Health Assessment Exam 3

Your disease is due to repeated stress on the patellar tendon. It is usually self-limited, and your symptoms should resolve with rest.

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?

Varicocele

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:

Swollen testis; mass that does not transilluminate; scrotum that is tender on palpation; and scrotal skin that is reddened

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?

Retracting the foreskin should be avoided until the infant is 3 months of age

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?

Absence of the testis in the scrotum, but the testis can be milked down

A 2-year-old boy has been diagnosed with physiologic cryptorchidism. Considering this diagnosis, during assessment the nurse will most likely observe:

Reflexes will be normal

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?

An enlarged spleen should not be palpated because it can easily rupture

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 handle bars. The nurse suspects that he may have injured his spleen. Which of these statements is trueregarding assessment of the spleen in this situation?

If you smoke, how many cigarettes do you smoke a day?

A 22-year-old woman has been considering using oral contraceptives. As a part of her health history, the nurse should ask:

Herpes simplex virus type 2

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. Inguinal lymphadenopathy present is also present. The most likely cause of these lesions is:

Pelvic inflammatory disease

A 25-year-old woman comes to the emergency department with a sudden fever of 38.3 C 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 decline in blood pressure is normal and is caused by peripheral vasodilation

A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous examination, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true?

Cerebellum

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?

Mitral regurgitation

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:

Chorea

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:

Enlarged and tender inguinal nodes

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?

After age 30 years, if you have three consecutive normal Pap tests, then you may be screened every 2 to 3 years.

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?

Acute gout

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 hernia is a loop of bowel protruding through a weak spot in the abdominal muscles

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?

Consider this finding as normal and proceed with the examination

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 approximately 11 cm. The nurse should:

Do you have any history of problems wit your heart?

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. Ill be sleeping great, and then I wake up and feel like I cant get my breath. The nurses best response to this would be:

Stress incontinence

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:

Women at high risk for ovarian cancer should have annual transvaginal ultrasonography for screening.

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. Which statement does the nurse know to be correct regarding ovarian cancer?

HRT has several side effects, including fluid retention, breast tenderness, and vaginal bleeding.

A 50-year-old woman calls the clinic because she has noticed some changes in her body and breasts and wonders if these changes could be attributable to the hormone replacement therapy (HRT) she started 3 months earlier. The nurse should tell her:

Complete neurologic examination

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?

Stress incontinence

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:

Should be aware that she is at increased risk for dyspareunia because of decreased vaginal secretions.

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:

Epididymitis

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?

Digital rectal examination (DRE) and Blood test for prostate-specific antigen (PSA)

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?

Hyporeflexia

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?

Dysuria

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:

Explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles

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:

Ischemia caused by a partial blockage of an artery supplying

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.

the nurse should plan to lubricate the instruments and the examining hand adequately to avoid a painful examination

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. Which statement does the nurse know to be true regarding this visit?

Claudication

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 approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing:

Subcutaneous nodules

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:

Difficulty performing familiar tasks, such as placing a telephone call; Misplacing items, such as putting dish soap in the refrigerator; Sometimes having trouble finding the right word; Rapid mood swings, from calm to tears, for no apparent reason; Getting lost in ones own neighborhood

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?

This vein can be removed without harming your circulation because the deeper veins in your leg are in good condition.

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 this vein is removed? The nurse should reply:

Atrial gallop

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 patients history, the nurse knows that this extra heart sound is most likely a(n):

You need to get up slowly when youve been lying down or sitting.

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:

Spastic hemiparesis

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?

Testes

A male patient with possible fertility problems asks the nurse where sperm is produced. The nurse knows that sperm production occurs in the:

Tophi

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:

Acute alcohol intoxication

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?

Explain that couples are considered infertile after 1 year of unprotected intercourse.

A married couple has come to the clinic seeking advice on pregnancy. They have been trying to conceive for 4 months and have not been successful. What should the nurse do first?

Limited range of motion during the Moro reflex

A mother brings her newborn baby boy in for a checkup; she tells the nurse that he does not seem to be moving his right arm as much as his left and that he seems to have pain when she lifts him up under the arms. The nurse suspects a fractured clavicle and would observe for:

Myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated.

A mother of a 1-month-old infant asks the nurse why it takes so long for infants to learn to roll over. The nurse knows that the reason for this is:

Do you use a condom with each episode of sexual intercourse?

A nurse is assessing a patients risk of contracting a sexually transmitted infection (STI). An appropriate question to ask would be:

Fluid

A nurse notices that a patient has ascites, which indicates the presence of:

Avoid intercourse, inserting anything into the vagina, or douching within 24 hours of your appointment.

A patient calls the clinic for instructions before having a Papanicolaou (Pap) smear. The most appropriate instructions from the nurse are:

Problems related to arterial insufficiency

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 health history information, the nurse interprets that the patient is most likely experiencing:

The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve.

A patient has a severed spinal nerve as a result of trauma. Which statement is true in this situation?

Patient has a history of diabetes and cigarette smoking; skin of the patient is cool and pale; He states that the pain gets worse when walking.

A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings?

Loss of bone density

A patient has been diagnosed with osteoporosis and asks the nurse, What is osteoporosis? The nurse explains that osteoporosis is defined as:

Brownish discoloration of the skin on the lower leg

A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe?

3; 2; 1

A patient has had three pregnancies and two live births. The nurse would record this information as grav _____, para _____, AB _____.

Nonpitting, hard edema occurs with lymphatic obstruction

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:

Peritonitis

A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:

Rotator cuff lesions

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:

Adduction

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:

Kidney inflammation

A patient is complaining of a sharp pain along the costovertebral angles. The nurse is aware that this symptom is most often indicative of:

Rheumatoid Arthritis

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?

Dysphagia

A patient is having difficulty swallowing medications and food. The nurse would document that this patient has:

Intense, sharp pain, with the deep muscle tender to the touch; sudden onset; Warm, red, and swollen calf

A patient is recovering from several hours of orthopedic surgery. During an assessment of the patients lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following?

Test for Murphy sign

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?

Presence of dysdiadochokinesia.

A patient is unable to perform rapid alternating movements such as rapidly patting her knees. The nurse should document this inability as:

Metacarpophalangeal

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.

Crepitation

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?

Flexion

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?

Genu Valgum

A patient tells the nurse that, All my life Ive been called knock knees. The nurse knows that another term for knock knees is:

Swan-neck deformities

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?

The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere.

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?

Protuberant

A patients abdomen is bulging and stretched in appearance. The nurse should describe this finding as:

Functional scoliosis

A patients 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:

Medial and lateral epicondyle

A professional tennis player comes into the clinic complaining of a sore elbow. The nurse will assess for tenderness at the:

Sharp pain that increases with movement

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 of a:

Cervical

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.

Menstrual history, because it is generally non threatening

A woman is in the clinic for an annual gynecologic examination. The nurse should plan to begin the interview with the:

Unusual vaginal discharge or itching?

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 any:

Ulnar deviation

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:

Lordosis

A woman who is 8 months pregnant comments that she has noticed a change in her 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:

Goodell and Chadwick

A woman who is 8 weeks pregnant is in the clinic for a checkup. The nurse reads on her chart that her cervix is softened and looks cyanotic. The nurse knows that the woman is exhibiting __________ sign and __________ sign.

Dislocated shoulder

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:

Use the tanner scale of the five stages of development

An 11-year-old girl is in the clinic for a sports physical examination. 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:

Raising the head of the examination table and giving her a mirror so she can view the examination

An 18-year-old patient is having her first pelvic examination. Which action by the nurse is appropriate?

Abduct her hip while she is lying on her back

An 80-year-old woman is visiting the clinic for a checkup. She states, I cant walk as much as I used to. The nurse is observing for motor dysfunction in her hip and should ask her to:

The vertebral column shortens

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:

Prostate

An accessory glandular structure for the male genital organs is the:

Fourth lumbar

An imaginary line connecting the highest point on each iliac crest would cross the __________ vertebra.

Side effects of medications

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:

Decreases gastric acid secretion

An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to:

Ovarian cancer

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:

Heart Failure

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 vibration that is palpable

During a cardiovascular assessment, the nurse knows that a thrill is:

Heard at the end of ventricular diastole

During a cardiovascular assessment, the nurse knows that an S4 heart sound is:

Volume overload (heart failure)

During a cardiovascular assessment, the nurse knows that an S4 heart sound is:

Genital herpes

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:

The vaccine cannot protect you if you already have an HPV infection

During a health history, a 22-year old woman asks, Can I get that vaccine for human papilloma virus (HPV)? I have genital warts and Id like them to go away! What is the nurses best response?

Hesitancy

During a health history, a patient tells the nurse that he has trouble in starting his urine stream. This problem is known as:

Duodenal ulcer

During a health history, the patient tells the nurse, I have pain all the time in my stomach. Its worse 2 hours after I eat, but it gets better if I eat again! Based on these symptoms, the nurse suspects that the patient has which condition?

Polydactyly

During a neonatal examination, the nurse notices that the newborn infant has six toes. This finding is documented as:

Phimosis

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:

Arterial ischemic ulcer

During a routine office visit, a patient takes off his shoes and shows the nurse this awful sore that wont 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:

Cervix

During a speculum inspection of the vagina, the nurse would expect to see what at the end of the vaginal canal?

candidiasis

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?

Varicose veins

During a visit to the clinic, 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 apparent in her lower legs. Which condition is reflected by these findings?

Appendix

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?

5 minutes

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patients abdomen. Before reporting this finding as silent bowel sounds, the nurse should listen for at least:

Ascites

During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with:

Tympanic percussion note in the umbilical region

During an abdominal assessment, the nurse would consider which of these findings as normal?

Increased intracranial pressure

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?

Is a very ominous sign and may indicate brainstem injury.

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:

Parkinsonism

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:

Blood flow turbulence

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:

Fifth left intercostal space at thee midclavicular line

During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?

Projectile vomiting

During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be exhibited by:

Normal changes attributable to aging

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:

Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure

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?

Motor component of CN VII

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?

Raynaud's Disease

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:

Venous filling within 15 seconds

During an assessment, the nurse has elevated a patients legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him sit up and dangle his legs over the side of the table, the nurse should expect that a normal finding at this point would be:

Lymphedema

During an assessment, the nurse notices that a patients 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?

Umbilical hernia

During an assessment, the nurse notices that a patients umbilicus is enlarged and everted. It is positioned midline with no change in skin color. The nurse recognizes that the patient may have which condition?

Early clubbing

During an assessment, the nurse uses the profile sign to detect:

Decrease in the size of the penis

During an examination of an aging man, the nurse recognizes that normal changes to expect would be:

Decreased penis size

During an examination of an aging man, the nurse recognizes that normal changes to expect would be:

Herniated nucleus pulposus

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, the patient complains of a pain going down his buttock into his leg. The nurse suspects:

May indicate disease of the cerebellum or brainstem.

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:

Syphilitic chancre

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:

Urethral meatus and vaginal oriface

During an examination, the nurse observes a female patients vestibule and expects to see the:

Small and round

During an examination, the nurse would expect the cervical os of a woman who has never had children to appear:

Endocervical specimen, cervical scrape, and vaginal pool

During an examination, which tests will the nurse collect to screen for cervical cancer?

HPV or genital warts

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:

Enlargement of the right ventricle

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):

The woman is instructed to bear down, the width of the blades are horizontally turned, and the speculum is inserted downward at a 45-degree angle toward the small of the womans back.

During an internal examination of a womans genitalia, the nurse will use which technique for proper insertion of the speculum?

Uterine prolapse, second degree

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:

Acromion process

During an interview the patient states, I can feel this bump on the top of both of my shouldersit doesnt hurt but I am curious about what it might be. The nurse should tell the patient that it is his:

Enlarged liver

During reporting, the student nurse hears that a patient has hepatomegaly and recognizes that this term refers to:

These findings are normal, resulting from aging

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?

Watch the patient's respirations while listening for the effect on the sound

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?

Elevate her head and shoulders to maintain eye contact

During the examination portion of a patients visit, she will be in lithotomy position. Which statement reflects some things that the nurse can do to make this position more comfortable for her?

I have been noticing that i have been sweating a lot more than I used to, especially at night

During the interview with a female patient, the nurse gathers data that indicate the patient is perimenopausal. Which of these statements made by this patient leads to this conclusion?

I'd like more information about the discharge. What color is it?

During the interview, a patient reveals that she has some vaginal discharge. She is worried that it may be a sexually transmitted infection. The nurses most appropriate response to this would be:

Mild, even resistance to movement

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?

Displacement of the heart caused by elevation of the diaphragm

During the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate:

Before testing, the nurse would assess the patients mental status and ability to follow directions.

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?

Vertigo

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:

AV node—SA node—Bundle of His—Bundle Branches

Electrical stimulus of the cardiac cycle

Ligaments

Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called:

Estrogen dependent

Generally, the changes normally associated with menopause occur because the cells in the reproductive tract are:

1+ (0-4+ scale)

How should the nurse document mild, slight pitting edema the ankles of a pregnant patient?

Hyperreflexia

In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect?

Increase in systolic blood pressure

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?

Hyperactive reflexes

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?

Smoking, hypertension, obesity, high cholesterol, and diabetes

In assessing a patients major risk factors for heart disease, which would the nurse want to include when taking a history?

Bell of the stethoscope 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:

Listen with the bell of the stethoscope to assess for bruits

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would:

Does the tremor change when you drink alcohol?

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?

Reefer the infant for further testing

In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or stimulation. The mother reports that in the last week he has been sleeping all of the time, and when he is awake all he does is cry. The nurse hears that the infants cries are very high pitched and shrill. What should be the nurses appropriate response to these findings?

It should fall of in 10-14 days

Just before going home, a new mother asks the nurse about the infants umbilical cord. Which of these statements is correct?

5 lumbar

Of the 33 vertebrae in the spinal column, there are:

Direction of Blood flow through the heart

Right atrium—right ventricle—pulmonary artery—lungs—pulmonary vein—left atrium—left ventricle—aorta—body—vena cava

Pericardium

Sac that surrounds and protects the heart

Pacemaker of the heart

Sinoatrial (SA) node

Corticospinal tract

The ability that humans have to perform very skilled movements such as writing is controlled by the:

Talus

The ankle joint is the articulation of the tibia, fibula, and:

Spinal cord

The area of the nervous system that is responsible for mediating reflexes is the:

Temporomandibular joint

The articulation of the mandible and the temporal bone is known as the:

This response is most likely the result of the summation effect.

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?

Atrial kick

The atria contract at the end of diastole and push the remaining blood into the ventricles.

Scrotum

The external male genital structures include the:

Elevated pressure related to heart failure

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5cm above the sternal angle when the head of his bed is elevated 45 degrees. Thee nurse knows these findings indicate:

Joints

The functional units of the musculoskeletal system are the:

Tetralogy of Fallot

The mother of a 10-month-old infant tells the nurse that she has noticed that her son becomes blue when he is crying and that the frequency of this is increasing. He is also not crawling yet. During the examination the nurse palpates a thrill at the left lower sternal border and auscultates a loud systolic murmur in the same area. What would be the most likely cause of these findings?

The first sign of puberty is enlargement of the testes

The mother of a 10-year-old boy asks the nurse to discuss the recognition of puberty. The nurse should reply by saying:

Presence of dyspnea or diaphoresis when sucking

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?

Swelling from fluid in the suprapatellar pouch

The nurse has completed the musculoskeletal examination of a patients knee and has found a positive bulge sign. The nurse interprets this finding to indicate:

Multiple nontender sebaceous cysts

The nurse has just completed an inspection of a nulliparous womans external genitalia. Which of these would be a description of a finding within normal limits?

Suspect that the infant may have weakness of the shoulder muscles

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:

Frequent use of nonsteroidal anti inflammatory drugs

The nurse is assessing a patient for possible peptic ulcer disease. Which condition or history often causes this problem?

The jugular veins will remain extended as long as pressure on the abdomen is maintained

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 patients abdomen, just below the rib cage?

Flexing the hip

The nurse is assessing a patients ischial tuberosity. To palpate the ischial tuberosity, the nurse knows that it is best to have the patient:

Pyrosis (heartburn)

The nurse is assessing the abdomen of a pregnant woman who is complaining of having acid indigestion all the time. The nurse knows that esophageal reflux during pregnancy can cause:

Abdominal musculature is thinner

The nurse is assessing the abdomen of an older adult. Which statement regarding the older adult and abdominal assessment is true?

Normal for this age

The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. The nurse interprets this result as:

Asymmetric joint involvement; Pain with motion of affected joints; Affected joints are swollen with hard, bony protuberances

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?

Positive Babinski sign, which is abnormal for adults.

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:

Bounding

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.

The patient is asked to bend his or her knees in a frog-like position

The nurse is attempting to assess the femoral pulse in a patient who is obese. Which of these actions would be most appropriate?

Men with a history of cryptorchidism are at the greatest risk for the development of testicular cancer.

The nurse is aware of which statement to be true regarding the incidence of testicular cancer?

Decreased gastric acid secretion

The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is:

Level of consciousness, motor function, pupillary response, and vital signs

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?

Flexion and extension

The nurse is checking the range of motion in a patients knee and knows that the knee is capable of which movement(s)?

Concave

The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a ______ profile.

Is hard to palpate, may fade in and out and is easily obliterated by pressure

The nurse is describing a weak, thready pulse on the documentation flow sheet. Which statement is correct?

If you notice an enlarged testicle or painless lump, call your healthcare provider

The nurse is describing how to perform a testicular self-examination to a patient. Which statement is most appropriate?

Hip dislocation

The nurse is examining a 2-month-old infant and notices asymmetry of the infants gluteal folds. The nurse should assess for other signs of what disorder?

Negative Ortolani sign

The nurse is examining a 3-month-old infant. While the nurse holds his or her thumbs on the infants inner mid thighs and the fingers on the outside of the infants hips, touching the greater trochanter, the nurse adducts the legs until the his or her thumbs touch and then abducts the legs until the infants knees touch the table. The nurse does not notice any clunking sounds and is confident to record a:

The cervical surface is glandular and red

The nurse is examining a 35-year-old female patient. During the health 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?

This finding is a positive Allis sign and suggest hip dislocation

The nurse is examining a 6-month-old infant and places the infants 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?

Studies show that percussed cardiac borders do not correlate will with the true cardiac borders

The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true?

Smegma may be present under the foreskin of an uncircumcised male

The nurse is examining the glans and knows which finding is normal for this area?

Greater trochanter

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:

Presence of palpable lymph nodes

The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect?

Epiphysis

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?

Intervertebral disks

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:

Skin on the scrotum are taut

The nurse is inspecting the scrotum and testes of a 43-year-old man. Which finding would require additional follow-up and evaluation?

Are usually high pitched, gurgling, and irregular sounds

The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? Bowel sounds:

Give her an immediate referral to a gynecologist

The nurse is palpating a female patients 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 nurses most appropriate course of action would be to:

Smooth and round; mobile and fluctuant

The nurse is palpating an ovarian mass during an internal examination of a 63-year-old woman. Which findings of the masss characteristics would suggest the presence of an ovarian cyst?

Dullness

The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear?

Inflammation of the precordium

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:

Compress the glans between the examiners thumb and forefinger and collect any discharge

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:

Direct inguinal

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.

Peripheral neuropathy

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?

Palpable, firm, small, shotty, mobile, and non tender lymph nodes

The nurse is performing a well-child checkup on a 5-year-old boy. He has no current condition that would lead the nurse to suspect an illness. His health history is unremarkable, and he received immunizations 1 week ago. Which of these findings should be considered normal in this patient?

Dysfunction of the cerebellum

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?

Consider this a delayed capillary refill time and investigate further.

The nurse is performing an assessment on an adult. The adults vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?

Tympany, hyperressonance, and dullness

The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include:

Blacks

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?

Speculum, bimanual, and rectovaginal

The nurse is preparing for an internal genitalia examination of a woman. Which order of the examination is correct?

An ABI of 0.9-0.7 indicates the presence of peripheral vascular disease and mild claudication

The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about the ABI is true?

Lateral to the extensor tendon of the great toe.

The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation?

Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex.

The nurse is preparing to auscultate for heart sounds. Which technique is correct?

Examine the tender area last

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:

In a frog-leg position on the examining table

The nurse is preparing to examine the external genitalia of a school-age girl. Which position would be most appropriate in this situation?

The nurse should ask a postmenopausal woman if she has ever had any bleeding.

The nurse is preparing to interview a postmenopausal woman. Which of these statements is true as it applies to obtaining the health history of a postmenopausal woman?

To evaluate the adequacy of collateral circulation before cannulating the radial artery

The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test?

Abnormal lipids, smoking, hypertension, and diabetes.

The nurse is presenting a class on risk factors for cardiovascular disease. Which of these are considered modifiable risk factors for MI?

Glenohumeral joint

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:

Priapism

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:

6

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?

Normal

The nurse is reviewing an assessment of a patients 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?

Blacks

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 pulsating mass is usually present

The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm?

Brachial

The nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the _____ artery.

Uterine and ovarian atrophy, along with a thinning of the vaginal epithelium

The nurse is reviewing the changes that occur with menopause. Which changes are associated with menopause?

Person who has been on bed rest for 4 days.

The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease?

Intraluminal valves ensure unidirectional flow toward the heart.

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?

Performing physical activity, such as fast walking

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?

The flow of lymph is slow, compared with that of the blood.

The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement?

Plantar reflex present

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?

Ask patient to lock her fingers and pull

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:

Moves the head and shoulders against resistance with equal strength.

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:

Auscultation prevents distortion of bowel sounds that might occur after palpation and percussion

The nurse is watching a new graduate nurse perform auscultation of a patients abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

Presence of a hydrocele, or fluid in the scrotum

The nurse knows that a common assessment finding in a boy younger than 2 years old is:

Cerebrum

The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)?

Enlarged organs

The nurse knows that during an abdominal assessment, deep palpation is used to determine:

Inspiration

The nurse knows that normal splitting of the S2 is associated with:

Position sense

The nurse knows that testing kinesthesia is a test of a persons:

Gastrointestinal bleeding

The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be:

Circumduction

The nurse notices that a woman in an exercise class is unable to jump rope. The nurse is aware that to jump rope, ones shoulder has to be capable of:

Astereognosis

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?

Ballottement

The nurse should use which test to check for large amounts of fluid around the patella?

Percuss and palpate the midline area above the Suprapubic bone

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?

Test for the Blumberg sign; Perform the iliopsoas muscle test

The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix?

Hold both hands back to back while flexing thee wrists 90 degree for 60 seconds

The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen test. To perform this test, the nurse should instruct the patient to:

Hyperactive bowel sounds

The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to:

Central and peripheral

The two parts of the nervous system are the:

Anteverted and anteflexed

The uterus is usually positioned tilting forward and superior to the bladder. This position is known as:

Frontal

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.

Raises the head and arches the back

To assess the head control of a 4-month-old infant, the nurse lifts up the infant in a prone position while supporting his chest. The nurse looks for what normal response? The infant:

Anterior to the tragus

To palpate the temporomandibular joint, the nurses fingers should be placed in the depression __________ of the ear.

Hop on one foot

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:

Blood can flow into the left side of the heart through an opening in the atrial septum.

When assessing a newborn infant who is 5 minutes old, the nurse knows which of these statements to be true?

This is a normal finding in newborns and should resolve within a few weeks

When assessing a newborn infants 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 infants mother states that she is worried about the labia being swollen. The nurse should reply:

Auscultate the site for a bruit

When assessing a patient, the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next?

Paradoxus

When assessing a patients 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:

5

When assessing muscle strength, the nurse observes that a patient has 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?

Sebaceous cysts

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:

Occur with turbulent blood flow, indicating partial occlusion

When auscultating over a patients femoral arteries, the nurse notices the presence of a bruit on the left side. The nurse knows that bruits:

Coincides with the carotid artery pulse

When listening to heart sounds, the nurse knows that the S1:

Aortic and pulmonic (S2)

When listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart are:

Spleen

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?

Genital warts

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:

Consider this finding as normal and proceed with the exam

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:

Indirect inguinal

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.

Called hypospadias

When performing a genitourinary assessment, the nurse notices that the urethral meatus is ventrally positioned. This finding is:

Proximal to distal

When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be:

Consider this finding normal and proceed with the peripheral vascular evaluation

When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patients skin is warm and capillary refill time is normal. Next, the nurse should:

Suspect the presence of serous fluid in the scrotum

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:

Examine the patients lower arm and hand, and check for the presence of infection or lesions.

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?

1

When performing an external genitalia examination of a 10-year-old girl, the nurse notices that no pubic hair has grown in 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.

The cervix should move with palpation. An immovable cervix may indicate malignancy.

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 nurses interpretation of these results should be which of these?

Bone marrow

When reviewing the musculoskeletal system, the nurse recalls that hematopoiesis takes place in the:

Do you have a warning sign before your seizures start?

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?

Positive Romberg sign

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:

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.

When the nurse is auscultating the carotid artery for bruits, which of these statements reflects the correct technique?

Often adolescents your age have questions about sexual activity

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?

Girls your age often have questions about sexual activity. Do you have any questions?

When the nurse is discussing sexuality and sexual issues with an adolescent, a permission statement helps convey that it is normal to think or feel a certain way. Which statement is the best example of a permission statement?

When did you notice that your body was changing?

When the nurse is interviewing a preadolescent girl, which opening question would be least threatening?

Reassure the patient that this is a normal response and continue with the examination

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:

Having the patient shift his weight onto the left (unexamined) leg when palpating for a hernia on the right side

When the nurse is performing a genital examination on a male patient, which action is correct?

Testes that feel oval and movable and are slightly sensitive to compression

When the nurse is performing a testicular examination on a 25-year-old man, which finding is considered normal?

Extension of the forearm

When the nurse is testing the triceps reflex, what is the expected response?

Swishing, whooshing sound

When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard?

Murmur at the second left intercostal space when supine

Which of these findings would the nurse expect to notice during a cardiac assessment on a 4-year-old child?

Dullness across the abdomen

Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites?

The peripheral nerves carry input to thee central nervous system by afferent fibers and away from the central nervous system by efferent fibers

Which of these statements about the peripheral nervous system is correct?

Do you need to get up at night to urinate?

Which of these statements is most appropriate when the nurse is obtaining a genitourinary history from an older man?

The corpus spongiosum expands into a cone of erectile tissue called the glans.

Which of these statements is true regarding the penis?

Denver II

Which of these tests would the nurse use to check the motor coordination of an 11-month-old infant?

The hypothalamus regulates body temperature and controls sleep

Which statement concerning the areas of the brain is true?

The cremaster muscle contracts in response to cold and draws the testicles closer to the body.

Which statement concerning the testes is true?

The arterial system is a high pressure system

Which statement is true regarding the arterial system?

Women often have questions about their sexual relationship and how it affects their health. Do you have any questions?

Which statement would be most appropriate when the nurse is introducing the topic of sexual relationships during an interview?

Sigmoid colon

Which structure is located in the left lower quadrant of the abdomen?

Superficial

Which vein(s) is(are) responsible for most of the venous return in the arm?

This reflex should have disappeared between 1 and 4 months of age.

While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of the arms and legs; fanning of the fingers, and curling of the index finger and thumb in a C position, followed by the infant bringing in the arms and legs to the body. What does the nurse know about this response?

These findings can all be normal in children

While auscultating heart sounds on a 7-year-old child for a routine physical examination, the nurse hears an S3, a soft murmur at the left midsternal border, and a venous hum when the child is standing. What would be a correct interpretation of these findings?

No further response is needed because sinus arrhythmia can occur normally.

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 nurses response?

Normal abdominal pulsations

While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. The nurse would suspect that these are:

Lateral spinothalamic tract, thalamus, and sensory cortex

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?

Reflexes

While obtaining a health history of a 3-month-old infant from the mother, the nurse asks about the infants ability to suck and grasp the mothers finger. What is the nurse assessing?

Decreased level of consciousness

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):

Tetralogy of Fallot

a congenital malformation of the heart involving four distinct defects

Describes the closure of the valves in a normal cardiac cycle

tricuspid closes slightly later than the mitral valve