HA II 304 Exam 2 Study Guide
a
A 23-year-old woman comes into the clinic with complaints of frequent urination and postcoital bleeding. She says she recently went out with her friends and went home with a man. Upon examination, the nurse notices green discharge and cervical tenderness. These findings are most consistent with: a. Chlamydia b. Atrophic vaginitis c. Bacterial vaginosis d. Trichomoniasis
a
A 38-year-old woman is scheduled for breast-conservation therapy with a lumpectomy. As the nurse prepares her for surgery, she begins to cry and says, "I just do not know how to handle all of this." An appropriate response to the patient by the nurse is: a. "Would you like to talk about how you are feeling right now?" b. "I can see you are really upset. Would you like to be alone for a while?" c. "The important thing is that the tumor is going to be removed." d. "With this surgery, you will have very little change in the appearance of your breast."
b
A 40-year-old man has come into the clinic with complaints of extreme pain in his 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
b
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 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: a. Aphthous ulcers b. Candidiasis c. Leukoplakia d. Koplik spots
a, d
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
d
A 60-year-old woman has developed reflexive sympathetic dystrophy after the arthroscopic repair of her shoulder. A key feature of this condition is that the: a. Affected extremity will eventually regain its function b. Pain is felt at one site but originates from another location c. Patients pain will be associated with nausea, pallor, and diaphoresis d. Slightest touch, such as a sleeve brushing against her arm, causes severe and intense pain
b
A nurse is assessing a client who is 2 days postpartum. Which of the following findings indicates a complication? a. Yellow-tinged discharge from breasts b. Hypotonic uterus c. Varicose veins in the legs d. Striae markings on the breast and abdomen
b
A nurse is assessing a patient's range of motion. The nurse knows that if the patient is able to perform the movements voluntarily, it is known as __________ range-of-motion. However, if the nurse is required to gently assist the patient's movements, it is known as __________ range-of-motion. a. Passive; active b. Active; passive c. Assisted; active d. Passive; independent
d
A nurse is assessing the Moro response in a newborn. Which of the following findings should the nurse expect? a. Abduction and extension of the arms are asymmetric b. The opposite leg flexes while a leg is extended and the sole of the foot is stimulated c. Toes hyperextend with dorsiflexion of the great toe d. The legs move in a similar pattern of response to the arms
d
A nurse is assessing the reflexes of a client who has an un-repaired femur fracture and has suddenly become stuporous. For which of the following findings should the nurse identify that the client exhibit's Babinski's sign? a. pinpoint pupils b. jerking contractions of the head and neck c. pronation of the arms d. dorsiflexion of the great toe
b
A nurse is caring for a client who has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention? a. Teach the client to scan to the right to see objects on the right side of her body b. Place the bedside table on the right side of her bed c. Orient the client to the food on her plate using the clock method d. Place the wheelchair on the client's lift side
b
A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following indicates the need for catheterization? a. Urge incontinence b. Dribbling of urine c. Weight gain d. Rectal distention
a
A nurse is caring for a client who has prostate cancer. The nurse should expect the provider to prescribe which of the following medications for this client? a. Leuprolide b. Finasteride c. Tamoxifen d. Cyclophosphamide
d
A nurse is caring for a client who is 12 hours postoperative following a transurethral resection of the prostate (TURP) and has a 3-way urinary catheter with continuous irrigation. The nurse notes there has not been any urinary output in the last hour. Which of the following actions should the nurse perform first? a. Notify the provider b. Administer a prescribed analgesic c. Offer oral fluids d. Determine the patency of the tubing
a
A nurse is caring for a client who is 32 hours postpartum. The client reports nipple soreness and breast engorgement. Which of the following recommendations should the nurse provide? a. "Call me so I can check your baby's latch the next time you breastfeed" b. "You should reduce the frequency of breastfeeding" c. "Apply expressed breast milk to sore nipples and cover them with nursing pads and a bra" d. "You should apply warm packs to the breasts between nursing sessions"
c
A nurse is caring for a patient who has been admitted due to an ischemic stroke. He reports difficulty seeing anything on the right side of his body. What area of the brain was affected based on this finding? a. Hippocampus b. Cerebellum c. Left hemisphere d. Right hemisphere
b
A nurse is caring for a patient who has suffered a spinal cord injury of the T3-T4 vertebrae. What disability would result from this type of injury? a. Hemiplegia b. Paraplegia c. Quadriplegia d. Paresis
c
A nurse is caring for an older adult client who comes to the clinic with dry, flaky skin on her upper back. Which of the following is an appropriate intervention? a. Note dry, flaky skin as a normal finding b. Perform examination of the back before the general inspection of the skin c. Pinch up a fold of skin to check for turgor d. Use penlight to examine the back in greater detail
a
A nurse is caring for an older adult client who has gout and refuses to eat. The client's provider has authorized the client's family to bring food from home. Which of the following foods should the nurse recommend that the client avoid? a. Lentil soup b. Cheese sandwich c. Yogurt d. Raisins
d
A nurse is discussing the difference between rheumatoid arthritis (RA) and osteoarthritis with a newly licensed nurse. Which of the following pieces of information should the nurse include about osteoarthritis? a. "Osteoarthritis is caused by autoimmune processes" b. "Osteoarthritis leads to a decreased erythrocyte sedimentation rate" c. "Osteoarthritis affects other organ systems" d. "Osteoarthritis can impair a joint on a single side of the body"
d
A nurse is giving instructions to a mother about how to breastfeed her newborn. Which of the following actions by the mother indicates an understanding of the teaching? a. The mother places a few drops on her nipple before feeding b. The mother gently removes her nipple from the infant's mouth to break the suction c. When she is ready to breastfeed, the mother gentle strokes the newborn's cheek with her finger d. When latched on, the infant's nose, cheek, and chin are touching the breast
a
A nurse is performing a cranial nerve assessment on a patient. Which of the following tests examines the function of CN III? a. PERRLA and 6 cardinal gazes b. Visual acuity c. Whisper test d. Cotton ball feeling
a
A nurse is performing a neurological assessment for a client. By asking the client to stick out his tongue, which of the following cranial nerves is the nurse testing? a. Cranial nerve XII b. Cranial nerve X c. Cranial nerve VIII d. Cranial nerve V
c
A nurse is planning care for a female who has a T4 spinal cord injury and is at risk of acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care? a. Cleanse the perineum from back to front b. Obtain a prescription for an indwelling urinary catheter c. Encourage fluid intake at and between meals d. Offer the client the bedpan every 2 hr
c
A nurse is preparing a community education program about reducing the risk of osteoporosis. Which of the following pieces of information should the nurse include? a. Avoid sun exposure b. Take a calcium supplement once each day if at risk for osteoporosis c. Walking is the preferred mode of exercise to maintain strong bones d. Caffeine intake minimizes the risk of developing osteoporosis
c
A nurse is providing discharge instructions to a client who is breastfeeding her newborn. Which of the following instructions should the nurse include? a. Offer the newborn 30 mL (1 oz) of water between feedings b. Feed the newborn 5 to 10 min per breast c. Allow the baby to feed at least every 3 hours d. Expect two to four wet diapers every 24 hours
a
A nurse is providing discharge teaching to a client who has osteoarthritis. Which of the following instructions should the nurse include? a. "Rest frequently after periods of activity" b. "Perform your exercises only on days that you feel good" c. "Perform your exercises after applying cold packs to your joints" d. "Place a large pillow under your knees when lying down"
c
A nurse is teaching a new mother about the signs of effective breastfeeding of her newborn. Which of the following information should the nurse include in the teaching? a. "Your baby should be gaining weight, so we will look into what is going on" b. "Your baby should lose 50% of its body weight throughout the first month of life" c. "Your baby can lose 5% of its body weight during the first few days of life" d. "Your baby should not lose any weight during the first month of life"
a, e, f
A nurse is teaching a woman how to perform breast self-examination as part of breast self-awareness. The nurse determines that the teaching was successful when the client states that she will complete the visual portion of the exam with her body in which position? Select all that apply. a. Arms hanging down at her side b. Sitting in a chair c. Leaning backwards d. Lying on her back with both arms raised e. Arms raised up behind the head f. Body bending forward
c
A nurse is teaching an older adult client about osteoporosis. Which of the following statements should the nurse include in the teaching? a. "Cottage cheese is a good source of calcium" b. "Increase your caffeine intake" c. "Brisk walking will prevent bone loss" d. "Hormone replacement therapy with estrogen will increase your risk of osteoporosis"
c
A nurse isthe client's safety? caring for a client who has an impairment of cranial nerve II. Which of the following actions should the nurse perform to promote a. Initiate seizure precautions b. Ensure the client receives a soft diet c. Provide an obstacle-free path for ambulation d. Instruct the client to use lukewarm water when showering
c
A nurse working in a community health center is preparing a flow sheet detailing essential screenings according to age group. At which developmental stage on the chart should the nurse add scoliosis screening? a. Infant b. Toddler/Preschooler c. Pre-adolescent/Adolescent d. Older Adult
b
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 sternocleidomastoid and submandibular neck muscles d. XII; assessing for a positive Romberg sign
b
A patient has been diagnosed with osteoporosis and asks the nurse, "What is osteoporosis?" The nurse explains that osteoporosis is defined as: a. Increased bone matrix b. Loss of bone density c. New, weaker bone growth d. Increased phagocytic activity
b
A patient is able to flex his right arm forward without difficulty or pain but is unable to abduct his arm before of pain and spasms. The nurse should suspect: a. Crepitation b. Rotator cuff lesions c. Dislocated shoulder d. Rheumatoid arthritis
c
A patient is being assessed for range-of-joint movement. The nurse asks him to move his arm toward the center of his body. This movement is called: a. Flexion b. Abduction c. Adduction d. Extension
c
A patient is complaining of pain in his joints that is worse in the morning, better after he moves around for a while, and then gets worse again if he sits for long periods. The nurse should assess for other signs of what problem? a. Tendinitis b. Osteoarthritis c. Rheumatoid arthritis d. Intermittent claudication
d
A patient is demonstrating signs and symptoms of stroke. The patient reports loss of vision. What area of the brain do you suspect is affected based on this finding? a. Brain stem b. Hippocampus c. Parietal lobe d. Occipital lobe
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
a
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
a
A patient with paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate? a. Teaching the patient how to self-catheterize b. Assisting the patient to the toilet every 2-3 hours c. Use of the Crede method to empty the bladder d. Catheterization for residual urine after voiding
c
A patient with severe osteoarthritis of the left knee has undergone left-knee arthroplasty of the total knee joint with a plastic prosthesis. Postoperatively, the nurse expects care of the leg to include: a. Bed rest for 3 days with the left leg immobilized in an extended position b. Use of a compression bandage to hold the left knee in a flexed position c. Progressive leg exercises to obtain 90-degree flexion d. Early ambulation with full weight bearing on the left leg
b
A postmenopausal woman comes into the clinic with complaints of vaginal itching, dryness, burning, and abnormal discharge. After the nurse does a vaginal examination, she notices the mucosa is pale and dry with a few abrasions. These findings are most consistent with: a. Chlamydia b. Atrophic vaginitis c. Bacterial vaginosis d. Trichomoniasis
b, e
A woman has been prescribed Anastrazole as treatment for breast cancer. Which of the following complications of this medication should the nurse warn the patient regarding the musculoskeletal system? Select all that apply. a. Hot flashes b. Increased risk of osteoporosis c. Vaginal bleeding d. Nausea and vomiting e. Muscle and joint pain f. Headaches
a, c, d, f
A woman has been prescribed Tamoxifen as treatment for breast cancer. Which of the following are contraindications to this medication? Select all that apply. a. Pregnancy risk category D b. Daily aspirin use c. Warfarin use d. History of blood clots e. Latex allergy f. History of pulmonary embolism
c
A woman who 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 contracture
d
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. The nurse suspects: a. Joint effusion b. Tear of rotator cuff c. Adhesive capsulitis d. Dislocated shoulder
b
An 85-year-old patient comments during his annual physical examination that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because: a. Long bones tend to shorten with age b. The vertebral column shortens c. A significant loss of subcutaneous fat occurs d. A thickening of the intervertebral disks develops
a
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
a
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 condition? a. Candidiasis b. Trichomoniasis c. Atrophic vaginitis d. Bacterial vaginosis
b
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
During an assessment of the CNs, the nurse ifnds 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 CN's 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
During an interview, a patient reveals that she is pregnant. She states that she is not sure whether she will breastfeed her baby and asks for some information about this. Which of these statements by the nurse is accurate? a. "Breastfed babies tend to be more colicky" b. "Breastfeeding provides the perfect food and antibodies for your baby" c. "Breastfed babes eat more often than infants on formula" d. "Breastfeeding is second nature, and every woman can do it"
b
During the assessment of deep tendon reflexes, the nurse finds that a patient's responses are bilaterally normal. What number is used to indicate normal deep tendon reflexes when documenting this finding? a. 1+ b. 2+ c. 3+ d. 4+
c
During trying to find the cause of the rash, which question would be important for the nurse to ask? a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for approximately 2 weeks. In 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?"
c
In a 3-month-old infant you assess the Babinski Reflex. What is the appropriate response in an infant at this stage? a. The big toe plantar flexes and the other toes curl downward b. All the toes curl downward c. The big toe dorsiflexes and the other toes spread outward d. The big toe plantar flexes and the other toes fan outward
d
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
c
The articulation of the mandible and the temporal bone is known as the: a. Intervertebral foramen b. The condyle of the mandible c. Temporomandibular joint d. Zygomatic arch of the temporal bone
c
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 3slip ́ 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. Conclude that this is a normal finding because the musculature of an infant at this age in undeveloped
c
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
a, d, f
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 is aware that characteristics of a cancerous mass include which of the following? Select all that apply. a. Nontender mass b. Dully, heavy pain on palpation c. Rubbery texture and mobile d. Hard, dense, and immobile e. Regular border f. Irregular, poorly delineated border
b, c, d
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? a. Symmetric joint involvement b. Asymmetric joint involvement c. Pain with motion of affected joints d. Affected joints are swollen with hard, bony protuberances e. Affected joints may have heat, redness, and swelling
a
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
a
The nurse is discussing BSEs with a postmenopausal woman. The best time for postmenopausal women to perform BSEs 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
a
The nurse is reviewing statistics regarding breast cancer. Which woman, aged 40 years in the United States, has the highest risk for developing breast cancer? a. Black b. White c. Asian d. American Indian
a
The nurse is reviewing the CBC findings for a female client who is receiving combination chemotherapy for breast cancer. Which finding should the nurse report to the healthcare provider? a. WBC 2,300 mm3 b. Hemoglobin 12 g/dL c. Platelets 150,000 mm3 d. RBC 5 million mm3
c
The nurse is teaching a class on preventing osteoporosis to a group of perimenopausal women. Which of these actions is the best way to prevent or delay bone loss in this group? a. Taking calcium and vitamin D supplements b. Taking medications to prevent osteoporosis c. Performing physical activity, such as fast walking d. Assessing bone density annually
D
The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? 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
The nurse notices that a woman in an exercise class is unable to jump rope. The nurse is aware that to jump rope, one's shoulder has to be capable of: a. Inversion b. Supination c. Protraction d. Circumduction
A
The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cried very easily and becomes angry. The nurse recalls the cerebral lobe responsible for these behaviors is the __________ lobe. a. Frontal b. Parietal c. Occipital d. Temporal
c
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
c, d, e
What are the common risk factors for osteoarthritis? Select all that apply. a. Autoimmune disorder b. Ingestion of large amounts of purine c. Activities affecting weight-bearing joints d. Overuse of joints from sports or strenuous activities e. Obesity
d
When assessing muscle strength, the nurse observes that a patient has a complete range of motion against gravity with full resistance. What grade of muscle strength should the nurse record using a 0- to 5-point scale? a. 2 b. 3 c. 4 d. 5
c
When assessing the pupillary light reflex, the nurse should use which technique? a. Shine a penlight 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, d
Which nursing actions are appropriate for preventing skin breakdown of a client with a spinal cord injury and paralysis? Select all that apply. a. Massage over erythematous bony prominences b. Implement a turning schedule every 4 hours c. Use pillows to keep heels off the bed d. Keep skins dry with powder e. Minimize skin exposure to moisture
a
a nurse is performing an assessment of the lymph nodes. When assessing the supraclavicular nodes, the nurse should: a. Palpate in a circular motion above the clavicles b. Palpate in a dragging motion above the clavicles c. Palpate in a circular motion along the sternocleidomastoid muscle d. Palpate in a dragging motion along the sternocleidomastoid muscle
a
the nurse is assisting with a BSE 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
c
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 as 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
c
the nurse is conducting a class on BSE. Which of these statements indicated the 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
b
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. Presence of palpable lymph nodes c. No palpable nodes because of the immature immune system of a child d. Fewer numbers and a smaller size of lymph nodes compared to those of an adult
