiration in each location. During auscultation of breath sounds with a stethoscope, it is important to listen to one full respiration in each location. During the examination, the nurse should monitor the breathing and offer times for the person to breathe normally to prevent possible dizziness.
During an assessment, the nurse notices that a patient's left arm is swollen from the shoulder down to the fingers, with nonpitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem? A) Venous stasis B) Lymphedema C) Arteriosclerosis D) Deep vein thrombosis
ANS: Lymphedema Lymphedema after breast cancer causes unilateral swelling and nonpitting brawny edema, with overlying skin indurated. It is caused by the removal of lymph nodes with breast surgery or damage to lymph nodes and channels with radiation therapy for breast cancer, and it can impede drainage of lymph. The other responses are not correct.
A new mother calls the clinic to report that part of her left breast is red, swollen, tender, very hot, and hard. She has a fever of 101 F. She has also had symptoms of the flu, such as chills, sweating, and feeling tired. The nurse notices that she has been breastfeeding for 1 month. From her description, what condition does the nurse suspect? a. Mastitis b. Paget disease c. Plugged milk duct d. Mammary duct ectasia
ANS: Mastitis The symptoms describe mastitis, which stems from infection or stasis caused by a plugged duct. A plugged duct does not have infection present. (See Table 17-7.) Refer to Table 17-6 for descriptions of Paget's disease and mammary duct ectasia.
During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of: a. Adventitious sounds and limited chest expansion. b. Increased tactile fremitus and dull percussion tones. c. Muffled voice sounds and symmetric tactile fremitus. d. Absent voice sounds and hyperresonant percussion tones.
ANS: Muffled voice sounds and symmetric tactile fremits. Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds.
The nurse is assessing the breasts of a 68-year-old woman and discovers a mass in the upper outer quadrant of the left breast. When assessing this mass, the nurse keeps in mind that characteristics of a cancerous mass include which of the following? Select all that apply. a. Nontender mass b. Dull, heavy pain on palpation c. Rubbery texture and mobile d. Hard, dense, and immobile e. Regular border f. Irregular, poorly delineated border
ANS: Nontender mass Hard, dense, and immobile Irregular,poorly delineated border Cancerous breast masses are solitary, unilateral, nontender, masses. They are solid, hard, dense, and fixed to underlying tissues or skin as cancer becomes invasive. Their borders are irregular and poorly delineated. They are often painless, although the person may have pain. They are most common in upper outer quadrant. A dull, heavy pain on palpation and a mass with a rubbery texture and a regular border are characteristics of benign breast disease.
The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radial pulses are "2+." The nurse recognizes that this reading indicates what type of pulse? A) Bounding B) Normal C) Weak D) Absent
ANS: Normal When documenting the force, or amplitude, of pulses, 3+ indicates an increased, full, or bounding pulse, 2+ indicates a normal pulse, 1+ indicates a weak pulse, and 0 indicates an absent pulse.
The nurse is performing a well-child check on a 5-year-old boy. He has no current history that would lead the nurse to suspect illness. His medical history is unremarkable, and he received immunizations 1 week ago. Which of these findings should be considered normal in this situation? A) Enlarged, warm, tender nodes B) Lymphadenopathy of the cervical nodes C) Palpable firm, small, shotty, mobile, nontender lymph nodes D) Firm, rubbery, large nodes, somewhat fixed to the underlying tissue
ANS: Palpable firm, small, shotty, mobile, nontender lymph nodes Palpable lymph nodes are often normal in children and infants. They are small, firm, shotty, mobile, and nontender. Vaccinations can produce lymphadenopathy. Enlarged, warm, tender nodes indicate current infection.
During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process? A) Hormonal changes causing vasodilation and a resulting drop in blood pressure B) Progressive atrophy of the intramuscular calf veins, causing venous insufficiency C) Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure D) Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities
ANS: Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure Peripheral blood vessels grow more rigid with age, resulting in a rise in systolic blood pressure. Aging produces progressive enlargement of the intramuscular calf veins, not atrophy. The other options are not correct.
The nurse is reviewing risk factors for venous disease. Which of these situations best describes a person at highest risk for development of venous disease? A) Woman in her second month of pregnancy B) Person who has been on bed rest for 4 days C) Person with a 30-year, 1 pack per day smoking history D) Elderly person taking anticoagulant medication
ANS: Person who has been on bed rest for 4 days At risk for venous disease are people who undergo prolonged standing, sitting, or bed rest. Hypercoagulable (not anticoagulated) states and vein wall trauma also place the person at risk for venous disease. Obesity and pregnancy are also risk factors, but not the early months of pregnancy.
During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition? a. Airway obstruction b. Emphysema c. Pulmonary consolidation d. Asthma
ANS: Pulmonary consolidation Pathologic conditions that increase lung density, such as pulmonary consolidation, will enhance transmission of voice sounds, such as bronchophony. See Table 18-7.
During a morning assessment, the nurse notices that the patient's sputum is frothy and pink. Which condition could this finding indicate? a. Croup b. Tuberculosis c. Viral infection d. Pulmonary edema
ANS: Pulmonary edema Sputum alone is not diagnostic, but some conditions have characteristic sputum production. Pink, frothy sputum indicates pulmonary edema (or it may be a side effect of sympathomimetic medications). Croup is associated with a "barking" cough, not sputum production. Tuberculosis may produce rust-colored sputum. Viral infections may produce white or clear mucoid sputum.
During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing: A) lymphedema. B) Raynaud's disease. C) deep vein thrombosis. D) chronic arterial insufficiency.
ANS: Raynaud's disease. The condition with episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress is known as Raynaud's disease. Lymphedema is described in Table 20-2; deep vein thrombosis is described in Table 20-5; chronic arterial insufficiency is described in Table 20-4.
A patient is complaining of pain in his joints that is worse in the morning, is better after he has moved around for awhile, and then gets worse again if he sits for long periods of time. The nurse should assess for other signs of what problem? A) Tendinitis B) Osteoarthritis C) Rheumatoid arthritis D) Intermittent claudication
ANS: Rheumatoid arthritis Rheumatoid arthritis is worse in the morning when arising. Movement increases most joint pain, except in rheumatoid arthritis, in which movement decreases pain. The other options are not correct.
A woman has just learned that she is pregnant. What are some things the nurse should teach her about her breasts? a. She can expect her areolae to become larger and darker in color. b. Breasts may begin secreting milk after the fourth month of pregnancy. c. She should inspect her breasts for visible veins and immediately report these. d. During pregnancy, breast changes are fairly uncommon; most of the changes occur after the birth.
ANS: She can expect her areolae to become larger and darker in color. The areolae become larger and grow a darker brown as pregnancy progresses, and the tubercles become more prominent. (The brown color fades after lactation, but the areolae never return to the original color). A venous pattern is prominent over the skin surface and does not need to be reported as it is an expected finding. After the fourth month, colostrum, a thick, yellow fluid (precursor to milk) may be expressed from the breasts.
A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this situation? a. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema b. Rasping cough, thick mucoid sputum, wheezing, and bronchitis c. Productive cough, dyspnea, weight loss, anorexia, and tuberculosis d. Fever, dry nonproductive cough, and diminished breath sounds
ANS: Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, ankle edema Heart failure often presents with increased respiratory rate, shortness of breath on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, and pallor in light-skinned individuals. A patient with rasping cough, thick mucoid sputum, and wheezing may have bronchitis. Productive cough, dyspnea, weight loss, and dyspnea are seen with tuberculosis; fever, dry nonproductive cough, and diminished breath sounds may indicate Pneumocystis jiroveci (P. carinii) pneumonia. See Table 18-8.
Which of these veins are responsible for most of the venous return in the arm? A) Deep B) Ulnar C) Subclavian D) Superficial
ANS: Superficial The superficial veins of the arms are in the subcutaneous tissue and are responsible for most of the venous return.
The nurse is palpating a female patient's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation? a. Supine with the arms raised over her head b. Sitting with the arms relaxed at her sides c. Supine with the arms relaxed at her sides d. Sitting with the arms flexed and fingertips touching her shoulders
ANS: Supine with arms raised over her head The nurse should help the woman to a supine position, tuck a small pad under the side to be palpated, and help the woman raise her arm over her head. These maneuvers will flatten the breast tissue and displace it medially. Any significant lumps will then feel more distinct.
A patient who has had rheumatoid arthritis for years comes to the clinic to ask about changes in her fingers. The nurse will assess for signs of what problems? A) Heberden's nodes B) Bouchard's nodules C) Swan neck deformities D) Dupuytren's contractures
ANS: Swan neck deformities Changes in the fingers caused by chronic rheumatoid arthritis include swan neck and boutonniere deformities. Heberden's nodes and Bouchard's nodules are associated with osteoarthritis. Dupuytren's contractures occur because of chronic hyperplasia of the palmar fascia and causes contractures of the digits (see Table 22-4).
When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard? A) Low humming sound B) Regular "lub, dub" pattern C) Swishing, whooshing sound D) Steady, even, flowing sound
ANS: Swishing, whooshing sound When using the Doppler ultrasonic stethoscope, the pulse site is found when one hears a swishing, whooshing sound.
A woman is in the family planning clinic seeking birth control information. She states that her breasts "change all month long" and that she is worried that this is unusual. What is the nurse's best response? a. Continual changes in her breasts are unusual. The breasts of nonpregnant women usually stay pretty much the same all month long. b. Breast changes in response to stress are very common and that she should assess her life for stressful events. c. Because of the changing hormones during the monthly menstrual cycle, cyclic breast changes are common. d. Breast changes normally occur only during pregnancy and that a pregnancy test is needed at this time.
ANS: Tell her that, because of the changing hormones during the monthly menstrual cycle, cyclic breast changes are common. Breasts of the nonpregnant woman change with the ebb and flow of hormones during the monthly menstrual cycle. During the 3 to 4 days before menstruation, the breasts feel full, tight, heavy, and occasionally sore. The breast volume is smallest on days 4 to 7 of the menstrual cycle.
A patient contacts the office and tells the nurse that she is worried about her 10-year-old daughter having breast cancer. She describes a unilateral enlargement of the right breast with associated tenderness. She is worried because the left breast is not enlarged. What would be the nurse's best response? a. Breast development is usually fairly symmetric and that the daughter should be examined right away. b. She should bring in her daughter right away because breast cancer is fairly common in preadolescent girls. c. Although an examination of her daughter would rule out a problem, her breast development is most likely normal. d. It is unusual for breasts that are first developing to feel tender because they haven't developed much fibrous tissue.
ANS: Tell the mother that, although an examination of her daughter would rule out a problem, it is most likely normal breast development. Occasionally one breast may grow faster than the other, producing a temporary asymmetry. This may cause some distress; reassurance is necessary. Tenderness is common also.
Which of these statements is true regarding the arterial system? A) Arteries are large-diameter vessels. B) The arterial system is a high-pressure system. C) The walls of arteries are thinner than those of veins. D) Arteries can expand greatly to accommodate a large blood volume increase
ANS: The arterial system is a high-pressure system. The pumping heart makes the arterial system a high-pressure system.
The nurse is conducting a class about breast self-examination (BSE). Which of these statements indicates proper BSE technique? a. The best time to perform BSE is in the middle of the menstrual cycle. b. The woman needs to perform BSE only bimonthly unless she has fibrocystic breast tissue. c. The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. d. If she suspects that she is pregnant, then the woman should not perform a BSE until her baby is born.
ANS: The best time to perform BSE is 4 to 7 days after the first day of the menstrual period. The nurse should help each woman establish a regular schedule of self-care. The best time to conduct breast self-examination is right after the menstrual period, or the fourth through seventh day of the menstrual cycle, when the breasts are the smallest and least congested. Advise the pregnant or menopausal woman who is not having menstrual periods to select a familiar date to examine her breasts each month, for example, her birth date or the day the rent is due.
The nurse is assessing the lungs of an older adult. Which of these describes normal changes in the respiratory system of the older adult? a. Severe dyspnea is experienced on exertion, resulting from changes in the lungs. b. Respiratory muscle strength increases to compensate for a decreased vital capacity. c. Decrease in small airway closure occurs, leading to problems with atelectasis. d. Lungs are less elastic and distensible, which decreases their ability to collapse and recoil.
ANS: The lungs are less elastic and distensible, which decreases their ability to collapse and recoil. In the aging adult the lungs are less elastic and distensible, which decreases their ability to collapse and recoil. There is a decreased vital capacity and a loss of intraalveolar septa, causing less surface area for gas exchange. The lung bases become less ventilated, and the older person is at risk for dyspnea with exertion beyond his or her usual workload.
When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect? a. Crepitus palpated at the costochondral junctions b. No diaphragmatic excursion as a result of a child's decreased inspiratory volume c. Presence of bronchovesicular breath sounds in the peripheral lung fields d. Irregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest
ANS: The presence of bronchovesicular breath sounds in the peripheral lung fields Bronchovesicular breath sounds in the peripheral lung fields of the infant and young child up to age 5 or 6 years are a normal finding. Their thin chest walls with underdeveloped musculature do not dampen the sound, as do the thicker chest walls of adults, so breath sounds are louder and harsher.
The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect? A) Excessive swelling of the lymph nodes B) The presence of palpable lymph nodes C) No nodes palpable because of the immature immune system of a child D) Fewer numbers and a smaller size of lymph nodes compared with those of an adult
ANS: The presence of palpable lymph nodes Lymph nodes are relatively large in children, and the superficial ones often are palpable even when the child is healthy.
When inspecting the anterior chest of an adult, the nurse should include which assessment? a. Diaphragmatic excursion b. Symmetric chest expansion c. Presence of breath sounds d. Shape and configuration of the chest wall
ANS: The shape and configuration of the chest wall Inspection of the anterior chest includes shape and configuration of the chest wall; assessment of the patient's level of consciousness, skin color and condition; quality of respirations; presence or absence of retraction and bulging of the intercostal spaces; and use of accessory muscles. Symmetric chest expansion is assessed by palpation. Diaphragmatic excursion is assessed by percussion of the posterior chest. Breath sounds are assessed by auscultation.
During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding? a. Breasts should always be symmetric. b. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about. c. Asymmetry is not unusual, but the nurse should verify that this change is not new. d. Asymmetry of breast size and shape is very unusual and means she may have an inflammation or growth.
ANS: This finding is not unusual, but the nurse should verify that this change is not new. The nurse should notice symmetry of size and shape. It is common to have a slight asymmetry in size; often the left breast is slightly larger than the right. A sudden increase in the size of one breast signifies inflammation or new growth.
The nurse is examining a 6-month-old infant and places the infant's feet flat on the table and flexes his knees up. The nurse notes that the right knee is significantly lower than the left. Which of these statements is true of this finding? A) This is a positive Allis sign and suggests hip dislocation. B) The infant probably has a dislocated patella on the right. C) This is a normal finding for the Allis test for an infant of this age. D) The infant should return to the clinic in 2 weeks to see if this has changed.
ANS: This is a positive Allis sign and suggests hip dislocation. Finding one knee significantly lower than the other is a positive Allis sign and suggests hip dislocation. Normally the tops of the knees are at the same elevation. The other statements are not correct.
The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test? A) To measure the rate of lymphatic drainage B) To evaluate the adequacy of capillary patency before venous blood draws C) To evaluate the adequacy of collateral circulation before cannulating the radial artery D) To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded
ANS: To evaluate the adequacy of collateral circulation before cannulating the radial artery A modified Allen test is used to evaluate the adequacy of collateral circulation before the radial artery is cannulated. The other responses are not reasons for a modified Allen test.
The nurse is auscultating the chest in an adult. Which technique is correct? a. Instructing the patient to take deep, rapid breaths b. Instructing the patient to breathe in and out through his or her nose c. Firmly holding the diaphragm of the stethoscope against the chest d. Lightly holding the bell of the stethoscope against the chest to avoid friction
ANS: Use the diaphragm of the stethoscope held firmly against the chest. The diaphragm of the stethoscope held firmly on the chest is the correct way to auscultate breath sounds. The patient should be instructed to breathe through his or her mouth, a little deeper than usual, but not to hyperventilate.
During a clinic visit, a woman in her seventh month of pregnancy complains that her legs feel "heavy in the calf" and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins in her lower legs. Which condition is reflected by these findings? A) Deep vein thrombophlebitis B) Varicose veins C) Lymphedema D) Raynaud's phenomenon
ANS: Varicose veins Superficial varicose veins are caused by incompetent distant valves on veins, which results in reflux of blood and producing dilated, tortuous veins. They are more common in women, and pregnancy can also be a cause. Symptoms include aching, heaviness in the calf, easy fatigability, and night leg or foot cramps. Dilated, tortuous veins are seen on assessment. See Table 20-5 for the description of deep vein thrombophlebitis. See Table 20-2 for descriptions of Raynaud's phenomenon and lymphedema.
The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? a. Wheezes b. Bronchial sounds c. Bronchophony d. Whispered pectoriloquy
ANS: Wheezes Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema.
During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation? a. In an obese patient b. When part of the lung is obstructed or collapsed c. When bulging of the intercostal spaces is present d. When accessory muscles are used to augment respiratory effort
ANS: When part of the lung is obstructed or collapsed Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia, or when guarding to avoid postoperative incisional pain or atelectasis.
During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation? a. When the bronchial tree is obstructed b. When adventitious sounds are present c. In conjunction with whispered pectoriloquy d. In conditions of consolidation, such as pneumonia
ANS: When the bronchial tree is obstructed Decreased or absent breath sounds occur when the bronchial tree is obstructed, as in emphysema, and when sound transmission is obstructed, as in pleurisy, pneumothorax, or pleural effusion.
To palpate the temporomandibular joint, the nurse's fingers should be placed in the depression _____ of the ear. A) distal to the helix B) proximal to the helix C) anterior to the tragus D) posterior to the tragus
ANS: anterior to the tragus The temporomandibular joint can be felt in the depression anterior to the tragus of the ear. The other locations are not correct.
During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for about 2 weeks. In trying to find the cause of the rash, which of these would be important for the nurse to determine? a. "Is the rash raised and red?" b. "Does it appear to be cyclic?" c. "Where did the rash first appear—on the nipple, the areola, or the surrounding skin?" d. "What was she doing when she first noticed the rash, and do her actions make it worse?"
ANS: Where did it first appear—on the nipple, the areola, or the surrounding skin? It is important for the nurse to determine where the rash first appeared. Paget's disease starts with a small crust on the nipple apex and then spreads to the areola. Eczema or other dermatitis rarely starts at nipple unless it results from breastfeeding. It usually starts on the areola or surrounding skin and then spreads to the nipple. See Table 17-6.
The nurse is assisting with a self-breast examination clinic. Which of these women reflect abnormal findings during the inspection phase of breast examination? a. Woman whose nipples are in different planes (deviated). b. Woman whose left breast is slightly larger than her right. c. Nonpregnant woman whose skin is marked with linear striae. d. Pregnant woman whose breasts have a fine blue network of veins visible under the skin.
ANS: Woman whose nipples are in different planes (deviated) The nipples should be symmetrically placed on the same plane on the two breasts. With deviation in pointing, an underlying cancer causes fibrosis in the mammary ducts, which pulls the nipple angle toward it. The other examples are normal findings. See Table 17-3.
A patient has been diagnosed with a ganglion cyst over the dorsum of his left wrist. He asks the nurse, "What is this thing?" The nurse's best answer would be, "It is: A) a common benign tumor." B) a tumor that will have to be watched because it may turn malignant." C) caused by chronic repetitive motion injury." D) a skin infection that will need to be drained."
ANS: a common benign tumor." A ganglionic cyst is a common benign tumor; it does not become malignant, and it does not need to be drained. It is not caused by chronic repetitive motion injury
When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is: a. Observed in patients with kyphosis. b. Indicative of pectus excavatum. c. A normal finding in a healthy adult. d. An expected finding in a patient with a barrel chest.
ANS: a normal finding in a healthy adult. The right and left costal margins form an angle where they meet at the xiphoid process. Usually, this angle is 90 degrees or less. The angle increases when the rib cage is chronically overinflated, as in emphysema.
A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. The nurse interprets that these assessment findings are consistent with: a. Bronchitis. b. Pneumothorax. c. Acute pneumonia. d. Asthmatic attack.
ANS: a pneumothorax. With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. If the pneumothorax is large, then tachypnea and cyanosis are seen. Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with the presence of pneumothorax. See Table 18-8 for descriptions of the other conditions.
During a breast examination on a female patient, the nurse notices that the nipple is flat, broad, and fixed. The patient states it "started doing that a few months ago." This finding suggests: a. Dimpling. b. Retracted nipple. c. Nipple inversion. d. Deviation in nipple pointing.
ANS: a retracted nipple. The retracted nipple looks flatter and broader, like an underlying crater. A recent retraction suggests cancer, which causes fibrosis of the whole duct system and pulls in the nipple. It also may occur with benign lesions such as ectasia of the ducts. The nurse should not confuse retraction with the normal long-standing type of nipple inversion, which has no broadening and is not fixed.
An 80-year-old woman is visiting the clinic for a checkup. She states, "I can't walk as much as I used to." The nurse is observing for motor dysfunction in her hip and should have her: A) internally rotate her hip while she is sitting. B) abduct her hip while she is lying on her back. C) adduct her hip while she is lying on her back. D) externally rotate her hip while she is standing.
ANS: abduct her hip while she is lying on her back. Limitation of abduction of the hip while supine is the most common motion dysfunction found in hip disease. The other options are not correct.
A 40-year-old man has come into the clinic with complaints of "extreme tenderness in my toes." The nurse notices that his toes are slightly swollen, reddened, and warm to the touch. His complaints would suggest: A) osteoporosis. B) acute gout. C) ankylosing spondylitis. D) degenerative joint disease.
ANS: acute gout. Acute gout occurs primarily in men over 40 years of age. Clinical findings consist of redness, swelling, heat, and extreme tenderness. Gout is a metabolic disorder of disturbed purine metabolism, associated with elevated serum uric acid. See Table 22-1 for descriptions of the other terms.
A patient is being assessed for range of joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called: A) flexion. B) abduction. C) adduction. D) extension.
ANS: adduction. Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body. Flexion is bending a limb at a joint; extension is straightening a limb at a joint.
During a routine office visit, a patient takes off his shoes and shows the nurse "this awful sore that won't heal." On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. The nurse should assess for other signs and symptoms of: A) varicosities. B) a venous stasis ulcer. C) an arterial ischemic ulcer. D) deep vein thrombophlebitis.
ANS: an arterial ischemic ulcer. Arterial ischemic ulcers occur at toes, metatarsal heads, heels, and lateral ankle, and they are characterized by a pale ischemic base, well-defined edges, and no bleeding. See Table 20-5 for a description of varicose veins and deep vein thrombophlebitis. See Table 20-4 for a description of venous stasis ulcers.
An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. The nurse interprets that these assessment findings are consistent with: a. Asthma. b. Atelectasis. c. Lobar pneumonia. d. Heart failure.
ANS: asthma. Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. Increased respiratory rate, use of accessory muscles, retraction of intercostal muscles, prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristic of asthma. See Table 18-8 for descriptions of the other conditions.
The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. The nurse recognizes that these breath sounds are: a. Atelectatic crackles that do not have a pathologic cause. b. Fine crackles and may be a sign of pneumonia. c. Vesicular breath sounds. d. Fine wheezes.
ANS: atelectatic crackles, and that they are not pathologic. One type of adventitious sound, atelectatic crackles, is not pathologic. They are short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths. When sections of alveoli are not fully aerated (as in people who are asleep or in the elderly), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough.
The nurse should use which test to check for large amounts of fluid around the patella? A) Ballottement B) Tinel sign C) Phalen's test D) McMurray's test
ANS: ballottement
When reviewing the musculoskeletal system, the nurse recalls that hematopoiesis takes place in the: A) liver. B) spleen. C) kidneys. D) bone marrow.
ANS: bone marrow. The musculoskeletal system functions to encase and protect inner vital organs, support the body, produce red blood cells in the bone marrow, and store minerals.
The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) _____ pulse. A) normal B) absent C) bounding D) weak, thready
ANS: bounding A full, bounding pulse occurs with hyperkinetic states (such as exercise, anxiety, fever), anemia, and hyperthyroidism. Absent pulse occurs with occlusion. Weak, thready pulses occur with shock and peripheral artery disease.
The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery. A) ulnar B) radial C) brachial D) deep palmar
ANS: brachial The major artery supplying the arm is the brachial artery. The brachial artery bifurcates into the ulnar and radial arteries immediately below the elbow. In the hand, the ulnar and radial arteries form two arches known as the superficial and deep palmar arches.
When auscultating over a patient's femoral arteries the nurse notices the presence of a bruit on the left side. The nurse knows that: A) bruits are often associated with venous disease. B) bruits occur in the presence of lymphadenopathy. C) hypermetabolic states will cause bruits in the femoral arteries. D) bruits occur with turbulent blood flow, indicating partial occlusion.
ANS: bruits occur with turbulent blood flow, indicating partial occlusion. A bruit occurs with turbulent blood flow and indicates partial occlusion of the artery. The other responses are not correct.
A 67-year-old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing: A) claudication. B) sore muscles. C) muscle cramps. D) venous insufficiency.
ANS: claudication Intermittent claudication feels like a "cramp" and is usually relieved by rest within 2 minutes. The other responses are not correct.
Which of the following statements is true regarding the internal structures of the breast? The breast is: a. Primarily muscle with very little fibrous tissue. b. Fibrous, glandular, and adipose tissues. c. Primarily milk ducts, known as lactiferous ducts. d. Glandular tissue, which supports the breast by attaching to the chest wall.
ANS: composed of fibrous, glandular, and adipose tissue. The breast is composed of glandular tissue, fibrous tissue (including the suspensory ligaments), and adipose tissue.
While inspecting a patient's breasts, the nurse finds that the left breast is slightly larger than the right with the presence of Montgomery's glands bilaterally. The nurse should: a. Palpate over the Montgomery glands, checking for drainage. b. Consider these findings as normal, and proceed with the examination. c. Ask extensive health history questions regarding the woman's breast asymmetry. d. Continue with the examination, and then refer the patient for further evaluation of the Montgomery glands.
ANS: consider these normal findings and proceed with the examination. Normal findings of the breast include one breast (most often the left) slightly larger than the other and the presence of Montgomery's glands across the areola.
When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. The nurse should next: A) check for the presence of claudication. B) refer the individual for further evaluation. C) consider this a normal finding and proceed with the peripheral vascular evaluation. D) ask the patient if he or she has experienced any unusual cramping or tingling in the arm.
ANS: consider this a normal finding and proceed with the peripheral vascular evaluation. It is not usually necessary to palpate the ulnar pulses. The ulnar pulses are often not palpable in the normal person. The other responses are not correct.
When assessing a patient's lungs, the nurse recalls that the left lung: a. Consists of two lobes. b. Is divided by the horizontal fissure. c. Primarily consists of an upper lobe on the posterior chest. d. Is shorter than the right lung because of the underlying stomach.
ANS: consists of two lobes. The left lung has two lobes, and the right lung has three lobes. The right lung is shorter than the left lung because of the underlying liver. The left lung is narrower than the right lung because the heart bulges to the left. The posterior chest is almost all lower lobe.
During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects: a. Tactile fremitus. b. Crepitus. c. Friction rub. d. Adventitious sounds.
ANS: crepitus. Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as after open thoracic injury or surgery.
The nurse knows that a normal finding when assessing the respiratory system of an elderly adult is: a. Increased thoracic expansion. b. Decreased mobility of the thorax. c. Decreased anteroposterior diameter. d. Bronchovesicular breath sounds throughout the lungs.
ANS: decreased mobility of the thorax. The costal cartilages become calcified with aging, resulting in a less mobile thorax. Chest expansion may be somewhat decreased, and the chest cage commonly shows an increased anteroposterior diameter.
A patient has a positive Homans' sign. The nurse knows that a positive Homans' sign may indicate: A) venous insufficiency. B) deep vein thrombosis. C) severe edema. D) problems with arterial circulation.
ANS: deep vein thrombosis. Calf pain on dorsiflexion of the foot is a positive Homans' sign, which occurs in about 35% of deep vein thromboses. It also occurs with superficial phlebitis, Achilles tendinitis, and gastrocnemius and plantar muscle injury.
The primary muscles of respiration include the: a. Diaphragm and intercostals. b. Sternomastoids and scaleni. c. Trapezii and rectus abdominis. d. External obliques and pectoralis major.
ANS: diaphragm and intercostals. The major muscle of respiration is the diaphragm. The intercostal muscles lift the sternum and elevate the ribs during inspiration, increasing the anteroposterior diameter. Expiration is primarily passive. Forced inspiration involves the use of other muscles, such as the accessory neck muscles (sternomastoids, scalene, trapezii). Forced expiration involves the abdominal muscles.
A young swimmer comes to the sports clinic complaining of a very sore shoulder. He was running at the pool, slipped on some wet concrete, and tried to catch himself with his outstretched hand. He landed on his outstretched hand and has not been able to move his shoulder since then. The nurse suspects: A) joint effusion. B) tear of rotator cuff. C) adhesive capsulitis. D) dislocated shoulder.
ANS: dislocated shoulder. Dislocated shoulder occurs with trauma involving abduction, extension, and external rotation (e.g., falling on an outstretched arm or diving into a pool). See Table 22-2 for a description of the other conditions.
The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal: a. Dullness. b. Tympany. c. Resonance. d. Hyperresonance.
ANS: dullness. A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor.
During an assessment, the nurse uses the "profile sign" to detect: A) pitting edema. B) early clubbing. C) symmetry of the fingers. D) insufficient capillary refill.
ANS: early clubbing. The nurse should use the profile sign (viewing the finger from the side) to detect early clubbing.
The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? They are: a. Musical in quality. b. Usually caused by a pathologic disease. c. Expected near the major airways. d. Similar to bronchial sounds except shorter in duration.
ANS: expected near the major airways. Bronchovesicular sounds are heard over major bronchi where fewer alveoli are located: posteriorly, between the scapulae, especially on the right; anteriorly, around the upper sternum in the first and second intercostal spaces. The other responses are not correct.
Which statement about the apices of the lungs is true? The apices of the lungs: a. Are at the level of the second rib anteriorly. b. Extend 3 to 4 cm above the inner third of the clavicles. c. Are located at the sixth rib anteriorly and the eighth rib laterally. d. Rest on the diaphragm at the fifth intercostal space in the midclavicular line (MCL).
ANS: extend 3 to 4 cm above the inner third of the clavicles. The apex of the lung on the anterior chest is 3 to 4 cm above the inner third of the clavicles. On the posterior chest, the apices are at the level of C7.
The primary purpose of the ciliated mucous membrane in the nose is to: 1. warm the inhaled air. 2. filter out dust and bacteria. 3. filter coarse particles from inhaled air. 4. facilitate movement of air through the nares.
ANS: filter out dust and bacteria. The nasal hairs filter the coarsest matter from inhaled air, whereas the mucous blanket filters out dust and bacteria.
The nurse is assessing a patient's ischial tuberosity. To palpate the ischial tuberosity, the nurse knows that it is best to have the patient:
ANS: flex the hip. The ischial tuberosity lies under the gluteus maximus muscle and is palpable when the hip is flexed.
A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement? A) flexion. B) abduction. C) adduction. D) extension.
ANS: flexion. Flexion, or bending a limb at a joint, would be required to move the hand to the mouth. Extension is straightening a limb at a joint. Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body.
An imaginary line connecting the highest point on each iliac crest would cross the _____ vertebra. A) first sacral B) fourth lumbar C) seventh cervical D) twelfth thoracic
ANS: fourth lumbar An imaginary line connecting the highest point on each iliac crest crosses the fourth lumbar vertebra.
A patient's annual physical examination reveals a lateral curvature of the thoracic and lumbar segments of his spine; however, this curvature disappears with forward bending. The nurse knows that this abnormality of the spine is called: A) structural scoliosis. B) functional scoliosis. C) herniated nucleus pulposus. D) dislocated hip.
ANS: functional scoliosis. Functional scoliosis is flexible; it is apparent with standing and disappears with forward bending. Structural scoliosis is fixed; the curvature shows both when standing and when bending forward. See Table 22-7 for description of herniated nucleus pulposus. These findings are not indicative of a dislocated hip.
The nurse is providing patient education for a man who has been diagnosed with a rotator cuff injury. The nurse knows that a rotator cuff injury involves the: A) nucleus pulposus. B) articular process. C) medial epicondyle. D) glenohumeral joint.
ANS: glenohumeral joint. A rotator cuff injury involves the glenohumeral joint, which is enclosed by a group of four powerful muscles and tendons that support and stabilize it. The nucleus pulposus is located in the center of each intervertebral disk. The medial epicondyle is located at the elbow.
The nurse is examining the hip area of a patient and palpates a flat depression on the upper, lateral side of the thigh when the patient is standing. The nurse interprets this finding as the: A) ischial tuberosity. B) greater trochanter. C) iliac crest. D) gluteus maximus muscle.
ANS: greater trochanter.
During an examination, the nurse asks a patient to bend forward from the waist and notices that the patient has lateral tilting. When his leg is raised straight up, he complains of a pain going down his buttock into his leg. The nurse suspects: A) scoliosis. B) meniscus tear. C) herniated nucleus pulposus. D) spasm of paravertebral muscles.
ANS: herniated nucleus pulposus. Lateral tilting and sciatic pain with straight leg raising are findings that occur with a herniated nucleus pulposus. The other options are not correct.
The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen's test. To perform this test, the nurse should instruct the patient to: A) dorsiflex the foot. B) plantarflex the foot. C) hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. D) hyperextend the wrists with the palmar surface of both hands touching and wait for 60 seconds.
ANS: hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. For the Phalen's test, the nurse should ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. The Phalen's test reproduces numbness and burning in a person with carpal tunnel syndrome. The other actions are not correct for testing for carpal tunnel syndrome.
During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from: a. Shallow breathing. b. Normal lung tissue. c. Decreased adipose tissue. d. Increased density of lung tissue.
ANS: increased density of lung tissue. A dull percussion note indicates an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or tumor. Resonance is the expected finding in normal lung tissue.
The nurse is explaining to a patient that there are "shock absorbers" in his back to cushion the spine and to help it move. The nurse is referring to his: A) vertebral column. B) nucleus pulposus. C) vertebral foramen. D) intervertebral disks.
ANS: intervertebral disks. Intervertebral disks are elastic fibrocartilaginous plates that cushion the spine like shock absorbers and help it move. The vertebral column is the spinal column itself. The nucleus pulposus is located in the center of each disk. The vertebral foramen is the channel, or opening, for the spinal cord in the vertebrae.
If a patient reports a recent breast infection, then the nurse should expect to find _____ node enlargement. a. Nonspecific b. Ipsilateral axillary c. Contralateral axillary d. Inguinal and cervical
ANS: ipsilateral axillary The breast has extensive lymphatic drainage. Most of the lymph, more than 75%, drains into the ipsilateral, or same side, axillary nodes.
The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? "Tactile remits: a. "Is caused by moisture in the alveoli." b. "Indicates that air is present in the subcutaneous tissues." c. "Is caused by sounds generated from the larynx." d. "Reflects the blood flow through the pulmonary arteries."
ANS: is caused by sounds generated from the larynx." Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall where they are felt as vibrations. Crepitus is the term for air in the subcutaneous tissues.
A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with _________ the left leg. A) venous obstruction of B) claudication due to venous abnormalities in C) ischemia caused by partial blockage of an artery supplying D) ischemia caused by complete blockage of an artery supplying
ANS: ischemia caused by partial blockage of an artery supplying Ischemia is a deficient supply of oxygenated arterial blood to a tissue. A partial blockage creates an insufficient supply, and the ischemia may be apparent only during exercise when oxygen needs increase.
The functional units of the musculoskeletal system are the: A) joints. B) bones. C) muscles. D) tendons.
ANS: joints. Joints are the functional units of the musculoskeletal system because they permit the mobility needed for the activities of daily living. The skeleton (bones) is the framework of the body.
Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called: A) bursa. B) tendons. C) cartilage. D) ligaments.
ANS: ligaments. Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called ligaments.
A woman who is 8 months pregnant comments that she has noticed a change in posture and is having lower back pain. The nurse tells her that during pregnancy women have a posture shift to compensate for the enlarging fetus. This shift in posture is known as: A) lordosis. B) scoliosis. C) ankylosis. D) kyphosis.
ANS: lordosis. Lordosis compensates for the enlarging fetus, which would shift the center of balance forward. This shift in balance in turn creates strain on the low back muscles, felt as low back pain during late pregnancy by some women. Scoliosis is lateral curvature of portions of the spine; ankylosis is extreme flexion of the wrist, as seen with severe rheumatoid arthritis; and kyphosis is an enhanced thoracic curvature of the spine.
A patient has been diagnosed with osteoporosis and asks the nurse, "What is osteoporosis?" The nurse explains to the patient that osteoporosis is defined as:
ANS: loss of bone density. After age 40, loss of bone matrix (resorption) occurs more rapidly than new bone formation. The net effect is a gradual loss of bone density, or osteoporosis. The other options are not correct.
A patient is newly diagnosed with benign breast disease. The nurse recognizes that which statement about benign breast disease is true? The presence of benign breast disease: a. Makes it hard to examine the breasts. b. Frequently turns into cancer in a woman's later years. c. Is easily reduced with hormone replacement therapy. d. Is usually diagnosed before a woman reaches childbearing age.
ANS: makes it harder to examine the breasts. The presence of benign breast disease (formerly fibrocystic breast disease) makes it harder to examine the breasts; the general lumpiness of the breast conceals a new lump. The other statements are not true.
A professional tennis player comes into the clinic complaining of a sore elbow. The nurse will assess for tenderness at the: A) olecranon bursa. B) annular ligament. C) base of the radius. D) medial and lateral epicondyle.
ANS: medial and lateral epicondyle. The epicondyles, the head of radius, and tendons are common sites of inflammation and local tenderness, or "tennis elbow." The other locations are not affected.
A patient is visiting the clinic for an evaluation of a swollen, painful knuckle. The nurse notices that the knuckle above his ring on the left hand is swollen and that he is unable to remove his wedding ring. This joint is called the _____ joint. A) interphalangeal B) tarsometatarsal C) metacarpophalangeal D) tibiotalar
ANS: metacarpophalangeal The joint located just above the ring on the finger is the metacarpophalangeal joint. The interphalangeal joint is located distal to the metacarpophalangeal joint. The tarsometatarsal and tibiotalar joints are found in the foot and ankle. See Figure 22-10 for a diagram of the bones and joints of the hand and fingers.
The nurse is examining a 3-month-old infant. While holding the thumbs on the infant's inner mid thighs and the fingers outside on the hips, touching the greater trochanter, the nurse adducts the legs until the nurse's thumbs touch and then abducts the legs until the infant's knees touch the table. The nurse does not notice any "clunking" sounds and is confident to record a: A) positive Allis test. B) negative Allis test. C) positive Ortolani's sign. D) negative Ortolani's sign.
ANS: negative Ortolani's sign. Normally this maneuver feels smooth and has no sound. With a positive Ortolani's sign, the nurse will feel and hear a "clunk" as the head of the femur pops back into place. A positive Ortolani's sign reflects hip instability. The Allis test also tests for hip dislocation, but is done by comparing leg lengths.
A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. Based on these findings, the nurse recalls that: A) nonpitting, hard edema occurs with lymphatic obstruction. B) alterations in arterial function will cause this edema. C) phlebitis of a superficial vein will cause bilateral edema. D) long-standing arterial obstruction will cause pitting edema.
ANS: nonpitting, hard edema occurs with lymphatic obstruction. Unilateral edema occurs with occlusion of a deep vein and with unilateral lymphatic obstruction. With these factors, the edema is nonpitting and feels hard to the touch (brawny edema).
A teenage girl has arrived complaining of pain in her left wrist. She was playing basketball when she fell and landed on her left hand. The nurse examines her hand and would expect a fracture if the girl complains: A) of a dull ache. B) that the pain in her wrist is deep. C) of sharp pain that increases with movement. D) of dull throbbing pain that increases with rest.
ANS: of sharp pain that increases with movement A fracture causes sharp pain that increases with movement. The other pains do not occur with a fracture.
An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because:
ANS: of the shortening of the vertebral column. Postural changes are evident with aging; decreased height is most noticeable and is due to shortening of the vertebral column. Long bones do not shorten with age. Intervertebral disks actually get thinner with age. Subcutaneous fat is not lost but is redistributed to the abdomen and hips.
A 68-year-old woman has come in for an assessment of her rheumatoid arthritis, and the nurse notices raised, firm, nontender nodules at the olecranon bursa and along the ulna. These nodules are most commonly diagnosed as: A) epicondylitis. B) gouty arthritis. C) olecranon bursitis. D) subcutaneous nodules.
ANS: olecranon bursitis. Subcutaneous nodules are raised, firm, and nontender and occur with rheumatoid arthritis in the olecranon bursa and along the extensor surface of the ulna. See Table 22-3 for a description of the other conditions.
A patient states during the interview that she noticed a new lump in the shower a few days ago. It was on her left breast near her axilla. The nurse should plan to: a. Palpate the lump first. b. Palpate the unaffected breast first. c. Avoid palpating the lump because it could be a cyst, which might rupture. d. Palpate the breast with the lump first but plan to palpate the axilla last.
ANS: palpate the unaffected breast first. If the woman mentions a breast lump she has discovered herself, the nurse should examine the unaffected breast first to learn a baseline of normal consistency for this individual.
When assessing a patient's pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulsus: A) alternans. B) bisferiens. C) bigeminus. D) paradoxus.
ANS: paradoxus In pulsus paradoxus, beats have a weaker amplitude with inspiration and a stronger amplitude with expiration. It is best determined during blood pressure measurement; reading decreases (>10 mm Hg) during inspiration and increases with expiration.
While examining a 75-year-old woman, the nurse notices that the skin over her right breast is thickened and the hair follicles are exaggerated. This condition is known as: a. Dimpling. b. Retraction. c. Peau d'orange. d. Benign breast disease.
ANS: peau d'orange. This condition is known as peau d'orange. Lymphatic obstruction produces edema, which thickens the skin and exaggerates the hair follicles. The skin has a pig-skin or orange-peel look, and this condition suggests cancer.
A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this may indicate: a. Pneumonia. b. Postnasal drip or sinusitis. c. Exposure to irritants at work. d. Chronic bronchial irritation from smoking.
ANS: postnasal drip or sinusitis. A cough that occurs mainly at night may indicate postnasal drip or sinusitis. Exposure to irritants at work causes an afternoon or evening cough. Smokers experience early morning coughing. Coughing associated with acute illnesses such as pneumonia is continuous throughout the day.
A patient complains of leg pain that wakes him at night. He states that he "has been having problems" with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed "a sore" on the inner aspect of the right ankle. On the basis of this history information, the nurse interprets that the patient is most likely experiencing: A) pain related to lymphatic abnormalities. B) problems related to arterial insufficiency. C) problems related to venous insufficiency. D) pain related to musculoskeletal abnormalities.
ANS: problems related to arterial insufficiency. Night leg pain is common in aging adults. It may indicate the ischemic rest pain of peripheral vascular disease. Alterations in arterial circulation cause pain that becomes worse with leg elevation and is eased when the extremity is dangled.
When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be: A) proximal to distal. B) distal to proximal. C) posterior to anterior. D) anterior to posterior.
ANS: proximal to distal. The musculoskeletal assessment should be done in an orderly approach, head to toe, proximal to distal, from the midline outward. The other options are not correct.
A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he had "a runny nose for a week." When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. The nurse's next action should be to: a. Assure the mother that these signs are normal symptoms of a cold. b. Recognize that these are serious signs, and contact the physician. c. Ask the mother if the infant has had trouble with feedings. d. Perform a complete cardiac assessment because these signs are probably indicative of early heart failure.
ANS: recognize that these are serious signs and contact the physician. The infant is an obligatory nose breather until the age of 3 months. Normally there is no flaring of the nostrils and no sternal or intercostal retraction. Marked retractions of the sternum and intercostal muscles and nasal flaring indicate increased inspiratory effort, as in pneumonia, acute airway obstruction, asthma, and atelectasis; therefore, immediate referral to the physician is warranted. These signs do not indicate heart failure, and assessment of the infant's feeding is not a priority at this time.
A patient is able to flex his right arm forward without difficulty or pain but is unable to abduct his arm because of pain and muscle spasms; the nurse should suspect: A) crepitation. B) rotator cuff lesions. C) dislocated shoulder. D) rheumatoid arthritis.
ANS: rotator cuff lesions. Rotator cuff lesions may cause limited range of motion and pain and muscle spasm during abduction, whereas forward flexion stays fairly normal. The other options are not correct.
The nurse is performing a peripheral vascular assessment on a bedridden patient and notices the following findings in the right leg: increased warmth, swelling, redness, tenderness to palpation, and a positive Homan's sign. The nurse should: A) reevaluate the patient in a few hours. B) consider this a normal finding for a bedridden patient. C) seek emergency referral because of the risk of pulmonary embolism. D) ask the patient to raise his leg off of the bed and check for pain on elevation.
ANS: seek emergency referral because of the risk of pulmonary embolism. Increased warmth, swelling, redness, and tenderness in the lower extremities require emergency referral because of the risk of pulmonary embolism from a deep vein thrombosis.
A 14-year-old girl is anxious about not having reached menarche. When taking the history, the nurse should ascertain which of the following? The age: a. The girl began to develop breasts. b. Her mother developed breasts. c. She began to develop pubic hair. d. She began to develop axillary hair.
ANS: she began to develop breasts Full development from stage 2 to stage 5 takes an average of 3 years, although the range is 1.5 to 6 years. Pubic hair develops during this time, and axillary hair appears 2 years after the onset of pubic hair. The beginning of breast development precedes menarche by about 2 years. Menarche occurs in breast development stage 3 or 4, usually just after the peak of the adolescent growth spurt, which occurs around age 12 years. See Figure 17-6.
The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ____ comparison. a. Side-to-side b. Top-to-bottom c. Posterior-to-anterior d. Interspace-by-interspace
ANS: side-to-side Side-to-side comparison is most important when auscultating the chest. The nurse should listen to at least one full respiration in each location. The other techniques are incorrect.
The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? Have the woman: a. Bend over and touch her toes. b. Lie down on her left side and notice any retraction. c. Shift from a supine position to a standing position, and note any lag or retraction. d. Slowly lift her arms above her head, and note any retraction or lag in movement.
ANS: slowly lift her arms above her head and note any retraction or lag in movement Direct the woman to change position while checking the breasts for skin retraction signs. First ask her to lift her arms slowly over her head. Both breasts should move up symmetrically. Retraction signs are due to fibrosis in the breast tissue, usually caused by growing neoplasms. The nurse should notice if there is a lag in movement of one breast.
The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal woman. A participant shows that she needs more instruction when she states, "I will: A) start swimming to increase my weight-bearing exercise." B) try to stop smoking as soon as possible." C) check with my doctor about taking calcium supplements." D) get a bone-density test soon."
ANS: start swimming to increase my weight-bearing exercise." Weight-bearing exercises include walking, low-impact aerobics, dancing, or stationary cycling. Swimming is not considered a weight-bearing exercise. The other responses are correct.
During an examination of the anterior thorax, the nurse keeps in mind that the trachea bifurcates anteriorly at the: a. Costal angle. b. Sternal angle. c. Xiphoid process. d. Suprasternal notch.
ANS: sternal angle. The sternal angle marks the site of tracheal bifurcation into the right and left main bronchi; it corresponds with the upper border of the atria of the heart, and it lies above the fourth thoracic vertebra on the back.
The nurse is assessing a 1-week-old infant and is testing his muscle strength. The nurse lifts the infant with hands under the axillae and notices that the infant starts to "slip" between the hands. The nurse should: A) suspect a fractured clavicle. B) suspect that the infant may have a deformity of the spine. C) suspect that the infant may have weakness of the shoulder muscles. D) consider this a normal finding because the musculature of an infant this age is undeveloped.
ANS: suspect that the infant may have weakness of the shoulder muscles. An infant who starts to "slip" between the nurse's hands shows weakness of the shoulder muscles. An infant with normal muscle strength wedges securely between the nurse's hands. The other responses are not correct.
The nurse has completed the musculoskeletal examination of a patient's knee and has found a positive bulge sign. The nurse interprets this finding to indicate: A) irregular bony margins. B) soft tissue swelling in the joint. C) swelling from fluid in the epicondyle. D) swelling from fluid in the suprapatellar pouch.
ANS: swelling from fluid in the suprapatellar pouch. For swelling in the suprapatellar pouch, the bulge sign confirms the presence of fluid. The other options are not correct.
The ankle joint is the articulation of the tibia, the fibula, and the: A) talus. B) cuboid. C) calcaneus. D) cuneiform bones. ANS: talus
ANS: talus
When a breastfeeding mother is diagnosed with a breast abscess, which of these instructions from the nurse is correct? The mother needs to: a. Continue to nurse on both sides to encourage milk flow. b. Immediately discontinue nursing to allow for healing. c. Temporarily discontinue nursing on the affected breast, and manually express milk and discard it. d. Temporarily discontinue nursing on affected breast, but manually express milk and give it to the baby.
ANS: temporarily discontinue nursing on affected breast and manually express milk and discard it. With a breast abscess, the patient must temporarily discontinue nursing on the affected breast, manually express the milk, and discard it. Nursing can continue on the unaffected side.
The articulation of the mandible and the temporal bone is known as the: A) intervertebral foramen. B) condyle of the mandible. C) temporomandibular joint. D) zygomatic arch of the temporal bone. ANS: temporomandibular joint. The articulation of the mandible and the temporal bone is the temporomandibular joint. The other responses are not correct.
ANS: temporomandibular joint. The articulation of the mandible and the temporal bone is the temporomandibular joint. The other responses are not correct.
The nurse knows that auscultation of fine crackles would most likely be noticed in: a. A healthy 5-year-old child. b. A pregnant woman. c. The immediate newborn period. d. Association with a pneumothorax.
ANS: the immediate newborn period. Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis.
In performing a breast examination, the nurse knows that it is especially important to examine the upper outer quadrant of the breast. The reason for this is that the upper outer quadrant is: a. The largest quadrant of the breast. b. The location of most breast tumors. c. Where most of the suspensory ligaments attach. d. More prone to injury and calcifications than other locations in the breast.
ANS: the location of most breast tumors. The upper outer quadrant is the site of most breast tumors. In the upper outer quadrant, the nurse should notice the axillary tail of Spence, the cone-shaped breast tissue that projects up into the axilla, close to the pectoral group of axillary lymph nodes.
The nurse is discussing breast self-examination with a postmenopausal woman. The best time for postmenopausal women to perform breast self-examination is: a. On the same day every month. b. Daily, during the shower or bath. c. One week after her menstrual period. d. Every year with her annual gynecologic examination.
ANS: the same day every month. Postmenopausal women are no longer experiencing regular menstrual cycles but need to continue to perform breast self-examination on a monthly basis. Choosing the same day of the month is a helpful reminder to perform breast self-examination.
The nurse has palpated a lump in a female patient's right breast. The nurse documents this as a small, round, firm, distinct, lump located at 2 o'clock, 2 cm from the nipple. It is nontender and fixed. There is no associated retraction of skin or nipple, no erythema, and no axillary lymphadenopathy. Which of these statements reveals the information that is missing from the documentation? It is missing information about: a. Shape of the lump b. Consistency of the lump c. Size of the lump d. Whether the lump is solitary or multiple
ANS: the size of the lump. If the nurse feels a lump or mass, he or she should note these characteristics: (1) location, (2) size—judge in centimeters in three dimensions: width length thickness, (3) shape, (4) consistency, (5) motility, (6) distinctness, (7) nipple, (8) the skin over the lump, (9) tenderness, and (10) lymphadenopathy.
Which of these statements is true regarding the vertebra prominens? The vertebra prominens is: a. The spinous process of C7. b. Usually nonpalpable in most individuals. c. Opposite the interior border of the scapula. d. Located next to the manubrium of the sternum.
ANS: the spinous process of C7. The spinous process of C7 is the vertebra prominens. It is the most prominent bony spur protruding at the base of the neck. Counting ribs and intercostal spaces on the posterior thorax is difficult because of the muscles and soft tissue. The vertebra prominens is easier to identify and is used as a starting point in counting thoracic processes and identifying landmarks on the posterior chest.
A man who has had gout for several years comes to the clinic with a problem with his toe. On examination, the nurse notices the presence of hard, painless nodules over the great toe; one has burst open with a chalky discharge. This finding is known as: A) a callus. B) a plantar wart. C) a bunion. D) tophi.
ANS: tophi. Tophi are collections of sodium urate crystals resulting from chronic gout in and around the joint that cause extreme swelling and joint deformity. They appear as hard, painless nodules (tophi) over the metatarsophalangeal joint of the first toe and they sometimes burst with a chalky discharge (See Table 22-6). See Table 22-6 for descriptions of the other conditions.
A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from: a. Bronchitis. b. Pneumonia. c. Tuberculosis. d. Pulmonary edema.
ANS: tuberculosis. Sputum is not diagnostic alone, but some conditions have characteristic sputum production. Tuberculosis often produces rust-colored sputum in addition to other symptoms of night sweats and low-grade afternoon fevers. See Table 18-8.
During an assessment the nurse has elevated a patient's legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him to sit up and dangle his legs over the side of the table, the nurse should expect a normal finding at this point would be: A) marked elevational pallor. B) venous filling within 15 seconds. C) no change in coloration of the skin. D) color returning to the feet within 20 seconds of assuming a sitting position
ANS: venous filling within 15 seconds. In this test it normally takes 10 seconds or less for the color to return to the feet and 15 seconds for the veins of the feet to fill. Marked elevational pallor as well as delayed venous filling occurs with arterial insufficiency.
When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are: a. Normally auscultated over the trachea. b. Bronchial breath sounds and normal in that location. c. Vesicular breath sounds and normal in that location. d. Bronchovesicular breath sounds and normal in that location.
ANS: vesicular breath sounds and are normal in that location. Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over peripheral lung fields where air flows through smaller bronchioles and alveoli.
As part of the health history of a 6-year-old boy at a clinic for a sports physical examination, the nurse reviews his immunization record and notes that his last measles-mumps-rubella (MMR) vaccination was at 15 months of age. What recommendation should the nurse make? a.No further MMR immunizations are needed. b.MMR vaccination needs to be repeated at 4 to 6 years of age. c.MMR immunization needs to be repeated every 4 years until age 21 years. d.A recommendation cannot be made until the physician is consulted.
B
During a complete health assessment, how would the nurse test the patient's hearing? A) By observing how the patient participates in normal conversation B) Using the whispered voice test C) Using the Weber and Rinne tests D) Testing with an audiometer
B
1. The two parts of the nervous system are the: a. Motor and sensory. b. Central and peripheral. c. Peripheral and autonomic. d. Hypothalamus and cerebral.
B. Central and peripheral.
7. The ability that humans have to perform very skilled movements such as writing is controlled by the: a. Basal ganglia. b. Corticospinal tract. c. Spinothalamic tract. d. Extrapyramidal tract.
B. Corticospinal tract.
In response to a question regarding the use of alcohol, a patient asks the nurse why the nurse needs to know. What is the reason for needing this information? a.This information is necessary to determine the patient's reliability. b.Alcohol can interact with all medications and can make some diseases worse. c.The nurse needs to be able to teach the patient about the dangers of alcohol use. d.This information is not necessary unless a drinking problem is obvious.
B
The nurse is assessing a new patient who has recently immigrated to the United States. Which question is appropriate to add to the health history? a."Why did you come to the United States?" b."When did you come to the United States and from what country?" c."What made you leave your native country?" d."Are you planning to return to your home?"
B
The nurse is incorporating a person's spiritual values into the health history. Which of these questions illustrates the "community" portion of the FICA (faith and belief, importance and influence, community, and addressing or applying in care) questions? a."Do you believe in God?" b."Are you a part of any religious or spiritual congregation?" c."Do you consider yourself to be a religious or spiritual person?" d."How does your religious faith influence the way you think about your health?"
B
The nurse is performing a functional assessment on an 82-year-old patient who recently had a stroke. Which of these questions would be most important to ask? a."Do you wear glasses?" b."Are you able to dress yourself?" c."Do you have any thyroid problems?" d."How many times a day do you have a bowel movement?"
B
The review of systems provides the nurse with: a.Physical findings related to each system. b.Information regarding health promotion practices. c.An opportunity to teach the patient medical terms. d.Information necessary for the nurse to diagnose the patient's medical problem.
B
When the nurse is evaluating the reliability of a patient's responses, which of these statements would be correct? The patient: a.Has a history of drug abuse and therefore is not reliable. b.Provided consistent information and therefore is reliable. c.Smiled throughout interview and therefore is assumed reliable. d.Would not answer questions concerning stress and therefore is not reliable.
B
Which of these statements is true regarding the complete physical assessment? A) The male genitalia should be examined in the supine position. B) The patient should be in the sitting position for examination of the head and neck. C) The vital signs, height, and weight should be obtained at the end of the examination. D) To promote consistency between patients, the examiner should not vary the order of the assessment.
B
Which of these statements is true regarding the recording of data from the history and physical examination? A) Use long, descriptive sentences to document findings. B) Record the data as soon as possible after the interview and physical examination. C) If the information is not documented, then it can be assumed that it was done as a standard of care. D) The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing rapport with the patient.
B
The nurse has used interpretation regarding a patients statement or actions. After using this technique, it would be best for the nurse to: a. Apologize, because using interpretation can be demeaning for the patient. b. Allow time for the patient to confirm or correct the inference. c. Continue with the interview as though nothing has happened. d. Immediately restate the nurses conclusion on the basis of the patients nonverbal response.
B Allow time for the patient to confirm or correct the inference.
28. The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding? a. Extinction b. Astereognosis c. Graphesthesia d. Tactile discrimination
B Astereognosis
A 16-year-old boy has just been admitted to the unit for overnight observation after being in an automobile accident. What is the nurses best approach to communicating with him? a. Use periods of silence to communicate respect for him. b. Be totally honest with him, even if the information is unpleasant. c. Tell him that everything that is discussed will be kept totally confidential. d. Use slang language when possible to help him open up.
B Be totally honest with him, even if the information is unpleasant.
A woman is discussing the problems she is having with her 2-year-old son. She says, He wont go to sleep at night, and during the day he has several fits. I get so upset when that happens. The nurses best verbal response would be: a. Go on, Im listening. b. Fits? Tell me what you mean by this. c. Yes, it can be upsetting when a child has a fit. d. Dont be upset when he has a fit; every 2 year old has fits.
B Fits? Tell me what you mean by this.
During a prenatal check, a patient begins to cry as the nurse asks her about previous pregnancies. She states that she is remembering her last pregnancy, which ended in miscarriage. The nurses best response to her crying would be: a. Im so sorry for making you cry! b. I can see that you are sad remembering this. It is all right to cry. c. Why dont I step out for a few minutes until youre feeling better? d. I can see that you feel sad about this; why dont we talk about something else?
B I can see that you are sad remembering this. It is all right to cry.
41. During an assessment of a 22-year-old woman who sustained a head injury from an automobile accident 4 hours earlier, the nurse notices the following changes: pupils were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What do these findings suggest? a. Injury to the right eye b. Increased intracranial pressure c. Test inaccurately performed d. Normal response after a head injury
B Increased intracranial pressure
The nurse is nearing the end of an interview. Which statement is appropriate at this time? a. Did we forget something? b. Is there anything else you would like to mention? c. I need to go on to the next patient. Ill be back. d. While Im here, lets talk about your upcoming surgery.
B Is there anything else you would like to mention?
50. During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? Severe nystagmus in both eyes: a. Is a normal occurrence. b. May indicate disease of the cerebellum or brainstem. c. Is a sign that the patient is nervous about the examination. d. Indicates a visual problem, and a referral to an ophthalmologist is indicated.
B May indicate disease of the cerebellum or brainstem.
22. During the neurologic assessment of a healthy 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find? a. Firm, rigid resistance to movement b. Mild, even resistance to movement c. Hypotonic muscles as a result of total relaxation d. Slight pain with some directions of movement
B Mild, even resistance to movement
A pregnant woman states, I just know labor will be so painful that I wont be able to stand it. I know it sounds awful, but I really dread going into labor. The nurse responds by stating, Oh, dont worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain. Which statement is true regarding this response? The nurses reply was a: a. Therapeutic response. By sharing something personal, the nurse gives hope to this woman. b. Nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the womans fears. c. Therapeutic response. By providing information about the medications available, the nurse is giving information to the woman. d. Nontherapeutic response. The nurse is essentially giving the message to the woman that labor cannot be tolerated without medication.
B Nontherapeutic response. By providing false reassurance, the nurse actually cut off further discussion of the womans fears.
51. The nurse knows that testing kinesthesia is a test of a persons: a. Fine touch. b. Position sense. c. Motor coordination. d. Perception of vibration.
B Position sense.
54. The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patients toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as: a. Negative Babinski sign, which is normal for adults. b. Positive Babinski sign, which is abnormal for adults. c. Clonus, which is a hyperactive response. d. Achilles reflex, which is an expected response.
B Positive Babinski sign, which is abnormal for adults.
A mother brings her 28-month-old daughter into the clinic for a well-child visit. At the beginning of the visit, the nurse focuses attention away from the toddler, but as the interview progresses, the toddler begins to warm up and is smiling shyly at the nurse. The nurse will be most successful in interacting with the toddler if which is done next? a. Tickle the toddler, and get her to laugh. b. Stoop down to her level, and ask her about the toy she is holding. c. Continue to ignore her until it is time for the physical examination. d. Ask the mother to leave during the examination of the toddler, because toddlers often fuss less if their parent is not in view.
B Stoop down to her level, and ask her about the toy she is holding.
26. The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception, the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one very sharp prick. What would be the most accurate explanation for this? a. The patient has hyperesthesia as a result of the aging process. b. This response is most likely the result of the summation effect. c. The nurse was probably not poking hard enough with the pin in the other areas. d. The patient most likely has analgesia in some areas of arm and hyperalgesia in others.
B This response is most likely the result of the summation effect.
. During a visit to the clinic, a patient states, The doctor just told me he thought I ought to stop smoking. He doesnt understand how hard Ive tried. I just dont know the best way to do it. What should I do? The nurses most appropriate response in this case would be: a. Id quit if I were you. The doctor really knows what he is talking about. b. Would you like some information about the different ways a person can quit smoking? c. Stopping your dependence on cigarettes can be very difficult. I understand how you feel. d. Why are you confused? Didnt the doctor give you the information about the smoking cessation program we offer?
B Would you like some information about the different ways a person can quit smoking?
During an inspection of the nares, a deviated septum is noted. The best action is to: A) request a consult with an ENT specialist B) document the deviation in the medical record in case the person needs to be suctioned C) teach the person what to do if a nosebleed should occur D) explore further because polyps frequently accompany a deviated septum
B) document the deviation in the medical record in case the person needs to be suctioned
A 70 year old woman complains of dry mouth. The most frequent cause of this problem is: A) the aging process B) related to medications she may be taking C) the use of dentures D) related to a diminished sense of smell
B) related to medications she may be taking
During an interview the patient states, "I can feel this bump on the top of both of my shoulders—it doesn't hurt but I am curious about what it might be." The nurse should tell the patient, "That is: A) your subacromial bursa." B) your acromion process." C) your glenohumeral joint." D) the greater tubercle of your humerus."
B) your acromion process."
The nurse is conducting a developmental history on a 5-year-old child. Which questions are appropriate to ask the parents for this part of the assessment? Select all that apply. a."How much junk food does your child eat?" b."How many teeth has he lost, and when did he lose them?" c."Is he able to tie his shoelaces?" d."Does he take a children's vitamin?" e."Can he tell time?" f."Does he have any food allergies?"
B, C, E
The nurse is presenting a class on risk factors for cardiovascular disease. Which of these are considered modifiable risk factors for MI? Select all that apply. a. Ethnicity b. Abnormal lipids c. Smoking d. Gender e. Hypertension f. Diabetes g. Family history
B, C, E, F Nine modifiable risk factors for MI, as identified by a recent study, include abnormal lipids, smoking, hypertension, diabetes, abdominal obesity, psychosocial factors, consumption of fruits and vegetables, alcohol use, and regular physical activity.
During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? Select all that apply. a. Patient may experience sensitivity to light, nausea, and halos around lights. b. Patient experiences tunnel vision in the late stages. c. Immediate treatment is needed. d. Vision loss begins with peripheral vision. e. Open-angle glaucoma causes sudden attacks of increased pressure that cause blurred vision. f. Virtually no symptoms are exhibited.
B, D, F b. Patient experiences tunnel vision in the late stages. d. Vision loss begins with peripheral vision. f. Virtually no symptoms are exhibited.
1. A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying Im just getting old! After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer disease? Select all that apply. a. Occasionally forgetting names or appointments b. Difficulty performing familiar tasks, such as placing a telephone call c. Misplacing items, such as putting dish soap in the refrigerator d. Sometimes having trouble finding the right word e. Rapid mood swings, from calm to tears, for no apparent reason f. Getting lost in ones own neighborhood
B,C,E,F Difficulty performing familiar tasks, such as placing a telephone call Misplacing items, such as putting dish soap in the refrigerator Rapid mood swings, from calm to tears, for no apparent reason Getting lost in ones own neighborhood
18. In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what response should the nurse make? a. Does your family know you are drinking every day? b. Does the tremor change when you drink alcohol? c. Well do some tests to see what is causing the tremor. d. You really shouldnt drink so much alcohol; it may be causing your tremor.
B. Does the tremor change when you drink alcohol?
3. Which statement concerning the areas of the brain is true? a. The cerebellum is the center for speech and emotions. b. The hypothalamus controls body temperature and regulates sleep. c. The basal ganglia are responsible for controlling voluntary movements. d. Motor pathways of the spinal cord and brainstem synapse in the thalamus.
B. The hypothalamus controls body temperature and regulates sleep.
20. During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs? a. Motor component of CN IV b. Motor component of CN VII c. Motor and sensory components of CN XI d. Motor component of CN X and sensory component of CN VII
B. Motor component of CN VII
The nurse has collected the following information on a patient: palpated blood pressure-180 mm Hg; auscultated blood pressure-170/100 mm Hg; apical pulse-60 beats per minute; radial pulse-70 beats per minute. What is the patient's pulse pressure? a. 10 b. 70 c. 80 d. 100
B: 70
The nurse is conducting a health fair for older adults. Which statement is true regarding vital sign measurements in aging adults? a. The pulse is more difficult to palpate because of the stiffness of the blood vessels. b. An increased respiratory rate and a shallower inspiratory phase are expected findings. c. A decreased pulse pressure occurs from changes in the systolic and diastolic blood pressures. d. Changes in the body's temperature regulatory mechanism leave the older person more likely to develop a fever.
B: An increased respiratory rate and a shallower inspiratory phase are expected findings.
A 1-month-old infant has a head measurement of 34 cm and has a chest circumference of 32 cm. Based on the interpretation of these findings, the nurse would: a. Refer the infant to a physician for further evaluation. b. Consider these findings normal for a 1-month-old infant. c. Expect the chest circumference to be greater than the head circumference. d. Ask the parent to return in 2 weeks to re-evaluate the head and chest circumferences.
B: Consider these findings normal for a 1-month-old infant.
When assessing the pulse of a 6-year-old boy, the nurse notices that his heart rate varies with his respiratory cycle, speeding up at the peak of inspiration and slowing to normal with expiration. The nurse's next action would be to: a. Immediately notify the physician. b. Consider this finding normal in children and young adults. c. Check the child's blood pressure, and note any variation with respiration. d. Document that this child has bradycardia, and continue with the assessment.
B: Consider this finding normal in children and young adults.
The nurse will perform a palpated pressure before auscultating blood pressure. The reason for this is to: a. More clearly hear the Korotkoff sounds. b. Detect the presence of an auscultatory gap. c. Avoid missing a falsely elevated blood pressure. d. More readily identify phase IV of the Korotkoff sounds.
B: Detect the presence of an auscultatory gap.
Which of these specific measurements is the best index of a child's general health? a. Vital signs b. Height and weight c. Head circumference d. Chest circumference
B: Height and weight
Which of these actions illustrates the correct technique the nurse should use when assessing oral temperature with a mercury thermometer?a. Wait 30 minutes if the patient has ingested hot or iced liquids. b. Leave the thermometer in place 3 to 4 minutes if the patient is a febrile. c .Place the thermometer in front of the tongue, and ask the patient to close his or her lips. d. Shake the mercury-in-glass thermometer down to below 36.6° C before taking the temperature.
B: Leave the thermometer in place 3 to 4 minutes if the patient is afebrile
A patient's weekly blood pressure readings for 2 months have ranged between 124/84 mm Hg and 136/88 mm Hg, with an average reading of 126/86 mm Hg. The nurse knows that this blood pressure falls within which blood pressure category? a. Normal blood pressure b. Prehypertension c. Stage 1 hypertension d. Stage 2 hypertension
B: Prehypertension
The nurse is examining a patient who is complaining of "feeling cold." Which is a mechanism of heat loss in the body? a. Exercise b. Radiation c. Metabolism d. Food digestion
B: Radiation
A nurse is helping at a health fair at a local mall. When taking blood pressures on a variety of people, the nurse keeps in mind that: a. After menopause, blood pressure readings in women are usually lower than those taken in men. b. The blood pressure of a Black adult is usually higher than that of a White adult of the same age. c. Blood pressure measurements in people who are overweight should be the same as those of people who are at a normal weight. d. A teenager's blood pressure reading will be lower than that of an adult.
B: The blood pressure of a Black adult is usually higher than that of a White adult of the same age.
A 70-year-old man has a blood pressure of 150/90 mm Hg in a lying position, 130/80 mm Hg in a sitting position, and 100/60 mm Hg in a standing position. How should the nurse evaluate these findings? a. These readings are a normal response and attributable to changes in the patient's position. b. The change in blood pressure readings is called orthostatic hypotension. c. The blood pressure reading in the lying position is within normal limits. d. The change in blood pressure readings is considered within normal limits for the patient's age.
B: The change in blood pressure readings is called orthostatic hypotension.
If the nurse records the results to the Hirschberg test, the nurse has: A) tested the patellar reflex. B) assessed for appendicitis. C) tested the corneal light reflex. D) assessed for thrombophlebitis.
C
The nurse is assessing the vital signs of a 20-year-old male marathon runner and documents the following vital signs: temperature-36° C; pulse-48 beats per minute; respirations-14 breaths per minute; blood pressure-104/68 mm Hg. Which statement is true concerning these results? a. The patient is experiencing tachycardia. b. These are normal vital signs for a healthy, athletic adult. c. The patient's pulse rate is not normal—his physician should be notified. d. On the basis of these readings, the patient should return to the clinic in 1 week.
B: These are normal vital signs for a healthy, athletic adult.
The nurse is counting an infant's respirations. Which technique is correct? a. Watching the chest rise and fall b. Watching the abdomen for movement c. Placing a hand across the infant's chest d. Using a stethoscope to listen to the breath sounds
B: Watching the abdomen for movement
When assessing an older adult, which vital sign changes occur with aging? a. Increase in pulse rate b. Widened pulse pressure c. Increase in body temperature d. Decrease in diastolic blood pressure
B: Widened pulse pressure
The nurse notices a colleague is preparing to check the blood pressure of a patient who is obese by using a standard-sized blood pressure cuff. The nurse should expect the reading to: a. Yield a falsely low blood pressure. b. Yield a falsely high blood pressure. c. Be the same, regardless of cuff size. d. Vary as a result of the technique of the person performing the assessment.
B: Yield a falsely high blood pressure
In response to a question about stress, a 39-year-old woman tells the nurse that her husband and mother both died in the past year. Which response by the nurse is most appropriate? a."This has been a difficult year for you." b."I don't know how anyone could handle that much stress in 1 year!" c."What did you do to cope with the loss of both your husband and mother?" d."That is a lot of stress; now let's go on to the next section of your history."
C
A patient is unable to shrug her shoulders against the nurse's resistant hands. What cranial nerve is involved with successful shoulder shrugging? A) VII B) IX C) XI D) XII
C
A patient tells the nurse that "sometimes I wake up at night and I have real trouble breathing. I have to sit up in bed to get a good breath." When documenting this information, the nurse would note: A) orthopnea. B) acute emphysema. C) paroxysmal nocturnal dyspnea. D) acute shortness of breath episode.
C
During an examination, the nurse notices that a patient's legs turn white when they are raised above the patient's head. The nurse should suspect: A) lymphedema. B) Raynaud's disease. C) chronic arterial insufficiency. D) chronic venous insufficiency.
C
During the examination of a patient, the nurse notices that the patient has several small, flat macules on the posterior portion of her thorax. These macules are less than 1 cm wide. Another name for these macules is: A) warts. B) bullae. C) freckles. D) papules.
C
The nurse is performing a review of systems on a 76-year-old patient. Which of these statements is correct for this situation? a.The questions asked are identical for all ages. b.The interviewer will start incorporating different questions for patients 70 years of age and older. c.Questions that are reflective of the normal effects of aging are added. d.At this age, a review of systems is not necessary—the focus should be on current problems.
C
The nurse is taking a family history. Important diseases or problems about which the patient should be specifically asked include: a.Emphysema. b.Head trauma. c.Mental illness. d.Fractured bones.
C
The nurse notices that a patient has ulcerations on the tips of the toes and on the lateral aspect of the ankles. This finding indicates: A) lymphedema. B) Raynaud's disease. C) arterial insufficiency. D) venous insufficiency.
C
The nurse will measure a patient's near vision with which tool? A) Snellen eye chart with letters B) Snellen "E" chart C) Jaeger card D) Ophthalmoscope
C
When the nurse asks for a description of who lives with a child, the method of discipline, and the support system of the child, what part of the assessment is being performed? a.Family history b.Review of systems c.Functional assessment d.Reason for seeking care
C
Which of these is included in assessment of general appearance? A) Height B) Weight C) Skin color D) Vital signs
C
Which of these statements represents subjective data the nurse obtained from the patient regarding the patient's skin? a.Skin appears dry. b.No lesions are obvious. c.Patient denies any color change. d.Lesion is noted on the lateral aspect of the right arm.
C
While recording in a patient's medical record, the nurse notices that a patient's Hematest results are positive. This means that there: A) are crystals in his urine. B) are parasites in his stool. C) is occult blood in his stool. D) are bacteria in his sputum.
C
53. A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination; he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurses finger, then his own nose, then the nurses finger again (which has been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger. The nurse should suspect which of the following? a. Cerebral injury b. Cerebrovascular accident c. Acute alcohol intoxication d. Peripheral neuropathy
C Acute alcohol intoxication
31. When the nurse is testing the triceps reflex, what is the expected response? a. Flexion of the hand b. Pronation of the hand c. Extension of the forearm d. Flexion of the forearm
C Extension of the forearm
A 17-year-old single mother is describing how difficult it is to raise a 3-year-old child by herself. During the course of the interview she states, I cant believe my boyfriend left me to do this by myself! What a terrible thing to do to me! Which of these responses by the nurse uses empathy? a. You feel alone. b. You cant believe he left you alone? c. It must be so hard to face this all alone. d. I would be angry, too; raising a child alone is no picnic.
C It must be so hard to face this all alone.
During an interview, a woman says, I have decided that I can no longer allow my children to live with their fathers violence, but I just cant seem to leave him. Using interpretation, the nurses best response would be: a. You are going to leave him? b. If you are afraid for your children, then why cant you leave? c. It sounds as if you might be afraid of how your husband will respond. d. It sounds as though you have made your decision. I think it is a good one.
C It sounds as if you might be afraid of how your husband will respond.
40. The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment? a. CNs, motor function, and sensory function b. Deep tendon reflexes, vital signs, and coordinated movements c. Level of consciousness, motor function, pupillary response, and vital signs d. Mental status, deep tendon reflexes, sensory function, and pupillary response
C Level of consciousness, motor function, pupillary response, and vital signs
27. The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect? a. Hyperalgesia b. Hyperesthesia c. Peripheral neuropathy d. Lesion of sensory cortex
C Peripheral neuropathy
32. The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding? a. Positive Babinski sign b. Plantar reflex abnormal c. Plantar reflex present d. Plantar reflex 2+ on a scale from 0 to 4+
C Plantar reflex present
48. A patient is unable to perform rapid alternating movements such as rapidly patting her knees. The nurse should document this inability as: a. Ataxia. b. Astereognosis. c. Presence of dysdiadochokinesia. d. Loss of kinesthesia.
C Presence of dysdiadochokinesia.
During an interview, the nurse would expect that most of the interview will take place at what distance? a. Intimate zone b. Personal distance c. Social distance d. Public distance
C Social distance
. The nurse makes this comment to a patient, I know it may be hard, but you should do what the doctor ordered because she is the expert in this field. Which statement is correct about the nurses comment? a. This comment is inappropriate because it shows the nurses bias. b. This comment is appropriate because members of the health care team are experts in their area of patient care. c. This type of comment promotes dependency and inferiority on the part of the patient and is best avoided in an interview situation. d. Using authority statements when dealing with patients, especially when they are undecided about an issue, is necessary at times.
C This type of comment promotes dependency and inferiority on the part of the patient and is best avoided in an interview situation.
A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, You dont smoke, drink, or take drugs, do you? This question is an example of: a. Talking too much. b. Using confrontation. c. Using biased or leading questions. d. Using blunt language to deal with distasteful topics.
C Using biased or leading questions.
16. When taking the health history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information? a. Does your muscle tone seem tense or limp? b. After the seizure, do you spend a lot of time sleeping? c. Do you have any warning sign before your seizure starts? d. Do you experience any color change or incontinence during the seizure?
C Do you have any warning sign before your seizure starts?
24. The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of always dropping things and falling down. While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect? a. Vestibular disease b. Lesion of CN IX c. Dysfunction of the cerebellum d. Inability to understand directions
C Dysfunction of the cerebellum
Receiving is a part of the communication process. Which receiver is most likely to misinterpret a message sent by a health care professional? a. Well-adjusted adolescent who came in for a sports physical b. Recovering alcoholic who came in for a basic physical examination c. Man whose wife has just been diagnosed with lung cancer d. Man with a hearing impairment who uses sign language to communicate and who has an interpreter with him
C Man whose wife has just been diagnosed with lung cancer
13. During an assessment of an 80-year-old patient, the nurse notices the following: an inability to identify vibrations at her ankle and to identify the position of her big toe, a slower and more deliberate gait, and a slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate: a. CN dysfunction. b. Lesion in the cerebral cortex. c. Normal changes attributable to aging. d. Demyelination of nerves attributable to a lesion.
C Normal changes attributable to aging.
The most common site of nosebleeds is: A) the turbinates B) the columnellae C) Kiesselbach plexus D) the meatus
C) Kiesselbach plexus
The examiner notes small, round, white, shiny papules on the hard palate and gums of a 2 month old. What is the significance of this finding? A) these are aphthous areas or ulcers that are resulting of sucking B) teeth buds are beginning to appear C) this is a normal finding called Epstein pearls D) it indicates the presence of a monilial infection
C) this is a normal finding called Epstein pearls
In a medical record, the tonsils are grades as 3+. The tonsils would be: A) visible B) halfway between the tonsillar pillars and uvula C) touching the uvula D) touching each other
C) touching the uvula
8. A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse? a. Thalamus b. Brainstem c. Cerebellum d. Extrapyramidal tract
C. Cerebellum
4. The area of the nervous system that is responsible for mediating reflexes is the: a. Medulla. b. Cerebellum. c. Spinal cord. d. Cerebral cortex.
C. Spinal cord.
10. A patient has a severed spinal nerve as a result of trauma. Which statement is true in this situation? a. Because there are 31 pairs of spinal nerves, no effect results if only one nerve is severed. b. The dermatome served by this nerve will no longer experience any sensation. c. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. d. A severed spinal nerve will only affect motor function of the patient because spinal nerves have no sensory component.
C. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve.
6. A patient with a lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. The nurse knows that the best explanation why this occurs is which one of these statements? a. A problem exists with the sensory cortex and its ability to discriminate the location. b. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing the pain. c. The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere. d. A lesion has developed in the dorsal root, which is preventing the sensation from being transmitted normally.
C. The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere.
A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. The area of the body the nurse will assess is: a.Just above the diaphragm. b.Just lateral to the knee cap. c.At the level of the C7 vertebra. d.At the level of the T11 vertebra. At the level of the C7 vertebra.
C. At the level of the C7 vertebra.
5. While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact? a. Corticospinal tract, medulla, and basal ganglia b. Pyramidal tract, hypothalamus, and sensory cortex c. Lateral spinothalamic tract, thalamus, and sensory cortex d. Anterior spinothalamic tract, basal ganglia, and sensory cortex
C. Lateral spinothalamic tract, thalamus, and sensory cortex
When measuring a patient's body temperature, the nurse keeps in mind that body temperature is influenced by: a. Constipation. b. Patient's emotional state. c. Diurnal cycle. d. Nocturnal cycle.
C: .Diurnal cycle
The nurse should measure rectal temperatures in which of these patients? a. School-age child b. Older adult c. Comatose adult d. Patient receiving oxygen by nasal cannula
C: Comatose adult
The nurse is taking an initial blood pressure reading on a 72-year-old patient with documented hypertension. How should the nurse proceed? a. Cuff should be placed on the patient's arm and inflated 30 mm Hg above the patient's pulse rate. b. Cuff should be inflated to 200 mm Hg in an attempt to obtain the most accurate systolic reading. c. Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears. d. After confirming the patient's previous blood pressure readings, the cuff should be inflated 30 mm Hg above the highest systolic reading recorded.
C: Cuff should be inflated 30 mm Hg above the point at which the palpated pulse disappears
During an examination, the nurse notices that a female patient has a round "moon" face, central trunk obesity, and a cervical hump. Her skin is fragile with bruises. The nurse determines that the patient has which condition? a. Marfan syndrome b. Gigantism c. Cushing syndrome d. Acromegaly
C: Cushing syndrome
A patient is seen in the clinic for complaints of "fainting episodes that started last week." How should the nurse proceed with the examination?a. Blood pressure readings are taken in both the arms and the thighs. b. The patient is assisted to a lying position, and his blood pressure is taken.c.His blood pressure is recorded in the lying, sitting, and standing positions.d.His blood pressure is recorded in the lying and sittingpositions; these numbers are then averaged to obtain a mean blood pressure.
C: His blood pressure is recorded in the lying, sitting, and standing positions.
The nurse is helping another nurse to take a blood pressure reading on a patient's thigh. Which action is correct regarding thigh pressure? a. Either the popliteal or femoral vessels should be auscultated to obtain a thigh pressure. b.The best position to measure thigh pressure is the supine position with the knee slightly bent. c. If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure. d. The thigh pressure is lower than the pressure in the arm, which is attributable to the distance away from the heart and the size of the popliteal vessels
C: If the blood pressure in the arm is high in an adolescent, then it should be compared with the thigh pressure
When assessing the force, or strength, of a pulse, the nurse recalls that the pulse:a.Is usually recorded on a 0- to 2-point scale. b. Demonstrates elasticity of the vessel wall. c. Is a reflection of the heart's stroke volume. d. Reflects the blood volume in the arteries during diastole.
C: Is a reflection of the heart's stroke volume
When considering the concepts related to blood pressure, the nurse knows that the concept of mean arterial pressure (MAP) is best described by which statement? a. MAP is the pressure of the arterial pulse. b. MAP reflects the stroke volume of the heart. c. MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle. d. MAP is an average of the systolic and diastolic blood pressures and reflects tissue perfusion.
C: MAP is the pressure forcing blood into the tissues, averaged over the cardiac cycle.
The nurse is preparing to measure the length, weight, chest, and head circumference of a 6-month-old infant. Which measurement technique is correct? a. Measuring the infant's length by using a tape measure b. Weighing the infant by placing him or her on an electronic standing scale c. Measuring the chest circumference at the nipple line with a tape measure d. Measuring the head circumference by wrapping the tape measure over the nose and cheekbones
C: Measuring the chest circumference at the nipple line with a tape measure
In a patient with acromegaly, the nurse will expect to discover which assessment findings? a. Heavy, flattened facial features b. Growth retardation and a delayed onset of puberty c. Overgrowth of bone in the face, head, hands, and feet d. Increased height and weight and delayed sexual development
C: Overgrowth of bone in the face, head, hands, and feet
The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal? a. Increase in body weight from his younger years b. Additional deposits of fat on the thighs and lower legs c. Presence of kyphosis and flexion in the knees and hips d. Change in overall body proportion, including a longer trunk and shorter extremities
C: Presence of kyphosis and flexion in the knees and hips
What type of blood pressure measurement error is most likely to occur if the nurse does not check for the presence of an auscultatory gap?a.Diastolic blood pressure may not be heard.b.Diastolic blood pressure may be falsely low.c.Systolic blood pressure may be falsely low.d.Systolic blood pressure may be falsely high.
C: Systolic blood pressure may be falsely low.
The nurse is taking temperatures in a clinic with a TMT. Which statement is true regarding use of the TMT? a. A tympanic temperature is more time consuming than a rectal temperature. b. The tympanic method is more invasive and uncomfortable than the oral method. c. The risk of cross contamination is reduced, compared with the rectal route. d. The tympanic membrane most accurately reflects the temperature in the ophthalmic artery.
C: The risk of cross contamination is reduced, compared with the rectal route.
A patient's blood pressure is 118/82 mm Hg. He asks the nurse, "What do the numbers mean?" The nurse's best reply is: a."The numbers are within the normal range and are nothing to worry about." b. "The bottom number is the diastolic pressure and reflects the stroke volume of the heart." c. "The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts." d. "The concept of blood pressure is difficult to understand. The primary thing to be concerned about is the top number, or the systolic blood pressure."
C: The top number is the systolic blood pressure and reflects the pressure of the blood against the arteries when the heart contracts."
A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen today in the clinic for an "unexplained" weight loss of 10 pounds over the last 6 weeks. The nurse knows that: a. Weight loss is probably the result of unhealthy eating habits. b. Chronic diseases such as hypertension cause weight loss. c. Unexplained weight loss often accompanies short-term illnesses. d. Weight loss is probably the result of a mental health dysfunction.
C: Unexplained weight loss often accompanies short-term illnesses.
A female American Indian has come to the clinic for follow-up diabetic teaching. During the interview, the nurse notices that she never makes eye contact and speaks mostly to the floor. Which statement is true regarding this situation? a. The woman is nervous and embarrassed. b. She has something to hide and is ashamed. c. The woman is showing inconsistent verbal and nonverbal behaviors. d. She is showing that she is carefully listening to what the nurse is saying.
D She is showing that she is carefully listening to what the nurse is saying.
A 29-year-old woman tells the nurse that she has "excruciating pain" in her back. Which would be the nurse's appropriate response to the woman's statement? a."How does your family react to your pain?" b."The pain must be terrible. You probably pinched a nerve." c."I've had back pain myself, and it can be excruciating." d."How would you say the pain affects your ability to do your daily activities?"
D
A 5-year-old boy is being admitted to the hospital to have his tonsils removed. Which information should the nurse collect before this procedure? a.Child's birth weight b.Age at which he crawled c.Whether the child has had the measles d.Child's reactions to previous hospitalizations
D
A 59-year-old patient tells the nurse that he has ulcerative colitis. He has been having "black stools" for the last 24 hours. How would the nurse best document his reason for seeking care? a.J.M. is a 59-year-old man seeking treatment for ulcerative colitis. b.J.M. came into the clinic complaining of having black stools for the past 24 hours. c.J.M. is a 59-year-old man who states that he has ulcerative colitis and wants it checked. d.J.M. is a 59-year-old man who states that he has been having "black stools" for the past 24 hours.
D
A 90-year-old patient tells the nurse that he cannot remember the names of the medications he is taking or for what reason he is taking them. An appropriate response from the nurse would be: a."Can you tell me what they look like?" b."Don't worry about it. You are only taking two medications." c."How long have you been taking each of the pills?" d."Would you have a family member bring in your medications?"
D
A patient is describing his symptoms to the nurse. Which of these statements reflects a description of the setting of his symptoms? a."It is a sharp, burning pain in my stomach." b."I also have the sweats and nausea when I feel this pain." c."I think this pain is telling me that something bad is wrong with me." d."This pain happens every time I sit down to use the computer."
D
A patient states, "Whenever I open my mouth real wide, I feel this popping sensation in front of my ears." To further examine this, the nurse would: A) place the stethoscope over the temporomandibular joint and listen for bruits. B) place the hands over his ears and ask him to open his mouth "really wide." C) place one hand on his forehead and the other on his jaw and ask him to try to open his mouth. D) place a finger on his temporomandibular joint and ask him to open and close his mouth.
D
A patient tells the nurse that he is allergic to penicillin. What would be the nurse's best response to this information? a."Are you allergic to any other drugs?" b."How often have you received penicillin?" c."I'll write your allergy on your chart so you won't receive any penicillin." d."Describe what happens to you when you take penicillin
D
After assessing a female patient, the nurse notices flesh-colored, soft, pointed, moist, papules in a cauliflower-like patch around her introitus. This finding is most likely: A) urethral caruncle. B) syphilitic chancre. C) herpes. D) human papillomavirus.
D
During an assessment, the nurse uses the CAGE test. The patient answers "yes" to two of the questions. What could this be indicating? a.The patient is an alcoholic. b.The patient is annoyed at the questions. c.The patient should be thoroughly examined for possible alcohol withdrawal symptoms. d.The nurse should suspect alcohol abuse and continue with a more thorough substance abuse assessment.
D
During an examination, a patient has just successfully completed the finger-to-nose and the rapid-alternating-movements tests and is able to run each heel down the opposite shin. The nurse will conclude that the patient's ____ function is intact. A) occipital B) cerebral C) temporal D) cerebellar
D
During an examination, the nurse notices that a patient is unable to stick out his tongue. Which cranial nerve is involved with successful performance of this action? A) I B) V C) XI D) XII
D
During the examination of a patient's mouth, the nurse observes a nodular bony ridge down the middle of the hard palate. The nurse would chart this finding as: A) cheilosis. B) leukoplakia. C) ankyloglossia. D) torus palatinus.
D
In obtaining a review of systems on a "healthy" 7-year-old girl, the health care provider knows that it would be important to include the: a.Last glaucoma examination. b.Frequency of breast self-examinations. c.Date of her last electrocardiogram. d.Limitations related to her involvement in sports activities.
D
In recording the childhood illnesses of a patient who denies having had any, which note by the nurse would be most accurate? a.Patient denies usual childhood illnesses. b.Patient states he was a "very healthy" child. c.Patient states his sister had measles, but he didn't. d.Patient denies measles, mumps, rubella, chickenpox, pertussis, and strep throat.
D
The mother of a 16-month-old toddler tells the nurse that her daughter has an earache. What would be an appropriate response? a."Maybe she is just teething." b."I will check her ear for an ear infection." c."Are you sure she is really having pain?" d."Describe what she is doing to indicate she is having pain."
D
The nurse has just completed an examination of a patient's extraocular muscles. When documenting the findings, the nurse should document the assessment of which cranial nerves? A) II, III, VI B) II, IV, V C) III, IV, V D) III, IV, VI
D
The nurse is obtaining a health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time? a.Obstetric history b.Childhood illnesses c.General health for the past 20 years d.Current health promotion activities
D
The nurse is preparing to complete a health assessment on a 16-year-old girl whose parents have brought her to the clinic. Which instruction would be appropriate for the parents before the interview begins? a."Please stay during the interview; you can answer for her if she does not know the answer." b."It would help to interview the three of you together." c."While I interview your daughter, will you please stay in the room and complete these family health history questionnaires?" d."While I interview your daughter, will you step out to the waiting room and complete these family health history questionnaires?"
D
The nurse is preparing to conduct a health history. Which of these statements best describes the purpose of a health history? a.To provide an opportunity for interaction between the patient and the nurse b.To provide a form for obtaining the patient's biographic information c.To document the normal and abnormal findings of a physical assessment d.To provide a database of subjective information about the patient's past and current health
D
The nurse is preparing to do a functional assessment. Which statement best describes the purpose of a functional assessment? a.The functional assessment assesses how the individual is coping with life at home. b.It determines how children are meeting developmental milestones. c.The functional assessment can identify any problems with memory the individual may be experiencing. d.It helps determine how a person is managing day-to-day activities.
D
When the nurse performs the confrontation test, the nurse has assessed: A) extraocular eye muscles (EOMs). B) pupils (PERRLA). C) near vision. D) visual fields.
D
Which of these responses might the nurse expect during a functional assessment of a patient whose leg is in a cast? a."I broke my right leg in a car accident 2 weeks ago." b."The pain is decreasing, but I still need to take acetaminophen." c."I check the color of my toes every evening just like I was taught." d."I'm able to transfer myself from the wheelchair to the bed without help."
D
While examining a 48-year-old patient's eyes, the nurse notices that he had to move the handheld vision screener farther away from his face. The nurse would suspect: A) myopia. B) omniopia. C) hyperopia. D) presbyopia.
D
25. During the taking of the health history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: He cant even remember how to button his shirt. When assessing his sensory system, which action by the nurse is most appropriate? a. The nurse would not test the sensory system as part of the examination because the results would not be valid. b. The nurse would perform the tests, knowing that mental status does not affect sensory ability. c. The nurse would proceed with an explanation of each test, making certain that the wife understands. d. Before testing, the nurse would assess the patients mental status and ability to follow directions.
D Before testing, the nurse would assess the patients mental status and ability to follow directions.
42. A 32-year-old woman tells the nurse that she has noticed very sudden, jerky movements mainly in her hands and arms. She says, They seem to come and go, primarily when I am trying to do something. I havent noticed them when Im sleeping. This description suggests: a. Tics. b. Athetosis. c. Myoclonus. d. Chorea.
D Chorea.
In using verbal responses to assist the patients narrative, some responses focus on the patients frame of reference and some focus on the health care providers perspective. An example of a verbal response that focuses on the health care providers perspective would be: a. Empathy. b. Reflection. c. Facilitation. d. Confrontation.
D Confrontation.
39. While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of a(n): a. Great sense of humor. b. Uncooperative behavior. c. Inability to understand questions. d. Decreased level of consciousness.
D Decreased level of consciousness.
45. A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing? a. Scissors gait b. Cerebellar ataxia c. Parkinsonian gait d. Spastic hemiparesis
D Spastic hemiparesis
When observing a patients verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should: a. Ask someone who knows the patient well to help interpret this discrepancy. b. Focus on the patients verbal message, and try to ignore the nonverbal behaviors. c. Try to integrate the verbal and nonverbal messages and then interpret them as an average. d. Focus on the patients nonverbal behaviors, because these are often more reflective of a patients true feelings.
D Focus on the patients nonverbal behaviors, because these are often more reflective of a patients true feelings.
During the interview portion of data collection, the nurse collects __________ data. a. Physical b. Historical c. Objective d. Subjective
D Subjective
A man arrives at the clinic for his annual wellness physical. He is experiencing no acute health problems. Which question or statement by the nurse is most appropriate when beginning the interview? a. How is your family? b. How is your job? c. Tell me about your hypertension. d. How has your health been since your last visit?
D How has your health been since your last visit?
30. In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side? a. Lack of reflexes b. Normal reflexes c. Diminished reflexes d. Hyperactive reflexes
D Hyperactive reflexes
44. During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion. Which statement concerning these findings is most accurate? This patients response: a. Indicates a lesion of the cerebral cortex. b. Indicates a completely nonfunctional brainstem. c. Is normal and will go away in 24 to 48 hours. d. Is a very ominous sign and may indicate brainstem injury.
D Is a very ominous sign and may indicate brainstem injury.
A female nurse is interviewing a male patient who is near the same age as the nurse. During the interview, the patient makes an overtly sexual comment. The nurses best reaction would be: a. Stop that immediately! b. Oh, you are too funny. Lets keep going with the interview. c. Do you really think I would be interested? d. It makes me uncomfortable when you talk that way. Please stop.
D It makes me uncomfortable when you talk that way. Please stop.
During an examination of a 3-year-old child, the nurse will need to take her blood pressure. What might the nurse do to try to gain the childs full cooperation? a. Tell the child that the blood pressure cuff is going to give her arm a big hug. b. Tell the child that the blood pressure cuff is asleep and cannot wake up. c. Give the blood pressure cuff a name and refer to it by this name during the assessment. d. Tell the child that by using the blood pressure cuff, we can see how strong her muscles are.
D Tell the child that by using the blood pressure cuff, we can see how strong her muscles are.
A man has been admitted to the observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, I quit smoking after my wife died 7 years ago. However, the nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say: a. Mr. K., I know that you are lying. b. Mr. K., come on, tell me how much you smoke. c. Mr. K., I didnt realize your wife had died. It must be difficult for you at this time. Please tell me more about that. d. Mr. K., you have said that you dont smoke, but I see that you have an open pack of cigarettes in your pocket.
D Mr. K., you have said that you dont smoke, but I see that you have an open pack of cigarettes in your pocket.
A patient has finished giving the nurse information about the reason he is seeking care. When reviewing the data, the nurse finds that some information about past hospitalizations is missing. At this point, which statement by the nurse would be most appropriate to gather these data? a. Mr. Y., at your age, surely you have been hospitalized before! b. Mr. Y., I just need permission to get your medical records from County Medical. c. Mr. Y., you mentioned that you have been hospitalized on several occasions. Would you tell me more about that? d. Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?
D Mr. Y., I just need to get some additional information about your past hospitalizations. When was the last time you were admitted for chest pain?
A woman has just entered the emergency department after being battered by her husband. The nurse needs to get some information from her to begin treatment. What is the best choice for an opening phase of the interview with this patient? a. Hello, Nancy, my name is Mrs. C. b. Hello, Mrs. H., my name is Mrs. C. It sure is cold today! c. Mrs. H., my name is Mrs. C. How are you? d. Mrs. H., my name is Mrs. C. Ill need to ask you a few questions about what happened.
D Mrs. H., my name is Mrs. C. Ill need to ask you a few questions about what happened.
During an interview, the nurse states, You mentioned having shortness of breath. Tell me more about that. Which verbal skill is used with this statement? a. Reflection b. Facilitation c. Direct question d. Open-ended question
D Open-ended question
The nurse asks, I would like to ask you some questions about your health and your usual daily activities so that we can better plan your stay here. This question is found at the __________ phase of the interview process. a. Summary b. Closing c. Body d. Opening or introduction
D Opening or introduction
23. When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as: a. Ataxia. b. Lack of coordination. c. Negative Homans sign. d. Positive Romberg sign.
D Positive Romberg sign.
During an interview, a parent of a hospitalized child is sitting in an open position. As the interviewer begins to discuss his sons treatment, however, he suddenly crosses his arms against his chest and crosses his legs. This changed posture would suggest that the parent is: a. Simply changing positions. b. More comfortable in this position. c. Tired and needs a break from the interview. d. Uncomfortable talking about his sons treatment.
D Uncomfortable talking about his sons treatment.
14. A 70-year-old woman tells the nurse that every time she gets up in the morning or after shes been sitting, she gets really dizzy and feels like she is going to fall over. The nurses best response would be: a. Have you been extremely tired lately? b. You probably just need to drink more liquids. c. Ill refer you for a complete neurologic examination. d. You need to get up slowly when youve been lying down or sitting.
D You need to get up slowly when youve been lying down or sitting.
The sinuses that are accessible to examination are the: A) ethmoid and sphenoid B) frontal and ethmoid C) maxillary and sphenoid D) frontal and maxillary
D) frontal and maxillary
Oral malignancies are most likely to develop: A) on the soft palate B) on the tongue C) in the buccal cheek mucosa D) in the mucosal "gutter" under the tongue
D) in the mucosal "gutter" under the tongue
The opening of an adult's parotid gland (Stensen's duct) is opposite the: A) lower 2nd molar B) lower incisors C) upper incisors D) upper second molar
D) upper second molar
For the abdominal assessment, place these assessment techniques in the correct order, with A being performed first and E being performed last. A. Deep palpation, all quadrants B. Light palpation, all quadrants C. Auscultate bowel sounds D. Inspect abdomen for contour, skin characteristics, and pulsations E. Percuss all quadrants
D, C, E, B, A
9. Which of these statements about the peripheral nervous system is correct? a. The CNs enter the brain through the spinal cord. b. Efferent fibers carry sensory input to the central nervous system through the spinal cord. c. The peripheral nerves are inside the central nervous system and carry impulses through their motor fibers. d. The peripheral nerves carry input to the central nervous system by afferent fibers and away from the central nervous system by efferent fibers.
D. The peripheral nerves carry input to the central nervous system by afferent fibers and away from the central nervous system by efferent fibers.
19. A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination? a. Glasgow Coma Scale b. Neurologic recheck examination c. Screening neurologic examination d. Complete neurologic examination
D. Complete neurologic examination
21. The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient: a. Demonstrates the ability to hear normal conversation. b. Sticks out the tongue midline without tremors or deviation. c. Follows an object with his or her eyes without nystagmus or strabismus. d. Moves the head and shoulders against resistance with equal strength.
D. Moves the head and shoulders against resistance with equal strength.
The nurse is performing a general survey of a patient. Which finding is considered normal? a. When standing, the patient's base is narrow. b. The patient appears older than his stated age. c. Arm span (fingertip to fingertip) is greater than the height. d. Arm span (fingertip to fingertip) equals the patient's height.
D: Arm span (fingertip to fingertip) equals the patient's height.
When measuring a patient's weight, the nurse is aware of which of these guidelines? a. The patient is always weighed wearing only his or her undergarments. b. The type of scale does not matter, as long as the weights are similar from day to day. c. The patient may leave on his or her jacket and shoes as long as these are documented next to the weight. d. Attempts should be made to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.
D: Attempts should be made to weigh the patient at approximately the same time of day, if a sequence of weights is necessary.
While measuring a patient's blood pressure, the nurse recalls that certain factors, such as __________, help determine blood pressure. a. Pulse rate b. Pulse pressure c. Vascular output d. Peripheral vascular resistance
D: Peripheral vascular resistance
When assessing a 75-year-old patient who has asthma, the nurse notes that he assumes a tripod position, leaning forward with arms braced on the chair. On the basis of this observation, the nurse should: a. Assume that the patient is eager and interested in participating in the interview. b. Evaluate the patient for abdominal pain, which may be exacerbated in the sitting position. c. Assume that the patient is having difficulty breathing and assist him to a supine position. d. Recognize that a tripod position is often used when a patient is having respiratory difficulties.
D: Recognize that a tripod position is often used when a patient is having respiratory difficulties.
The nurse is assessing children in a pediatric clinic. Which statement is true regarding the measurement of blood pressure in children? a. Blood pressure guidelines for children are based on age. b. Phase II Korotkoff sounds are the best indicator of systolic blood pressure in children. c. Using a Doppler device is recommended for accurate blood pressure measurements until adolescence. d. The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children.
D: The disappearance of phase V Korotkoff sounds can be used for the diastolic reading in children.
A 4-month-old child is at the clinic for a well-baby check-up and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant's vital signs? a. The infant's radial pulse should be palpated, and the nurse should notice any fluctuations resulting from activity or exercise. b. The nurse should auscultate an apical rate for 1 minute and then assess for any normal irregularities, such as sinus arrhythmia. c. The infant's blood pressure should be assessed by using a stethoscope with a large diaphragm piece to hear the soft muffled Korotkoff sounds. d. The infant's chest should be observed and the respiratory rate counted for 1 minute; the respiratory pattern may vary significantly.
D: The infant's chest should be observed and the respiratory rate counted for 1 minute; the respiratory pattern may vary significantly.
When checking for proper blood pressure cuff size, which guideline is correct? a. The standard cuff size is appropriate for all sizes. b. The length of the rubber bladder should equal 80% of the arm circumference. c. The width of the rubber bladder should equal 80% of the arm circumference. d. The width of the rubber bladder should equal 40% of the arm circumference.
D: The width of the rubber bladder should equal 40% of the arm circumference.
19. The nurse recognizes that the concept of prevention in describing health is essential because: a. Disease can be prevented by treating the external environment. b. The majority of deaths among Americans under age 65 years are not preventable. c. Prevention places the emphasis on the link between health and personal behavior. d. The means to prevention is through treatment provided by primary health care practitioners.
NS: C A natural progression to prevention rounds out the present concept of health. Guidelines to prevention place the emphasis on the link between health and personal behavior.
ANS: circumduction. Circumduction is defined as moving the arm in a circle around the shoulder.
The nurse notices that a woman in an exercise class is unable to jump rope. The nurse knows that to jump rope, one's shoulder has to be capable of: A) inversion. B) supination. C) protraction. D) circumduction.
When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. The nurse should: a. Consider this a normal finding. b. Refer the individual for further evaluation. c. Document this finding as an asymmetric light reflex. d. Perform the confrontation test to validate the findings.
a. Consider this a normal finding.
A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse would: a. Consider this a normal finding. b. Assess the pupillary light reflex for possible blindness. c. Continue with the examination, and assess visual fields. d. Expect that a 2-week-old infant should be able to fixate and follow an object
a. Consider this a normal finding.
A patient's vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient: a. Has poor vision. b. Has acute vision. c. Has normal vision. d. Is presbyopic.
a. Has poor vision.
When examining the eye, the nurse notices that the patient's eyelid margins approximate completely. The nurse recognizes that this assessment finding: a. Is expected. b. May indicate a problem with extraocular muscles. c. May result in problems with tearing. d. Indicates increased intraocular pressure.
a. Is expected.
A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that she may have: a. Macular degeneration. b. Vision that is normal for someone her age. c. The beginning stages of cataract formation. d. Increased intraocular pressure or glaucoma.
a. Macular degeneration.
The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal? a. Optic disc that is a yellow-orange color b. Optic disc margins that are blurred around the edges c. Presence of pigmented crescents in the macular area d. Presence of the macula located on the nasal side of the retina
a. Optic disc that is a yellow-orange color
The nurse is testing a patient's visual accommodation, which refers to which action? a. Pupillary constriction when looking at a near object b. Pupillary dilation when looking at a far object c. Changes in peripheral vision in response to light d. Involuntary blinking in the presence of bright light
a. Pupillary constriction when looking at a near object
The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true? a. The outer layer of the eye is very sensitive to touch. b. The outer layer of the eye is darkly pigmented to prevent light from reflecting internally. c. The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when the outer surface of the eye is stimulated. d. The visual receptive layer of the eye in which light waves are changed into nerve impulses is located in the outer layer of the eye.
a. The outer layer of the eye is very sensitive to touch.
During a cardiovascular assessment, the nurse knows that a thrill is: a. Vibration that is palpable. b. Palpated in the right epigastric area. c. Associated with ventricular hypertrophy. d. Murmur auscultated at the third intercostal space.
a. Vibration that is palpable. A thrill is a palpable vibration that signifies turbulent blood flow and accompanies loud murmurs. The absence of a thrill does not rule out the presence of a murmur.
The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. These findings are characteristic of: a.Allergies. b.Sinus infection. c.Nasal congestion. d.Upper respiratory infection.
a.Allergies.
A 70-year-old man is visiting the clinic for difficulty in passing urine. In the health history, he indicates that he has to urinate frequently, especially at night. He has burning when he urinates and has noticed pain in his back. Considering this history, what might the nurse expect to find during the physical assessment? a.Asymmetric, hard, and fixed prostate gland b.Occult blood and perianal pain to palpation c.Symmetrically enlarged, soft prostate gland d.Soft nodule protruding from the rectal mucosa
a.Asymmetric, hard, and fixed prostate gland Subjective symptoms of carcinoma of the prostate include frequency, nocturia, hematuria, weak stream, hesitancy, pain or burning on urination, and continuous pain in lower back, pelvis, and thighs. Objective symptoms of carcinoma of the prostate include a malignant neoplasm that often starts as a single hard nodule on the posterior surface, producing asymmetry and a change in consistency. As it invades normal tissue, multiple hard nodules appear, or the entire gland feels stone hard and fixed.
During a health history of a patient who complains of chronic constipation, the patient asks the nurse about high-fiber foods. The nurse relates that an example of a high-fiber food would be: a.Broccoli. b.Hamburger. c.Iceberg lettuce. d.Yogurt.
a.Broccoli. High-fiber foods are either soluble type (e.g., beans, prunes, barley, broccoli) or insoluble type (e.g., cereals, wheat germ). The other examples are not considered high-fiber foods.
When examining children affected with Down syndrome (trisomy 21), the nurse looks for the possible presence of: a.Ear dysplasia. b.Long, thin neck. c.Protruding thin tongue. d.Narrow and raised nasal bridge.
a.Ear dysplasia.
The nurse is preparing to palpate the rectum and should use which of these techniques? The nurse should: a.Flex the finger, and slowly insert it toward the umbilicus. b.First instruct the patient that this procedure will be painful. c.Insert an extended index finger at a right angle to the anus. d.Place the finger directly into the anus to overcome the tight sphincter.
a.Flex the finger, and slowly insert it toward the umbilicus. The nurse should gently place the pad of the index finger against the anal verge. The nurse will feel the sphincter tighten and then relax. As it relaxes, the nurse should flex the tip of the finger and slowly insert it into the anal canal in a direction toward the umbilicus. The nurse should never approach the anus at right angles with the index finger extended; doing so would cause pain. The nurse should instruct the patient that palpation is not painful but may feel like needing to move the bowels.
The mother of a 5-year-old girl tells the nurse that she has noticed her daughter "scratching at her bottom a lot the last few days." During the assessment, the nurse finds redness and raised skin in the anal area. This finding most likely indicates: a.Pinworms. b.Chickenpox. c.Constipation. d.Bacterial infection.
a.Pinworms. In children, pinworms are a common cause of intense itching and irritated anal skin. The other options are not correct.
A 62-year-old man is experiencing fever, chills, malaise, urinary frequency, and urgency. He also reports urethral discharge and a dull aching pain in the perineal and rectal area. These symptoms are most consistent with which condition? a.Prostatitis b.Polyps c.Carcinoma of the prostate d.BPH
a.Prostatitis The common presenting symptoms of prostatitis are fever, chills, malaise, and urinary frequency and urgency. The individual may also have dysuria, urethral discharge, and a dull aching pain in the perineal and rectal area. These symptoms are not consistent with polyps.
When examining a patient's CN function, the nurse remembers that the muscles in the neck that are innervated by CN XI are the: a.Sternomastoid and trapezius. b.Spinal accessory and omohyoid. c.Trapezius and sternomandibular. d.Sternomandibular and spinal accessory.
a.Sternomastoid and trapezius.
The nurse is caring for a newborn infant. Thirty hours after birth, the infant passes a dark green meconium stool. The nurse recognizes this is important because the: a.Stool indicates anal patency. b.Dark green color indicates occult blood in the stool. c.Meconium stool can be reflective of distress in the newborn. d.Newborn should have passed the first stool within 12 hours after birth.
a.Stool indicates anal patency. The first stool passed by the newborn is dark green meconium and occurs within 24 to 48 hours of birth, indicating anal patency. The other responses are not correct.
The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patient's T4 and T3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination? a.Tachycardia b.Constipation c.Rapid dyspnea d.Atrophied nodular thyroid gland
a.Tachycardia
A patient's laboratory data reveal an elevated thyroxine (T4) level. The nurse would proceed with an examination of the _____ gland. a.Thyroid b.Parotid c.Adrenal d.Parathyroid
a.Thyroid
During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? a.Using gentle pressure, palpate with both hands to compare the two sides. b.Using strong pressure, palpate with both hands to compare the two sides. c.Gently pinch each node between one's thumb and forefinger, and then move down the neck muscle. d.Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.
a.Using gentle pressure, palpate with both hands to compare the two sides.
A 70-year-old patient with a history of hypertension has a blood pressure of 180/100 mm Hg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound at the apex immediately before the S1. The sound is heard only with the bell of the stethoscope while the patient is in the left lateral position. With these findings and the patient's history, the nurse knows that this extra heart sound is most likely a(n): a. Split S1. b. Atrial gallop. c. Diastolic murmur. d. Summation sound.
b. Atrial gallop. A pathologic S4 is termed an atrial gallop or an S4 gallop. It occurs with decreased compliance of the ventricle and with systolic overload (afterload), including outflow obstruction to the ventricle (aortic stenosis) and systemic hypertension. A left-sided S4 occurs with these conditions and is heard best at the apex with the patient in the left lateral position.
In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the: a. Bell of the stethoscope at the base with the patient leaning forward. b. Bell of the stethoscope at the apex with the patient in the left lateral position. c. Diaphragm of the stethoscope in the aortic area with the patient sitting. d. Diaphragm of the stethoscope in the pulmonic area with the patient supine.
b. Bell of the stethoscope at the apex with the patient in the left lateral position. The S4 is a ventricular filling sound that occurs when the atria contract late in diastole and is heard immediately before the S1. The S4 is a very soft sound with a very low pitch. The nurse needs a good bell and must listen for this sound. An S4 is heard best at the apex, with the person in the left lateral position
During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate: a. Valvular disorder. b. Blood flow turbulence. c. Fluid volume overload. d. Ventricular hypertrophy.
b. Blood flow turbulence. A bruit is a blowing, swishing sound indicating blood flow turbulence; normally, none is present.
A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. The nurse suspects: a.Bell palsy. b.Damage to the trigeminal nerve. c.Frostbite with resultant paresthesia to the cheeks. d.Scleroderma.
b. Damage to the trigeminal nerve.
Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient? a. Increased night vision b. Dark retinal background c. Increased photosensitivity d. Narrowed palpebral fissures
b. Dark retinal background
A patient comes into the clinic complaining of pain in her right eye. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse recognizes that this is a: a. Chalazion. b. Hordeolum (stye). c. Dacryocystitis. d. Blepharitis.
b. Hordeolum (stye).
During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notices the presence of blood in the anterior chamber of the eye. This finding indicates the presence of: a. Hypopyon. b. Hyphema. c. Corneal abrasion. d. Pterygium.
b. Hyphema.
The nurse is reviewing in age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia? a. Degeneration of the cornea b. Loss of lens elasticity c. Decreased adaptation to darkness d. Decreased distance vision abilities
b. Loss of lens elasticity
In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 beats per minute and slightly irregular; and the split S2 heart sound. Which of these findings can be explained by expected hemodynamic changes related to age? a. Increase in resting heart rate b. Increase in systolic blood pressure c. Decrease in diastolic blood pressure d. Increase in diastolic blood pressure
b. Increase in systolic blood pressure With aging, an increase in systolic blood pressure occurs. No significant change in diastolic pressure and no change in the resting heart rate occur with aging. Cardiac output at rest is does not changed with aging
The nurse knows that normal splitting of the S2 is associated with: a. Expiration. b. Inspiration. c. Exercise state. d. Low resting heart rate.
b. Inspiration. Normal or physiologic splitting of the S2 is associated with inspiration because of the increased blood return to the right side of the heart, delaying closure of the pulmonic valve.
In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would: a. Palpate the artery in the upper one third of the neck. b. Listen with the bell of the stethoscope to assess for bruits. c. Simultaneously palpate both arteries to compare amplitude. d. Instruct the patient to take slow deep breaths during auscultation.`
b. Listen with the bell of the stethoscope to assess for bruits. If cardiovascular disease is suspected, then the nurse should auscultate each carotid artery for the presence of a bruit. The nurse should avoid compressing the artery, which could create an artificial bruit and compromise circulation if the carotid artery is already narrowed by atherosclerosis. Excessive pressure on the carotid sinus area high in the neck should be avoided, and excessive vagal stimulation could slow down the heart rate, especially in older adults. Palpating only one carotid artery at a time will avoid compromising arterial blood to the brain
The nurse is preparing to auscultate for heart sounds. Which technique is correct? a. Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas b. Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex c. Listening to the sounds only at the site where the apical pulse is felt to be the strongest d. Listening for all possible sounds at a time at each specified area
b. Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex Auscultation of breath sounds should not be limited to only four locations. Sounds produced by the valves may be heard all over the precordium. The stethoscope should be inched in a rough Z pattern from the base of the heart across and down, then over to the apex; or, starting at the apex, it should be slowly worked up (see Figure 19-22). Listening selectively to one sound at a time is best.
The nurse is performing the diagnostic positions test. Normal findings would be which of these results? a. Convergence of the eyes b. Parallel movement of both eyes c. Nystagmus in extreme superior gaze d. Slight amount of lid lag when moving the eyes from a superior to an inferior position
b. Parallel movement of both eyes
The direction of blood flow through the heart is best described by which of these? a. Vena cava -->right atrium--> right ventricle lungs -->pulmonary artery --> left atrium --> left ventricle b. Right atrium--> right ventricle -->pulmonary artery -->lungs pulmonary vein --> left atrium -->left ventricle c. Aorta --> right atrium -->right ventricle--> lungs pulmonary vein --> left atrium --> left ventricle --> vena cava d. Right atrium --> right ventricle --> pulmonary vein--> lungs --> pulmonary artery -->left atrium --> left ventricle
b. Right atrium--> right ventricle -->pulmonary artery -->lungs pulmonary vein --> left atrium -->left ventricle Returning blood from the body empties into the right atrium and flows into the right ventricle and then goes to the lungs through the pulmonary artery. The lungs oxygenate the blood, and it is then returned to the left atrium through the pulmonary vein. The blood goes from there to the left ventricle and then out to the body through the aorta.
A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include: a. Loss of central vision. b. Shadow or diminished vision in one quadrant or one half of the visual field. c. Loss of peripheral vision. d. Sudden loss of pupillary constriction and accommodation.
b. Shadow or diminished vision in one quadrant or one half of the visual field.
The component of the conduction system referred to as the pacemaker of the heart is the: a. Atrioventricular (AV) node. b. Sinoatrial (SA) node. c. Bundle of His. d. Bundle branches.
b. Sinoatrial (SA) node. Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. Because the SA node has an intrinsic rhythm, it is called the pacemaker of the heart.
The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true? a. The right side of the brain interprets the vision for the right eye. b. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. c. Light rays are refracted through the transparent media of the eye before striking the pupil. d. Light impulses are conducted through the optic nerve to the temporal lobes of the brain.
b. The image formed on the retina is upside down and reversed from its actual appearance in the outside world.
The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, then the nurse should recognize which finding while pushing on the right upper quadrant of the patient's abdomen, just below the rib cage? a. The jugular veins will rise for a few seconds and then recede back to the previous level if the heart is properly working. b. The jugular veins will remain elevated as long as pressure on the abdomen is maintained. c. An impulse will be visible at the fourth or fifth intercostal space at or inside the midclavicular line. d. The jugular veins will not be detected during this maneuver.
b. The jugular veins will remain elevated as long as pressure on the abdomen is maintained. When performing hepatojugular reflux, the jugular veins will rise for a few seconds and then recede back to the previous level if the heart is able to pump the additional volume created by the pushing. However, with heart failure, the jugular veins remain elevated as long as pressure on the abdomen is maintained.
A patient's vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that: a. At 30 feet the patient can read the entire chart. b. The patient can read at 20 feet what a person with normal vision can read at 30 feet. c. The patient can read the chart from 20 feet in the left eye and 30 feet in the right eye. d. The patient can read from 30 feet what a person with normal vision can read from 20 feet.
b. The patient can read at 20 feet what a person with normal vision can read at 30 feet.
The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal? a. Decrease in tear production b. Unequal pupillary constriction in response to light c. Presence of arcus senilis observed around the cornea d. Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles
b. Unequal pupillary constriction in response to light
During a discussion for a men's health group, the nurse relates that the group with the highest incidence of prostate cancer is: a.Asian Americans. b.Blacks. c.American Indians. d.Hispanics.
b.Blacks. According to the American Cancer Society (2010), black men have a higher rate of prostate cancer than other racial groups.
A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. The nurse should suspect: a.Hypertension. b.Cluster headaches. c.Tension headaches. d.Migraine headaches.
b.Cluster headaches.
After completing an assessment of a 60-year-old man with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n): a.Annual proctoscopy. b.Colonoscopy every 10 years. c.Fecal test for blood every 6 months. d.DREs every 2 years.
b.Colonoscopy every 10 years. Early detection measures for colon cancer include a DRE performed annually after age 50 years, an annual fecal occult blood test after age 50 years, a sigmoidoscopic examination every 5 years or a colonoscopy every 10 years after age 50 years, and a PSA blood test annually for men over 50 years old, except beginning at age 45 years for black men
During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition? a.Rickets b.Dehydration c.Mental retardation d.Increased intracranial pressure
b.Dehydration
During a digital examination of the rectum, the nurse notices that the patient has hard feces in the rectum. The patient complains of feeling "full," has a distended abdomen, and states that she has not had a bowel movement "for several days." The nurse suspects which condition? a.Rectal polyp b.Fecal impaction c.Rectal abscess d.Rectal prolapse
b.Fecal impaction A fecal impaction is a collection of hard, desiccated feces in the rectum. The obstruction often results from decreased bowel motility, in which more water is reabsorbed from the stool.
A 30-year-old woman is visiting the clinic because of "pain in my bottom when I have a bowel movement." The nurse should assess for which problem? a.Pinworms b.Hemorrhoids c.Colon cancer d.Fecal incontinence
b.Hemorrhoids Having painful bowel movements, known as dyschezia, may be attributable to a local condition (hemorrhoid or fissure) or constipation. The other responses are not correct.
A patient says that she has recently noticed a lump in the front of her neck below her "Adam's apple" that seems to be getting bigger. During the assessment, the finding that leads the nurse to suspect that this may not be a cancerous thyroid nodule is that the lump (nodule): a.Is tender. b.Is mobile and not hard. c.Disappears when the patient smiles. d.Is hard and fixed to the surrounding structures.
b.Is mobile and not hard.
The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. The nurse knows that most lymph nodes in healthy adults are normally: a.Shotty. b.Nonpalpable. c.Large, firm, and fixed to the tissue. d.Rubbery, discrete, and mobile.
b.Nonpalpable.
A male patient with a history of acquired immunodeficiency syndrome (AIDS) has come in for an examination and he states, "I think that I have the mumps." The nurse would begin by examining the: a.Thyroid gland. b.Parotid gland. c.Cervical lymph nodes. d.Mouth and skin for lesions.
b.Parotid gland.
A patient has come in for an examination and states, "I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is?" The nurse notes swelling below the angle of the jaw and suspects that it could be an inflammation of his: a.Thyroid gland. b.Parotid gland. c.Occipital lymph node. d.Submental lymph node.
b.Parotid gland.
The structure that secretes a thin, milky alkaline fluid to enhance the viability of sperm is the: a.Cowper gland. b.Prostate gland. c.Median sulcus. d.Bulbourethral gland.
b.Prostate gland. In men, the prostate gland secretes a thin milky alkaline fluid that enhances sperm viability. The Cowper glands (also known as bulbourethral glands) secrete a clear, viscid mucus. The median sulcus is a groove that divides the lobes of the prostate gland and does not secrete fluid.
The physician reports that a patient with a neck tumor has a tracheal shift. The nurse is aware that this means that the patient's trachea is: a.Pulled to the affected side. b.Pushed to the unaffected side. c.Pulled downward. d.Pulled downward in a rhythmic pattern.
b.Pushed to the unaffected side.
A 40-year-old black man is in the office for his annual physical examination. Which statement regarding the PSA blood test is true, according to the American Cancer Society? The PSA: a.Should be performed with this visit. b.Should be performed at age 45 years. c.Should be performed at age 50 years. d.Is only necessary if a family history of prostate cancer exists.
b.Should be performed at age 45 years. According to the American Cancer Society (2006), the PSA blood test should be performed annually for black men beginning at age 45 years and annually for all other men over age 50 years.
Which characteristic of the prostate gland would the nurse recognize as an abnormal finding while palpating the prostate gland through the rectum? a.Palpable central groove b.Tenderness to palpation c.Heart shaped d.Elastic and rubbery consistency
b.Tenderness to palpation The normal prostate gland should feel smooth, elastic, and rubbery; slightly movable; heart-shaped with a palpable central groove; and not be tender to palpation.
The nurse is performing an examination of the anus and rectum. Which of these statements is correct and important to remember during this examination? a.The rectum is approximately 8 cm long. b.The anorectal junction cannot be palpated. c.Above the anal canal, the rectum turns anteriorly. d.No sensory nerves are in the anal canal or rectum.
b.The anorectal junction cannot be palpated. The anal columns are folds of mucosa that extend vertically down from the rectum and end in the anorectal junction. This junction is not palpable but is visible on proctoscopy. The rectum is 12 cm long; just above the anal canal, the rectum dilates and turns posteriorly.
Which statement concerning the sphincters is correct? a.The internal sphincter is under voluntary control. b.The external sphincter is under voluntary control. c.Both sphincters remain slightly relaxed at all times. d.The internal sphincter surrounds the external sphincter.
b.The external sphincter is under voluntary control. The external sphincter surrounds the internal sphincter but also has a small section overriding the tip of the internal sphincter at the opening. The external sphincter is under voluntary control. Except for the passing of feces and gas, the sphincters keep the anal canal tightly closed.
A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. The nurse suspects damage to CN ______ and proceeds with the examination by _____________. a.XI; palpating the anterior and posterior triangles b.XI; asking the patient to shrug her shoulders against resistance c.XII; percussing the sternomastoid and submandibular neck muscles d.XII; assessing for a positive Romberg sign
b.XI; asking the patient to shrug her shoulders against resistance
The nurse notices that a patient's palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)? a.III b.V c.VII d.VIII
c. VII
A 45-year-old man is in the clinic for a routine physical examination. During the recording of his health history, the patient states that he has been having difficulty sleeping. "I'll be sleeping great, and then I wake up and feel like I can't get my breath." The nurse's best response to this would be: a. "When was your last electrocardiogram?" b. "It's probably because it's been so hot at night." c. "Do you have any history of problems with your heart?" d. "Have you had a recent sinus infection or upper respiratory infection?"
c. "Do you have any history of problems with your heart?" Paroxysmal nocturnal dyspnea (shortness of breath generally occurring at night) occurs with heart failure. Lying down increases the volume of intrathoracic blood, and the weakened heart cannot accommodate the increased load. Classically, the person awakens
When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are: a. Mitral and tricuspid. b. Tricuspid and aortic. c. Aortic and pulmonic. d. Mitral and pulmonic.
c. Aortic and pulmonic. The second heart sound (S2) occurs with the closure of the semilunar (aortic and pulmonic) valves and signals the end of systole. Although it is heard over all the precordium, the S2 is loudest at the base of the heart
The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should: a. Check for the presence of exophthalmos. b. Suspect that the patient has hyperthyroidism. c. Ask the patient if he or she has a history of heart failure. d. Assess for blepharitis, which is often associated with periorbital edema.
c. Ask the patient if he or she has a history of heart failure.
During an assessment, the nurse notices that an older adult patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling "dry and itchy." Which action by the nurse is correct? a. Assessing the eye for a possible foreign body b. Documenting the finding as ptosis c. Assessing for other signs of ectropion d. Contacting the prescriber; these are signs of basal cell carcinoma
c. Assessing for other signs of ectropion
When assessing a newborn infant who is 5 minutes old, the nurse knows which of these statements to be true? a. The left ventricle is larger and weighs more than the right ventricle. b. The circulation of a newborn is identical to that of an adult. c. Blood can flow into the left side of the heart through an opening in the atrial septum. d. The foramen ovale closes just minutes before birth, and the ductus arteriosus closes immediately after.
c. Blood can flow into the left side of the heart through an opening in the atrial septum. First, approximately two thirds of the blood is shunted through an opening in the atrial septum, the foramen ovale, into the left side of the heart, where it is pumped out through the aorta. The foramen ovale closes within the first hour after birth because the pressure in the right side of the heart is now lower than in the left side
When listening to heart sounds, the nurse knows that the S1: a. Is louder than the S2 at the base of the heart. b. Indicates the beginning of diastole. c. Coincides with the carotid artery pulse. d. Is caused by the closure of the semilunar valves.`
c. Coincides with the carotid artery pulse. The S1 coincides with the carotid artery pulse, is the start of systole, and is louder than the S2 at the apex of the heart; the S2 is louder than the S1 at the base. The nurse should gently feel the carotid artery pulse while auscultating at the apex; the sound heard as each pulse is felt is the S1.
In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the patient's pupils. On the basis of this finding, the nurse would: a. Suspect that an opacity is present in the lens or cornea. b. Check the light source of the ophthalmoscope to verify that it is functioning. c. Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina. d. Continue with the ophthalmoscopic examination, and refer the patient for further evaluation.
c. Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina.
When examining a patient's eyes, the nurse recalls that stimulation of the sympathetic branch of the autonomic nervous system: a. Causes pupillary constriction. b. Adjusts the eye for near vision. c. Elevates the eyelid and dilates the pupil. d. Causes contraction of the ciliary body.
c. Elevates the eyelid and dilates the pupil.
During a cardiovascular assessment, the nurse knows that an S4 heart sound is: a. Heard at the onset of atrial diastole. b. Usually a normal finding in the older adult. c. Heard at the end of ventricular diastole. d. Heard best over the second left intercostal space with the individual sitting upright.
c. Heard at the end of ventricular diastole. An S4 heart sound is heard at the end of diastole when the atria contract (atrial systole) and when the ventricles are resistant to filling. The S4 occurs just before the S1.
The nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction (MI). Heart sounds are normal when she is supine, but when she is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse suspects: a. Increased cardiac output. b. Another MI. c. Inflammation of the precordium. d. Ventricular hypertrophy resulting from muscle damage.
c. Inflammation of the precordium. Inflammation of the precordium gives rise to a friction rub. The sound is high pitched and scratchy, similar to sandpaper being rubbed. A friction rub is best heard with the diaphragm of the stethoscope, with the person sitting up and leaning forward, and with the breath held in expiration. A friction rub can be heard any place on the precordium. Usually, however, the sound is best heard at the apex and left lower sternal border, which are places where the pericardium comes in close contact with the chest wall
While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse's response? a. Talk with the patient about his intake of caffeine. b. Perform an electrocardiogram after the examination. c. No further response is needed because sinus arrhythmia can occur normally. d. Refer the patient to a cardiologist for further testing.
c. No further response is needed because sinus arrhythmia can occur normally. The rhythm should be regular, although sinus arrhythmia occurs normally in young adults and children. With sinus arrhythmia, the rhythm varies with the person's breathing, increasing at the peak of inspiration and slowing with expiration.
A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this? a. Perform the confrontation test. b. Assess the individual's near vision. c. Observe the distance between the palpebral fissures. d. Perform the corneal light test, and look for symmetry of the light reflex.
c. Observe the distance between the palpebral fissures.
When a light is directed across the iris of a patient's eye from the temporal side, the nurse is assessing for: a. Drainage from dacryocystitis. b. Presence of conjunctivitis over the iris. c. Presence of shadows, which may indicate glaucoma. d. Scattered light reflex, which may be indicative of cataracts.
c. Presence of shadows, which may indicate glaucoma.
In a patient who has anisocoria, the nurse would expect to observe: a. Dilated pupils. b. Excessive tearing. c. Pupils of unequal size. d. Uneven curvature of the lens.
c. Pupils of unequal size.
The electrical stimulus of the cardiac cycle follows which sequence? a. AV node SA node bundle of His b. Bundle of His AV node SA node c. SA node AV node bundle of His bundle branches d. AV node SA node bundle of His bundle branches
c. SA node AV node bundle of His bundle branches Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. The current flows in an orderly sequence, first across the atria to the AV node low in the atrial septum. There it is delayed slightly, allowing the atria the time to contract before the ventricles are stimulated. Then the impulse travels to the bundle of His, the right and left bundle branches, and then through the ventricles
When assessing the pupillary light reflex, the nurse should use which technique? a. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction. b. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction. c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. d. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose
c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction.
In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history? a. Family history, hypertension, stress, and age b. Personality type, high cholesterol, diabetes, and smoking c. Smoking, hypertension, obesity, diabetes, and high cholesterol d. Alcohol consumption, obesity, diabetes, stress, and high cholesterol
c. Smoking, hypertension, obesity, diabetes, and high cholesterol To assess for major risk factors of coronary artery disease, the nurse should collect data regarding elevated serum cholesterol, elevated blood pressure, blood glucose levels above 100 mg/dL or known diabetes mellitus, obesity, any length of hormone replacement therapy for post menopausal women, cigarette smoking, and low activity level.
The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true? a. Percussion is a useful tool for outlining the heart's borders. b. Percussion is easier in patients who are obese. c. Studies show that percussed cardiac borders do not correlate well with the true cardiac border. d. Only expert health care providers should attempt percussion of the heart.
c. Studies show that percussed cardiac borders do not correlate well with the true cardiac border. Numerous comparison studies have shown that the percussed cardiac border correlates only moderately with the true cardiac border. Percussion is of limited usefulness with the female breast tissue, in a person who is obese, or in a person with a muscular chest wall. Chest x-ray images or echocardiographic examinations are significantly more accurate in detecting heart enlargement.
The nurse is assessing color vision of a male child. Which statement is correct? The nurse should: a. Check color vision annually until the age of 18 years. b. Ask the child to identify the color of his or her clothing. c. Test for color vision once between the ages of 4 and 8 years. d. Begin color vision screening at the child's 2-year checkup.
c. Test for color vision once between the ages of 4 and 8 years.
Which of these statements describes the closure of the valves in a normal cardiac cycle? a. The aortic valve closes slightly before the tricuspid valve. b. The pulmonic valve closes slightly before the aortic valve. c. The tricuspid valve closes slightly later than the mitral valve. d. Both the tricuspid and pulmonic valves close at the same time.
c. The tricuspid valve closes slightly later than the mitral valve. Events occur just slightly later in the right side of the heart because of the route of myocardial depolarization. As a result, two distinct components to each of the heart sounds exist, and sometimes they can be heard separately. In the first heart sound, the mitral component (M1) closes just before the tricuspid component (T1).
The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed? a. Perform the confrontation test. b. Ask the patient to read the print on a handheld Jaeger card. c. Use the Snellen chart positioned 20 feet away from the patient. d. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches.
c. Use the Snellen chart positioned 20 feet away from the patient.
When the nurse is auscultating the carotid artery for bruits, which of these statements reflects the correct technique? a. While listening with the bell of the stethoscope, the patient is asked to take a deep breath and hold it. b. While auscultating one side with the bell of the stethoscope, the carotid artery is palpated on the other side to check pulsations. c. While lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it. d. While firmly placing the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it.
c. While lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it. The correct technique for auscultating the carotid artery for bruits involves the nurse lightly applying the bell of the stethoscope over the carotid artery at three levels. While listening, the nurse asks the patient take a breath, exhale, and briefly hold it. Holding the breath on inhalation will also tense the levator scapulae muscles, which makes it hard to hear the carotid arteries. Examining only one carotid artery at a time will avoid compromising arterial blood flow to the brain. Pressure over the carotid sinus, which may lead to decreased heart rate, decreased blood pressure, and cerebral ischemia with syncope, should be avoided
While assessing a patient who is hospitalized and bedridden, the nurse notices that the patient has been incontinent of stool. The stool is loose and gray-tan in color. The nurse recognizes that this finding indicates which of the following? a.Occult blood b.Inflammation c.Absent bile pigment d.Ingestion of iron preparations
c.Absent bile pigment The presence of gray-tan stool indicates absent bile pigment, which can occur with obstructive jaundice. The ingestion of iron preparations and the presence of occult blood turns the stools to a black color. Jellylike mucus shreds mixed in the stool would indicate inflammation.
The nurse notices that a patient's submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, the nurse would assess the patient's: a.Infraclavicular area. b.Supraclavicular area. c.Area distal to the enlarged node. d.Area proximal to the enlarged node.
c.Area distal to the enlarged node.
The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. She tells the nurse that she noticed the lump approximately 8 hours after her baby's birth and that it seems to be getting bigger. One possible explanation for this is: a.Hydrocephalus. b.Craniosynostosis. c.Cephalhematoma. d.Caput succedaneum.
c.Cephalhematoma.
During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for: a.Exophthalmos. b.Bowed long bones. c.Coarse facial features. d.Acorn-shaped cranium.
c.Coarse facial features.
A 46-year-old man requires an assessment of his sigmoid colon. Which instrument or technique is most appropriate for this examination? a.Proctoscope b.Ultrasound c.Colonoscope d.Rectal examination with an examining finger
c.Colonoscope The sigmoid colon is 40 cm long, and the nurse knows that it is accessible to examination only with the colonoscope. The other responses are not appropriate for an examination of the entire sigmoid colon.
During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. Acutely infected lymph nodes would be: a.Clumped. b.Unilateral. c.Firm but freely movable. d.Firm and nontender.
c.Firm but freely movable.
During a well-baby checkup, the nurse notices that a 1-week-old infant's face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notices dilated scalp veins and downcast or "setting sun" eyes. The nurse suspects which condition? a.Craniotabes b.Microcephaly c.Hydrocephalus d.Caput succedaneum
c.Hydrocephalus
The nurse notices that a patient has had a pale, yellow, greasy stool, or steatorrhea, and recalls that this is caused by: a.Occult bleeding. b.Absent bile pigment. c.Increased fat content. d.Ingestion of bismuth preparations.
c.Increased fat content. Steatorrhea (pale, yellow, greasy stool) is caused by increased fat content in the stools, as in malabsorption syndrome. Occult bleeding and ingestion of bismuth products cause a black stool, and absent bile pigment causes a gray-tan stool.
While performing a well-child assessment on a 5 year old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 cm in size, round, mobile, and nontender. The nurse suspects that this child: a.Has chronic allergies. b.May have an infection. c.Is exhibiting a normal finding for a well child of this age. d.Should be referred for additional evaluation.
c.Is exhibiting a normal finding for a well child of this age.
The nurse is examining only the rectal area of a woman and should place the woman in what position? a.Lithotomy b.Prone c.Left lateral decubitus d.Bending over the table while standing
c.Left lateral decubitus The nurse should place the female patient in the lithotomy position if the genitalia are being examined as well. The left lateral decubitus position is used for the rectal area alone.
A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her? a.Diets low in protein and high in carbohydrates may cause enhanced facial bones. b.Bones can become more noticeable if the person does not use a dermatologically approved moisturizer. c.More noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin. d.Facial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial bones.
c.More noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin.
A woman comes to the clinic and states, "I've been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." The nurse will assess for other signs and symptoms of: a.Cachexia. b.Parkinson syndrome. c.Myxedema. d.Scleroderma.
c.Myxedema.
A patient who is visiting the clinic complains of having "stomach pains for 2 weeks" and describes his stools as being "soft and black" for approximately the last 10 days. He denies taking any medications. The nurse is aware that these symptoms are mostly indicative of: a.Excessive fat caused by malabsorption. b.Increased iron intake, resulting from a change in diet. c.Occult blood, resulting from gastrointestinal bleeding. d.Absent bile pigment from liver problems.
c.Occult blood, resulting from gastrointestinal bleeding. Black stools may be tarry as a result of occult blood (melena) from gastrointestinal bleeding or nontarry from ingestion of iron medications (not diet). Excessive fat causes the stool to become frothy. The absence of bile pigment causes clay-colored stools.
When examining the face of a patient, the nurse is aware that the two pairs of salivary glands that are accessible to examination are the ___________ and ___________ glands. a.Occipital; submental b.Parotid; jugulodigastric c.Parotid; submandibular d.Submandibular; occipital
c.Parotid; submandibular
A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. A bruit is a __________ sound that is heard best with the __________ of the stethoscope. a.Low gurgling; diaphragm b.Loud, whooshing, blowing; bell c.Soft, whooshing, pulsatile; bell d.High-pitched tinkling; diaphragm
c.Soft, whooshing, pulsatile; bell
During an examination, the nurse finds that a patient's left temporal artery is tortuous and feels hardened and tender, compared with the right temporal artery. The nurse suspects which condition? a.Crepitation b.Mastoiditis c.Temporal arteritis d.Bell palsy
c.Temporal arteritis
A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. He would probably be more comfortable with the nurse examining his thyroid gland from: a.Behind with the nurse's hands placed firmly around his neck. b.The side with the nurse's eyes averted toward the ceiling and thumbs on his neck. c.The front with the nurse's thumbs placed on either side of his trachea and his head tilted forward. d.The front with the nurse's thumbs placed on either side of his trachea and his head tilted backward.
c.The front with the nurse's thumbs placed on either side of his trachea and his head tilted forward.
The nurse needs to palpate the temporomandibular joint for crepitation. This joint is located just below the temporal artery and anterior to the: a.Hyoid bone. b.Vagus nerve. c.Tragus. d.Mandible.
c.Tragus.
During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus? a. Presence of tears along the inner canthus b. Blocked nasolacrimal duct in a newborn infant c. Slight swelling over the upper lid and along the bony orbit if the individual has a cold d. Absence of drainage from the puncta when pressing against the inner orbital rim
d. Absence of drainage from the puncta when pressing against the inner orbital rim
The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure? a. Thickness or bulging of the lens b. Posterior chamber as it accommodates increased fluid c. Contraction of the ciliary body in response to the aqueous within the eye d. Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber
d. Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber
A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that: a. The eyes converge to focus on the light. b. Light is reflected at the same spot in both eyes. c. The eye focuses the image in the center of the pupil. d. Constriction of both pupils occurs in response to bright light.
d. Constriction of both pupils occurs in response to bright light.
The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding? a. Dilation of the pupils b. Consensual light reflex c. Conjugate movement of the eyes d. Convergence of the axes of the eyes
d. Convergence of the axes of the eyes
The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates: a. Decreased fluid volume. b. Increased cardiac output. c. Narrowing of jugular veins. d. Elevated pressure related to heart failure.
d. Elevated pressure related to heart failure. Because no cardiac valve exists to separate the superior vena cava from the right atrium, the jugular veins give information about the activity on the right side of the heart. They reflect filling pressures and volume changes. Normal jugular venous pulsation is 2 cm or less above the sternal angle. Elevated pressure is more than 3 cm above the sternal angle at 45 degrees and occurs with heart failure.
During an inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests a(n): a. Normal heart. b. Systolic murmur. c. Enlargement of the left ventricle. d. Enlargement of the right ventricle.
d. Enlargement of the right ventricle. Normally, the examiner may or may not see an apical impulse; when visible, it occupies the fourth or fifth intercostal space at or inside the midclavicular line. A heave or lift is a sustained forceful thrusting of the ventricle during systole. It occurs with ventricular hypertrophy as a result of increased workload. A right ventricular heave is seen at the sternal border; a left ventricular heave is seen at the apex
During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? a. Third left intercostal space at the midclavicular line b. Fourth left intercostal space at the sternal border c. Fourth left intercostal space at the anterior axillary line d. Fifth left intercostal space at the midclavicular line
d. Fifth left intercostal space at the midclavicular line The apical impulse should occupy only one intercostal space, the fourth or fifth, and it should be at or medial to the midclavicular line.
During a cardiac assessment on a 38-year-old patient in the hospital for "chest pain," the nurse finds the following: jugular vein pulsations 4 cm above the sternal angle when the patient is elevated at 45 degrees, blood pressure 98/60 mm Hg, heart rate 130 beats per minute, ankle edema, difficulty breathing when supine, and an S3 on auscultation. Which of these conditions best explains the cause of these findings? a. Fluid overload b. Atrial septal defect c. MI d. Heart failure
d. Heart failure Heart failure causes decreased cardiac output when the heart fails as a pump and the circulation becomes backed up and congested. Signs and symptoms include dyspnea, orthopnea, paroxysmal nocturnal dyspnea, decreased blood pressure, dependent and pitting edema; anxiety; confusion; jugular vein distention; and fatigue. The S3 is associated with heart failure and is always abnormal after 35 years of age. The S3 may be the earliest sign of heart failure.
An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates: a. Retinal detachment. b. Diabetic retinopathy. c. Acute-angle glaucoma. d. Increased intracranial pressure.
d. Increased intracranial pressure.
A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. The nurse should: a. Examine the retina to determine the number of floaters. b. Presume the patient has glaucoma and refer him for further testing. c. Consider these to be abnormal findings, and refer him to an ophthalmologist. d. Know that floaters are usually insignificant and are caused by condensed vitreous fibers.
d. Know that floaters are usually insignificant and are caused by condensed vitreous fibers.
A 30-year-old woman with a history of mitral valve problems states that she has been "very tired." She has started waking up at night and feels like her "heart is pounding." During the assessment, the nurse palpates a thrill and lift at the fifth left intercostal space midclavicular line. In the same area, the nurse also auscultates a blowing, swishing sound right after the S1. These findings would be most consistent with: a. Heart failure. b. Aortic stenosis. c. Pulmonary edema. d. Mitral regurgitation.
d. Mitral regurgitation. These findings are consistent with mitral regurgitation. Its subjective findings include fatigue, palpitation, and orthopnea, and its objective findings are: (1) a thrill in systole at the apex; (2) a lift at the apex; (3) the apical impulse displaced down and to the left; (4) the S1 is diminished, the S2 is accentuated, and the S3 at the apex is often present; and (5) a pansystolic murmur that is often loud, blowing, best heard at the apex, and radiating well to the left axilla
The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short time, hungry again. What other information would the nurse want to have? a. Infant's sleeping position b. Sibling history of eating disorders c. Amount of background noise when eating d. Presence of dyspnea or diaphoresis when sucking
d. Presence of dyspnea or diaphoresis when sucking To screen for heart disease in an infant, the focus should be on feeding. Fatigue during feeding should be noted. An infant with heart failure takes fewer ounces each feeding, becomes dyspneic with sucking, may be diaphoretic, and then falls into exhausted sleep and awakens after a short time hungry again
During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding? a. Yellow fatty deposits over the cornea b. Pallor near the outer canthus of the lower lid c. Yellow color of the sclera that extends up to the iris d. Presence of small brown macules on the sclera
d. Presence of small brown macules on the sclera
A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion? a. Smooth and clear corneas b. Opacity of the lens behind the cornea c. Bleeding from the areas across the cornea d. Shattered look to the light rays reflecting off the cornea
d. Shattered look to the light rays reflecting off the cornea
A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next? a. Refer the patient to an ophthalmologist or optometrist for further evaluation. b. Assess whether the patient can count the nurse's fingers when they are placed in front of his or her eyes. c. Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart again. d. Shorten the distance between the patient and the chart until the letters are seen, and record that distance.
d. Shorten the distance between the patient and the chart until the letters are seen, and record that distance.
During ocular examinations, the nurse keeps in mind that movement of the extraocular muscles is: a. Decreased in the older adult. b. Impaired in a patient with cataracts. c. Stimulated by cranial nerves (CNs) I and II. d. Stimulated by CNs III, IV, and VI.
d. Stimulated by CNs III, IV, and VI.
The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has a "lazy eye" and should: a. Examine the external structures of the eye. b. Assess visual acuity with the Snellen eye chart. c. Assess the child's visual fields with the confrontation test. d. Test for strabismus by performing the corneal light reflex test.
d. Test for strabismus by performing the corneal light reflex test.
The nurse is reviewing the anatomy and physiologic functioning of the heart. Which statement best describes what is meant by atrial kick? a. The atria contract during systole and attempt to push against closed valves. b. Contraction of the atria at the beginning of diastole can be felt as a palpitation. c. Atrial kick is the pressure exerted against the atria as the ventricles contract during systole. d. The atria contract toward the end of diastole and push the remaining blood into the ventricles.
d. The atria contract toward the end of diastole and push the remaining blood into the ventricles. Toward the end of diastole, the atria contract and push the last amount of blood (approximately 25% of stroke volume) into the ventricles. This active filling phase is called presystole, or atrial systole, or sometimes the atrial kick
During an assessment, the nurse notes that the patient's apical impulse is laterally displaced and is palpable over a wide area. This finding indicates: a. Systemic hypertension. b. Pulmonic hypertension. c. Pressure overload, as in aortic stenosis. d. Volume overload, as in heart failure.
d. Volume overload, as in heart failure. With volume overload, as in heart failure and cardiomyopathy, cardiac enlargement laterally displaces the apical impulse and is palpable over a wider area when left ventricular hypertrophy and dilation are present.
During the cardiac auscultation, the nurse hears a sound immediately occurring after the S2 at the second left intercostal space. To further assess this sound, what should the nurse do? a. Have the patient turn to the left side while the nurse listens with the bell of the stethoscope. b. Ask the patient to hold his or her breath while the nurse listens again. c. No further assessment is needed because the nurse knows this sound is an S3. d. Watch the patient's respirations while listening for the effect on the sound.
d. Watch the patient's respirations while listening for the effect on the sound. A split S2 is a normal phenomenon that occurs toward the end of inspiration in some people. A split S2 is heard only in the pulmonic valve area, the second left interspace. When the split S2 is first heard, the nurse should not be tempted to ask the person to hold his or her breath so that the nurse can concentrate on the sounds. Breath holding will only equalize ejection times in the right and left sides of the heart and cause the split to go away. Rather, the nurse should concentrate on the split while watching the person's chest rise up and down with breathing.
A 60-year-old man has just been told that he has benign prostatic hypertrophy (BPH). He has a friend who just died from cancer of the prostate. He is concerned this will happen to him. How should the nurse respond? a."The swelling in your prostate is only temporary and will go away." b."We will treat you with chemotherapy so we can control the cancer." c."It would be very unusual for a man your age to have cancer of the prostate." d."The enlargement of your prostate is caused by hormonal changes, and not cancer."
d."The enlargement of your prostate is caused by hormonal changes, and not cancer." The prostate gland commonly starts to enlarge during the middle adult years. BPH is present in 1 in 10 men at the age of 40 years and increases with age. It is believed that the hypertrophy is caused by hormonal imbalance that leads to the proliferation of benign adenomas. The other responses are not appropriate.
A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has: a.Cushing syndrome. b.Parkinson disease. c.Bell palsy. d.Experienced a cerebrovascular accident (CVA) or stroke.
d.Experienced a cerebrovascular accident (CVA) or stroke.
During the taking of a health history, the patient states, "It really hurts back there, and sometimes it itches, too. I have even seen blood on the tissue when I have a bowel movement. Is there something there?" The nurse should expect to see which of these upon examination of the anus? a.Rectal prolapse b.Internal hemorrhoid c.External hemorrhoid that has resolved d.External hemorrhoid that is thrombosed
d.External hemorrhoid that is thrombosed These symptoms are consistent with an external hemorrhoid. An external hemorrhoid, when thrombosed, contains clotted blood and becomes a painful, swollen, shiny blue mass that itches and bleeds with defecation. When the external hemorrhoid resolves, it leaves a flabby, painless skin sac around the anal orifice. An internal hemorrhoid is not palpable but may appear as a red mucosal mass when the person performs a Valsalva maneuver. A rectal prolapse appears as a moist, red doughnut with radiating lines.
The nurse is aware that the four areas in the body where lymph nodes are accessible are the: a.Head, breasts, groin, and abdomen. b.Arms, breasts, inguinal area, and legs. c.Head and neck, arms, breasts, and axillae. d.Head and neck, arms, inguinal area, and axillae.
d.Head and neck, arms, inguinal area, and axillae.
A 13-year-old girl is visiting the clinic for a sports physical examination. The nurse should remember to include which of these tests in the examination? a.Testing for occult blood b.Valsalva maneuver c.Internal palpation of the anus d.Inspection of the perianal area
d.Inspection of the perianal area The perianal region of the school-aged child and adolescent should be inspected during the examination of the genitalia. Internal palpation is not routinely performed at this age. Testing for occult blood and performing the Valsalva maneuver are also not necessary.
Which statement concerning the anal canal is true? The anal canal: a.Is approximately 2 cm long in the adult. b.Slants backward toward the sacrum. c.Contains hair and sebaceous glands. d.Is the outlet for the gastrointestinal tract.
d.Is the outlet for the gastrointestinal tract. The anal canal is the outlet for the gastrointestinal tract and is approximately 3.8 cm long in the adult. It is lined with a modified skin that does not contain hair or sebaceous glands, and it slants forward toward the umbilicus.
A 19-year-old college student is brought to the emergency department with a severe headache he describes as, "Like nothing I've ever had before." His temperature is 40° C, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem? a.Head injury b.Cluster headache c.Migraine headache d.Meningeal inflammation
d.Meningeal inflammation
A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from: a.Hypertension. b.Cluster headaches. c.Tension headaches. d.Migraine headaches
d.Migraine headaches
During an assessment of a 20-year-old man, the nurse finds a small palpable lesion with a tuft of hair located directly over the coccyx. The nurse knows that this lesion would most likely be a: a.Rectal polyp. b.Pruritus ani. c.Carcinoma. d.Pilonidal cyst.
d.Pilonidal cyst. A pilonidal cyst or sinus is a hair-containing cyst or sinus located in the midline over the coccyx or lower sacrum. It often opens as a dimple with a visible tuft of hair and, possibly, an erythematous halo. (See Table 25-1 for more information, and also for the description of a pruritus ani. .)
During an examination, the nurse asks the patient to perform the Valsalva maneuver and notices that the patient has a moist, red, doughnut-shaped protrusion from the anus. The nurse knows that this finding is consistent with a: a.Rectal polyp. b.Hemorrhoid. c.Rectal fissure. d.Rectal prolapse.
d.Rectal prolapse. In rectal prolapse, the rectal mucous membrane protrudes through the anus, appearing as a moist red doughnut with radiating lines. It occurs after a Valsalva maneuver, such as straining at passing stool or with exercising
While performing a rectal examination, the nurse notices a firm, irregularly shaped mass. What should the nurse do next? a.Continue with the examination, and document the finding in the chart. b.Instruct the patient to return for a repeat assessment in 1 month. c.Tell the patient that a mass was felt, but it is nothing to worry about. d.Report the finding, and refer the patient to a specialist for further examination.
d.Report the finding, and refer the patient to a specialist for further examination. A firm or hard mass with an irregular shape or rolled edges may signify carcinoma. Any mass that is discovered should be promptly reported for further examination. The other responses are not correct.
While performing an assessment of the perianal area of a patient, the nurse notices that the pigmentation of anus is darker than the surrounding skin, the anal opening is closed, and a skin sac that is shiny and blue is noted. The patient mentioned that he has had pain with bowel movements and has occasionally noted some spots of blood. What would this assessment and history most likely indicate? a.Anal fistula b.Pilonidal cyst c.Rectal prolapse d.Thrombosed hemorrhoid
d.Thrombosed hemorrhoid The anus normally looks moist and hairless, with coarse folded skin that is more pigmented than the perianal skin, and the anal opening is tightly closed. The shiny blue skin sac indicates a thrombosed hemorrhoid.
A woman who has had rheumatoid arthritis for years is starting to notice that her fingers are drifting to the side. The nurse knows that this condition is commonly referred to as: A) radial drift. B) ulnar deviation. C) swan neck deformity. D) Dupuytren's contracture.
ulnar deviation. Fingers drift to the ulnar side because of stretching of the articular capsule and muscle imbalance caused by chronic rheumatoid arthritis. Radial drift is not seen. See Table 22-4 for descriptions of swan neck deformity and Dupuytren's contracture.
