Health Assessment - Test Bank (Exam 4)

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A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. What does the nurse suspect? a. Bell palsy b. Scleroderma c. Damage to the trigeminal nerve d. Frostbite with resultant paresthesia to the cheeks

While palpating the prostate gland through the rectum, which finding would the nurse recognize as abnormal? a. Heart shaped b. Palpable central groove c. Tenderness to palpation d. Elastic and rubbery consistency

ANS: C The normal prostate gland should feel smooth, elastic, and rubbery; slightly movable; heart-shaped with a palpable central groove; and not be tender to palpation.

The nurse is caring for a newborn infant. Thirty hours after birth, the infant passes a dark green meconium stool. What is the importance of this finding? a. The stool indicates anal patency. b. The dark green color indicates occult blood in the stool. c. Meconium stool can be reflective of distress in the newborn. d. The newborn should have passed the first stool within 12 hours of birth.

ANS: A The first stool passed by the newborn is dark green meconium and occurs within 24 to 48 hours of birth, indicating anal patency. The other responses are not correct.

BEGINNING OF CHAPTER 13 - SKIN, HAIR, AND NAILS ***FOCUS ONLY ON THE AGING ADULT QUESTIONS!!

BEGINNING OF CHAPTER 13 - SKIN, HAIR, AND NAILS

BEGINNING OF CHAPTER 14 - HEAD, FACE, AND NECK, AND REGIONAL LYMPHATICS ***FOCUS ONLY ON THE AGING ADULT QUESTIONS!!

BEGINNING OF CHAPTER 14 - HEAD, FACE, AND NECK, AND REGIONAL LYMPHATICS

BEGINNING OF CHAPTER 15 - EYES ***FOCUS ONLY ON THE AGING ADULT QUESTIONS!!

BEGINNING OF CHAPTER 15 - EYES

BEGINNING OF CHAPTER 17 - NOSE, MOUTH, AND THROAT ***FOCUS ONLY ON THE AGING ADULT QUESTIONS!!

BEGINNING OF CHAPTER 17 - NOSE, MOUTH, AND THROAT

BEGINNING OF CHAPTER 18 - BREASTS, AXILLAE, AND REGIONAL LYMPHATICS ***FOCUS ONLY ON THE AGING ADULT QUESTIONS!!

BEGINNING OF CHAPTER 18 - BREASTS, AXILLAE, AND REGIONAL LYMPHATICS

A 46-year-old man requires an assessment of his sigmoid colon. Which instrument or technique is most appropriate for this examination? a. Ultrasound b. Proctoscope c. Colonoscope d. Rectal examination with an examining finger

ANS: C The sigmoid colon is 40 cm long, and it is accessible to examination only with a colonoscope. The other responses are not appropriate for an examination of the entire sigmoid colon.

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse pays special attention to the danger signs for pigmented lesions and is concerned with which additional finding? a. Color variation b. Border regularity c. Symmetry of lesions d. Diameter of less than 6 mm

ANS: A Abnormal characteristics of pigmented lesions are summarized in the mnemonic ABCD: asymmetry of pigmented lesion, border irregularity, color variation, and diameter greater than 6 mm.

BEGINNING OF CHAPTER 19 - THORAX AND LUNGS ***FOCUS ONLY ON THE AGING ADULT QUESTIONS!!

BEGINNING OF CHAPTER 19 - THORAX AND LUNGS

BEGINNING OF CHAPTER 20 - HEART AND NECK VESSELS ***FOCUS ONLY ON THE AGING ADULT QUESTIONS!!

BEGINNING OF CHAPTER 20 - HEART AND NECK VESSELS

BEGINNING OF CHAPTER 21 - PERIPHERAL VASCULAR SYSTEM AND LYMPHATIC SYSTEM ***FOCUS ONLY ON THE AGING ADULT QUESTIONS!!

BEGINNING OF CHAPTER 21 - PERIPHERAL VASCULAR SYSTEM AND LYMPHATIC SYSTEM

BEGINNING OF CHAPTER 22 - ABDOMEN

BEGINNING OF CHAPTER 23 - MUSCULOSKELETAL SYSTEM

BEGINNING OF CHAPTER 25 - MALE GENITOURINARY SYSTEM

BEGINNING OF CHAPTER 26 - ANUS, RECTUM, AND PROSTATE

BEGINNING OF CHAPTER 27 - FEMALE GENITOURINARY SYSTEM

A 65-year-old patient is experiencing pain in his left calf when he exercises which disappears after resting for a few minutes. What problem in the left leg does this indicate? a. Venous obstruction b. Partial blockage of an artery c. Claudication due to venous abnormalities d. Ischemia caused by the complete blockage of an artery

ANS B: These symptoms indicate ischemia, a deficient supply of oxygenated arterial blood to the tissue, in the leg. A partial blockage creates an insufficient supply and may be apparent only during exercise when oxygen needs increase and is relieved with rest. Although the term for this is claudication, it is due to insufficient arterial blood, not venous abnormalities. With a complete blockage of an artery, the pain would be constant, not just with walking/exercise, and would not be relieved with rest.

The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient? a. Hypertrophy of the gums b. Increased production of saliva c. Decreased ability to identify odors d. Finer and less prominent nasal hair

ANS C: The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers with aging. Nasal hairs grow coarser and stiffer with aging. The gums may recede with aging, not hypertrophy, and saliva production decreases. The gums may recede with aging, not hypertrophy, and saliva production decreases. Nasal hairs grow coarser and stiffer with aging. Because of a decrease in the number of olfactory nerve fibers with aging, the nurse should expect a reduced sense of smell in this patient.

Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites? a. Dullness across the abdomen b. Flatness in the right upper quadrant c. Hyperresonance in the left upper quadrant d. Tympany in the right and left lower quadrants

ANS: A A large amount of ascitic fluid produces a dull sound to percussion. Flatness is not a term used to describe a percussed sound. Hyperresonance is a lower-pitched, booming sound found when too much air is present such as with gaseous distention of the intestines in the abdomen, not with ascites or fluid. Tympany normally is the predominant sound heard on abdominal auscultation, but it is not heard with ascites, or fluid, in the abdomen.

A patient has been diagnosed with osteoporosis and asks the nurse, "What is osteoporosis?" What is the best explanation by the nurse? a. "It is the loss of bone density." b. "It is an increase in bone matrix." c. "It is new bone growth that is weaker." d. "There is a decrease in phagocytic activity."

ANS: A After age 40 years, a loss of bone matrix (resorption) occurs more rapidly than new bone formation. The net effect is a gradual loss of bone density, or osteoporosis. The other options are not correct. There is a decrease, not increase, in bone matrix with aging; new bone growth is slower than the loss of bone matrix (not weaker bone growth); and phagocytic activity has nothing to do with bones.

Just before going home, a new mother asks the nurse about the infant's umbilical cord. Which of these statements is correct? a. "It should fall off in 10 to 14 days." b. "It will soften before it falls off." c. "It contains two veins and one artery." d. "Skin will cover the area within 1 week."

ANS: A At birth, the umbilical cord is white and contains two umbilical arteries and one vein inside the Wharton's jelly. The umbilical stump dries within a week, hardens, and falls off in 10 to 14 days. Skin will cover the area in 3 to 4 weeks.

During a speculum inspection of the vagina, what would the nurse expect to see at the end of the vaginal canal? a. Cervix b. Uterus c. Ovaries d. Fallopian tubes

ANS: A At the end of the canal, the uterine cervix projects into the vagina.

A 40-year-old man has come into the clinic reporting extreme pain in his toes. The nurse notices that his toes are slightly swollen, reddened, and warm to the touch. What does the nurse suspect? a. Acute gout b. Osteoporosis c. Ankylosing spondylitis d. Degenerative joint disease

ANS: A Clinical findings for acute gout consist of redness, swelling, heat, and extreme pain like a continuous throbbing. Gout is a metabolic disorder of disturbed purine metabolism, associated with elevated serum uric acid. Osteoporosis is a decrease in skeletal bone mass leading to low bone mineral density and impaired bone density which increases the risk for fractures. It occurs primarily in postmenopausal white women. Ankylosing spondylitis is chronic inflamed vertebrae and is characterized by inflammatory back pain that is dull and deep in lower back or buttocks. Degenerative joint disease (osteoarthritis) is a localized, progressive disorder involving deterioration of articular cartilages and subchondral bone remodeling, synovial inflammation, and formation of new bone at joint surfaces. Asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. This patient's symptoms are consistent with acute gout.

During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. What does this finding indicate? a. Crepitus b. Friction rub c. Tactile fremitus d. Adventitious sounds

ANS: A Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, such as after open thoracic injury or surgery. A pleural friction rub is produced when inflammation of the parietal or visceral pleura causes a decrease in the normal lubricating fluid. The opposing surfaces make a coarse grating sound when rubbed together during breathing and is best detected by auscultation, not palpation. Tactile fremitus occurs with conditions that increase the density of lung tissue, thereby making a better conducting medium for palpable vibrations, not a coarse crackling sensation. Adventitious sounds are abnormal lung sounds heard by auscultation, not palpated.

BEGINNING OF CHAPTER 28 - THE COMPLETE HEALTH ASSESSMENT: ADULT

During auscultation of breath sounds, the nurse should correctly use the stethoscope in which of the following ways? a. Listening to at least one full respiration in each location b. Listening as the patient inhales and then going to the next site during exhalation c. If the patient is modest, listening to sounds over his or her clothing or hospital gown d. Instructing the patient to breathe in and out rapidly while listening to the breath sounds

ANS: A During auscultation of breath sounds with a stethoscope, listening to one full respiration in each location is important. During the examination, the nurse should monitor the breathing and offer times for the person to breathe normally to prevent possible dizziness. The nurse should listen with the diaphragm of the stethoscope directly on the skin, not over a patient's gown or clothing.

A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for reports of burning and pain during urination. How should the nurse document this finding? a. Dysuria b. Nocturia c. Polyuria d. Hematuria

ANS: A Dysuria (burning with urination) is common with acute cystitis, prostatitis, and urethritis. Nocturia is voiding during the night. Polyuria is voiding in excessive quantities. Hematuria is voiding with blood in the urine.

BEGINNING OF UNITS 8 AND 9 **DO NOT DELETE ANY QUESTIONS; CHAPTER 22 AND 23 DOES FOCUS ON OLDER ADULT ASSESSMENTS AS WELL

BEGINNING OF UNITS 8 AND 9 **DO NOT DELETE ANY QUESTIONS; CHAPTER 22 AND 23 DOES FOCUS ON OLDER ADULT ASSESSMENTS AS WELL; SHE SAID NOT TO FOCUS SO MUCH ON STIs

The nurse is examining a 6-month-old infant and places the infant's feet flat on the table and flexes his knees up. The nurse notes that the right knee is significantly lower than the left. Which of these statements is true of this finding? a. This finding is a positive Allis sign and suggests hip dislocation. b. The infant probably has a dislocated patella on the right knee. c. This finding is a negative Allis sign and normal for an infant of this age. d. The infant should return to the clinic in 2 weeks to see if his condition has changed.

ANS: A Finding one knee significantly lower than the other is a positive Allis sign and suggests hip dislocation. Normally the tops of the knees are at the same elevation. The other statements are not correct.

A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement? a. Flexion b. Abduction c. Adduction d. Extension

ANS: A Flexion, or bending a limb at a joint, is required to move the hand to the mouth. Extension is straightening a limb at a joint. Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body.

During an abdominal assessment, the nurse tests for a fluid wave. What condition would produce a positive fluid wave test? a. Ascites b. Splenomegaly c. Constipation d. Distended bladder

ANS: A If ascites (fluid in the abdomen) is present, then the examiner will feel a fluid wave when assessing the abdomen. A fluid wave is not present with splenomegaly, a distended bladder, or constipation.

The mother of a 5-year-old girl tells the nurse that she has noticed her daughter "scratching at her bottom a lot the last few days." During the assessment, the nurse finds redness and raised skin in the anal area. What does this finding likely indicate? a. Pinworms b. Chickenpox c. Constipation d. Bacterial infection

ANS: A In children, pinworms are a common cause of intense itching and irritated anal skin. The other options are not correct.

When assessing a newborn infant's genitalia, the nurse notices that the genitalia are somewhat engorged. The labia majora are swollen, the clitoris looks large, and the hymen is thick. The vaginal opening is difficult to visualize. The infant's mother states that she is worried about the labia being swollen. How should the nurse reply? a. "This is a normal finding in newborns and should resolve within a few weeks." b. "This finding could indicate an abnormality and may need to be evaluated by a physician." c. "We will need to have estrogen levels evaluated to ensure that they are within normal limits." d. "We will need to keep close watch over the next few days to see if the genitalia decrease in size."

ANS: A It is normal for a newborn's genitalia to be somewhat engorged. A sanguineous vaginal discharge or leukorrhea is normal during the first few weeks because of the maternal estrogen effect. During the early weeks, the genital engorgement resolves, and the labia minora atrophy and remain small until puberty.

During an examination, which tests will the nurse collect to screen for cervical cancer? a. Endocervical specimen, cervical scrape, and vaginal pool b. Endocervical specimen, vaginal pool, and acetic acid wash c. Cervical scrape, acetic acid wash, saline mount (wet prep) d. Endocervical specimen, potassium hydroxide (KOH) preparation, and acetic acid wash

ANS: A Laboratories may vary in method, but usually the test consists of three specimens: endocervical specimen, cervical scrape, and vaginal pool. The other tests (acetic acid wash, KOH preparation, and saline mount) are used to test for sexually transmitted infections.

A woman 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. What is the term for this shift in posture? a. Lordosis b. Scoliosis c. Ankylosis d. Kyphosis

ANS: A Lordosis compensates for the enlarging fetus, which would shift the center of balance forward. This shift in balance, in turn, creates a strain on the low back muscles, felt as low back pain during late pregnancy by some women. Scoliosis is lateral curvature of portions of the spine; ankylosis is extreme flexion of the wrist, as observed with severe rheumatoid arthritis; and kyphosis is an enhanced thoracic curvature of the spine. Scoliosis is lateral curvature of portions of the spine; ankylosis is extreme flexion of the wrist, as observed with severe rheumatoid arthritis; and kyphosis is an enhanced thoracic curvature of the spine. The symptoms this patient is experiencing are lordosis.

A woman is in the clinic for an annual gynecologic examination. How should the nurse begin the interview? a. Menstrual history, because it is generally nonthreatening. b. Sexual history, because discussing it first will build rapport. c. Obstetric history, because it includes the most important information. d. Urinary system history, because problems may develop in this area as well.

ANS: A Menstrual history is usually nonthreatening and therefore a good topic with which to begin the interview. Obstetric, urinary, and sexual histories are also part of the interview but not necessarily the best topics with which to start.

When performing a genitourinary assessment, the nurse notices that the urethral meatus is ventrally positioned. What does this indicate? a. Hypospadias b. A result of phimosis c. Probably due to a stricture d. Often associated with aging

ANS: A Normally the urethral meatus is positioned just about centrally. Hypospadias is the ventral location of the urethral meatus. The position of the meatus does not change with aging. Phimosis is the inability to retract the foreskin. A stricture is a narrow opening of the meatus.

An 85-year-old patient comments during his annual physical examination that he seems to be getting shorter as he ages. Why does height decrease with aging? a. The vertebral column shortens. b. Long bones tend to shorten with age. c. A significant loss of subcutaneous fat occurs. d. A thickening of the intervertebral disks develops.

ANS: A Postural changes are evident with aging and decreased height is most noticeable due to shortening of the vertebral column. Long bones do not shorten with age. Intervertebral disks actually get thinner with age. Subcutaneous fat is not lost but is redistributed to the abdomen and hips.

The nurse is inspecting the scrotum and testes of a 43-year-old man. Which finding would require additional follow-up and evaluation? a. Skin on the scrotum is taut. b. Left testicle hangs lower than the right testicle. c. Scrotal skin has yellowish 1-cm nodules that are firm and nontender. d. Testes move closer to the body in response to cold temperatures.

ANS: A Scrotal swelling may cause the skin to be taut and to display pitting edema. Normal scrotal skin is rugae, and asymmetry is normal with the left scrotal half usually lower than the right. The testes may move closer to the body in response to cold temperatures.

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. According to the Sexual Maturity Rating scale, what stage of sexual maturity do these findings indicate? a. 1 b. 2 c. 3 d. 4

ANS: A Sexual Maturity Rating stage 1 is the preadolescent stage. There is no pubic hair, and the mons and labia are covered with fine, vellus hair as on the abdomen. In stage 2 hair growth is sparse and mostly on the labia; long, downy hair, slightly pigmented, straight or only slightly curly. In stage 3 hair growth is sparse and spreading over mons pubis. Hair is darker, coarser, and curlier. In stage 4 hair is adult in type but over smaller area, none on medial thigh.

During an assessment of a newborn infant, the nurse suspects the infant has pyloric stenosis. What finding would cause the nurse to suspect this? a. Projectile vomiting b. Hypoactive bowel activity c. Palpable olive-sized mass in the right lower quadrant d. Pronounced peristaltic waves crossing from right to left

ANS: A Significant peristalsis, together with projectile vomiting, in the newborn suggests pyloric stenosis. After feeding, pronounced peristaltic waves cross from left to right, leading to projectile vomiting. One can also palpate an olive-sized mass in the right upper quadrant.

A male patient with possible fertility problems asks the nurse where sperm is produced. Which answer should the nurse give the patient? a. Testes b. Prostate c. Epididymis d. Vas deferens

ANS: A Sperm production occurs in the testes, not in the other structures listed.

A 70-year-old man is visiting the clinic for difficulty in passing urine. In the health history, he indicates that he has to urinate frequently, especially at night. He has burning when he urinates and has noticed pain in his back. Considering this history, what might the nurse expect to find during the physical assessment? a. Asymmetric, hard, and fixed prostate gland b. Occult blood and perianal pain to palpation c. Symmetrically enlarged, soft prostate gland d. Soft nodule protruding from the rectal mucosa

ANS: A Subjective symptoms of carcinoma of the prostate include frequency, nocturia, hematuria, weak stream, hesitancy, pain or burning on urination, and continuous pain in lower back, pelvis, and thighs. Objective symptoms of carcinoma of the prostate include a malignant neoplasm that often starts as a single hard nodule on the posterior surface, producing asymmetry and a change in consistency. As it invades normal tissue, multiple hard nodules appear, or the entire gland feels stone hard and fixed.

When standing with their eyes closed, feet together, and arms at their sides, a patient sways and starts to fall. How should the nurse document this finding? a. Positive Romberg sign b. Positive Babinski sign c. Positive Ortolani sign d. Positive modified Allen test

ANS: A The Romberg test is an assessment of posture and balance (cerebellar function). Abnormal findings occur when the person sways, falls, or widens the base of the feet to avoid falling. A positive Romberg sign is loss of balance that occurs when closing the eyes and occurs with cerebellar ataxia, loss of proprioception, and loss of vestibular function. A positive Babinski sign is an abnormal superficial reflex response. Ortolani sign tests hip stability. A modified Allen test is used to evaluate the adequacy of collateral circulation before cannulating the radial artery.

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? a. Use the Tanner scale on the five stages of sexual development. b. Describe her development and compare it with that of other girls her age. c. Use the Jacobsen table on expected development on the basis of height and weight data. d. Reassure her that her development is within normal limits and tell her not to worry about the next step.

ANS: A The Tanner scale on the five stages of pubic hair development is helpful in teaching girls the expected sequence of sexual development (see Table 26-1). The other responses are not appropriate.

What is articulated with the tibia and fibula in the ankle joint? a. Talus b. Cuboid c. Calcaneus d. Cuneiform bones

ANS: A The ankle or tibiotalar joint is the articulation of the tibia, fibula, and talus. The other bones listed are foot bones and not part of the ankle joint.

The examiner is assessing the extraocular muscles. Which of the following tests would be inappropriate? a. Confrontation test b. Corneal light reflex c. Six cardinal positions of gaze d. Cranial nerve III, IV, and VI testing

ANS: A The confrontation test assesses cranial nerve II and visual fields, but not the extraocular muscles. Extraocular muscles can be tested by the corneal light reflex, the six cardinal positions of gaze, and by cranial nerve III, IV, and VI testing.

In which situation should the examiner auscultate for carotid bruits? a. Middle-aged or older patient b. Pregnant patient with gestational diabetes c. Patient that reports abdominal pain d. Patient with enlarged, tender cervical lymph nodes

ANS: A The examiner should auscultate for carotid bruits if the patient is middle-aged or older or shows symptoms or signs of cardiovascular disease.

The nurse is examining a female patient's vestibule. What does the nurse expect to visualize? a. Urethral meatus and vaginal orifice b. Vaginal orifice and vestibular (Bartholin) glands c. Urethral meatus and paraurethral (Skene) glands d. Paraurethral (Skene) and vestibular (Bartholin) glands

ANS: A The labial structures encircle a boat-shaped space, or cleft, termed the vestibule. Within the vestibule are numerous openings. The urethral meatus and vaginal orifice are visible. The ducts of the paraurethral (Skene) glands and the vestibular (Bartholin) glands are present but not visible.

When performing a musculoskeletal assessment, what is the correct approach? a. Proximal to distal b. Distal to proximal c. Posterior to anterior d. Anterior to posterior

ANS: A The musculoskeletal assessment should be performed in an orderly approach, head to toe, proximal to distal, from the midline outward. The other options are not correct.

The nurse is preparing to palpate the rectum and should use which of these techniques? a. Flex the finger, and slowly insert it toward the umbilicus. b. Insert an extended index finger at a right angle to the anus. c. First instruct the patient that this procedure will be painful. d. Place the finger directly into the anus to overcome the tight sphincter.

ANS: A The nurse should gently place the pad of the index finger against the anal verge. The nurse will feel the sphincter tighten and then relax. As it relaxes, the nurse should flex the tip of the finger and slowly insert it into the anal canal in a direction toward the umbilicus. The nurse should never approach the anus at right angles with the index finger extended; doing so would cause pain. The nurse should instruct the patient that palpation is not painful but may feel like needing to move the bowels.

Which of these statements is most appropriate when the nurse is obtaining a genitourinary history from an older man? a. "Do you need to get up at night to urinate?" b. "Do you experience nocturnal emissions, or 'wet dreams'?" c. "Do you know how to perform a testicular self-examination?" d. "Has anyone ever touched your genitals when you did not want them to?"

ANS: A The older male patient should be asked about the presence of nocturia. Awaking at night to urinate may be attributable to a diuretic medication, fluid retention from mild heart failure or varicose veins, or fluid ingestion 3 hours before bedtime, especially coffee and alcohol. The other questions are more appropriate for younger men.

During a group discussion on men's health, what group should the nurse inform them has the highest incidence of prostate cancer? a. Blacks b. Hispanics c. Asian Americans d. American Indians

ANS: A The risk for prostate cancer is 74% higher in African-American and African-Caribbean men. Reasons are not known but may be r/t inherited genetic factors.

When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved? a. Spleen b. Appendix c. Gallbladder d. Sigmoid colon

ANS: A The spleen is located in the left upper quadrant of the abdomen. The gallbladder is in the right upper quadrant, the sigmoid colon is in the left lower quadrant, and the appendix is in the right lower quadrant.

During the change-of-shift report, the student nurse hears that a patient has hepatomegaly. What should the student recognizes that this term means? a. Enlarged liver b. Enlarged spleen c. Distended bowel d. Excessive diarrhea

ANS: A The term hepatomegaly refers to an enlarged liver. The term splenomegaly refers to an enlarged spleen. The other responses are not correct.

The uterus is usually positioned tilting forward and superior to the bladder. What is this position called? a. Anteverted and anteflexed b. Retroverted and anteflexed c. Retroverted and retroflexed d. Superiorverted and anteflexed

ANS: A The uterus is freely movable, not fixed, and usually tilts forward and superior to the bladder (a position labeled as anteverted and anteflexed).

The nurse is reviewing the changes that occur with menopause. Which changes are expected? a. Uterine and ovarian atrophy, along with thinning of vaginal epithelium b. Ovarian atrophy, increased vaginal secretions, and increasing clitoral size c. Cervical hypertrophy, ovarian atrophy, and increased acidity of vaginal secretions d. Vaginal mucosa fragility, increased acidity of vaginal secretions, and uterine hypertrophy

ANS: A The uterus shrinks because of its decreased myometrium. The ovaries atrophy to 1 to 2 cm and are not palpable after menopause. The sacral ligaments relax, and the pelvic musculature weakens; consequently, the uterus droops. The cervix shrinks and looks paler with a thick glistening epithelium. The vaginal epithelium atrophies, becoming thinner, drier, and itchy. The vaginal pH becomes more alkaline, and secretions are decreased, which results in a fragile mucosal surface that is at risk for vaginitis.

During a vaginal examination of a 38-year-old woman, the nurse notices that the vulva and vagina are erythematous and edematous with thick, white, curdlike discharge adhering to the vaginal walls. The woman reports intense pruritus and thick white discharge from her vagina. The nurse knows that these history and physical examination findings are most consistent with which condition? a. Candidiasis b. Trichomoniasis c. Atrophic vaginitis d. Bacterial vaginosis

ANS: A The woman with candidiasis often reports intense pruritus and thick white discharge. The vulva and vagina are erythematous and edematous. The discharge is usually thick, white, and curdlike. Infection with trichomoniasis causes a profuse, watery, gray-green, and frothy discharge. Bacterial vaginosis causes a profuse discharge that has a "foul, fishy, rotten" odor. Atrophic vaginitis may have a mucoid discharge.

Of the 33 vertebrae in the spinal column, which is correct? a. 5 lumbar b. 5 thoracic c. 7 sacral d. 12 cervical

ANS: A There are 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 3 to 4 coccygeal vertebrae in the spinal column.

The nurse is assessing a patient's ischial tuberosity. How should the nurse position the patient to palpate the ischial tuberosity? a. Standing b. Flexing the hip c. Flexing the knee d. Lying in the supine position

ANS: B The ischial tuberosity lies under the gluteus maximus muscle and is palpable when the hip is flexed. The other options are not correct.

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. What is this called? a. Tophi b. Callus c. Bunion d. Plantar wart

ANS: A Tophi are collections of monosodium urate crystals resulting from chronic gout in and around the joint that cause extreme swelling and joint deformity. They appear as hard, painless nodules (tophi) over the metatarsophalangeal joint of the first toe and they sometimes burst with a chalky discharge. A callus is a hard, thickened area of skin that forms as a result of friction or pressure. A bunion is a bony bump that forms on the joint at the base of your big toe (metatarsophalangeal joint). A plantar wart is vascular papillomatous growth that occurs on the sole of the foot, commonly at the ball and has small dark spots and is painful. A callus is a hard, thickened area of skin that forms as a result of friction or pressure. A bunion is a bony bump that forms on the joint at the base of your big toe (metatarsophalangeal joint). A plantar wart is vascular papillomatous growth that occurs on the sole of the foot, commonly at the ball and has small dark spots and is painful.

During a physical examination, the nurse finds that a male patient's foreskin is fixed and tight and will not retract over the glans. What is this condition called? a. Phimosis b. Epispadias c. Peyronie disease d. Urethral stricture

ANS: A With phimosis, the foreskin is nonretractable, forming a pointy tip of the penis with a tiny orifice at the end of the glans. The foreskin is advanced and so tight that it is impossible to retract over the glans. This condition may be congenital or acquired from adhesions related to infection. Epispadias is when the meatus opens on the dorsal (upper) side of glans or shaft above a broad, spadelike penis. It is rare but more disabling than hypospadias because of associated urinary incontinence and separation of pubic bones. A urethral stricture is a narrowing of the urethra which appears as a pinpoint, constricted opening at the meatus or inside along the urethra. A gradual decrease in force and caliber of urine stream is the most common symptom. Peyronie disease presents as subcutaneous plaques on the penis and is associated with painful bending of the penis during erection. Its cause is trauma to the penis with resulting scar, deformity, and often erectile dysfunction. The physical findings from this patient's examination indicate phimosis.

The nurse is performing an ear examination of an 80-year-old patient. Which of these findings would be considered normal? a. High-tone frequency loss b. Thin, translucent membrane c. Shiny, pink tympanic membrane d. Increased elasticity of the pinna

ANS: A A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging. The pinna loses elasticity (not increases), causing ear lobes to be pendulous. The eardrum may be whiter in color and more opaque and duller (not translucent or shiny, pink) in the older person than in the younger adult.

A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a lump in her right breast for years. Recently, it has begun to change in consistency and is becoming harder. She reports that 5 years ago her physician evaluated the lump and determined that it was "nothing to worry about." The nurse's examination validates the presence of a mass in the right upper outer quadrant at 1 o'clock, approximately 5 cm from the nipple. It is firm, mobile, and nontender, with borders that are not well defined. What is the best response by the nurse? a. "Because of the change in consistency of the lump, it should be further evaluated by a physician." b. "The changes could be r/t your menstrual cycles. Keep track of the changes in the mass each month." c. "The lump is probably nothing to worry about because it has been present for years and was determined to be noncancerous 5 years ago." d. "Because you are experiencing no pain and the size has not changed, you should continue to monitor the lump and return to the clinic in 3 months."

ANS: A A lump that has been present for years and is not exhibiting changes may not be serious but should still be explored. Any recent change or a new lump should be evaluated. The other responses are not correct.

A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. Why is it important that the nurse encourage her to stop trying to remove the corn with scissors? a. The woman could be at increased risk for infection and lesions because of her chronic disease. b. With her diabetes, she has increased circulation to her foot, and it could cause severe bleeding. c. She is 75 years old and is unable to see; consequently, she places herself at greater risk for self-injury with the scissors. d. With her peripheral vascular disease, her range of motion is limited and she may not be able to reach the corn safely.

ANS: A A personal history of diabetes and peripheral vascular disease increases a person's risk for skin lesions in the feet or ankles. The patient needs to seek a professional for assistance with corn removal. Diabetes does not cause increased circulation to the feet; instead, it often results in decreased circulation. Although this older adult may have vision problems and decreased range of motion that could result in self-injury, those are not the best options.

During an examination, the nurse notes a supernumerary nipple just under the patient's left breast. The patient tells the nurse that she always thought it was a mole. Which statement about this finding is correct? a. This variation is normal and not a significant finding. b. This finding is significant and needs further investigation. c. A supernumerary nipple also contains glandular tissue and may leak milk during pregnancy and lactation. d. The patient is correct—a supernumerary nipple is actually a mole that happens to be located under the breast

ANS: A A supernumerary nipple looks like a mole, but close examination reveals a tiny nipple and areola; it is not a significant finding. This is not a significant finding and does not need further investigation, will not leak milk during pregnancy and lactation, and is not a mole. Although a supernumerary nipple looks like a mole, upon close examination a tiny nipple and areola are revealed.

The nurse is preparing to teach a class on cardiovascular assessment. When explaining a thrill, what should the nurse include in the teaching? a. A vibration that is palpable b. Palpated in the right epigastric area c. Associated with ventricular hypertrophy d. A murmur auscultated at the third intercostal space

ANS: A A thrill is a palpable vibration that signifies turbulent blood flow and accompanies loud murmurs. The absence of a thrill does not rule out the presence of a murmur.

The nurse is preparing for a class on risk factors for hypertension and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world? a. Blacks b. Whites c. Hispanics d. American Indians

ANS: A According to the American Heart Association, the prevalence of hypertension is higher among blacks than in other racial groups.

During an annual physical examination, a 43-year-old patient states that she does not perform monthly breast self-examinations (BSEs). She tells the nurse that she believes that mammograms "do a much better job than I ever could to find a lump." What should the nurse include in his or her response to this patient? a. BSEs may detect lumps that appear between mammograms. b. She is correct—mammography is a good replacement for BSE. c. The American Cancer Society recommends women over 40 years old perform a monthly BSE. d. She does not need to perform BSEs as long as a physician checks her breasts annually.

ANS: A Although the American Cancer Society no longer recommends a structured monthly BSE because many women with breast cancer have detected their lumps by chance as when bathing or dressing, the goal of BSE is that a woman becomes familiar with the look and feel of her breasts so she can detect any change and report it promptly. Intermittent BSEs along with clinical breast examinations and mammograms are complementary screening measures. Mammography can reveal cancers too small to be detected by the woman or by the most experienced examiner. However, interval lumps may become palpable between mammograms.

The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane? a. Hypomobility b. Fiery red and bulging of entire eardrum c. Retraction with landmarks clearly visible d. Flat, slightly pulled in at the center, and moves with insufflation

ANS: A An early sign of otitis media is hypomobility of the tympanic membrane. As pressure increases, the tympanic membrane begins to bulge. A fiery red color and bulging of the entire eardrum is not an early sign of otitis media but occurs a little later. A retracted tympanic membrane with landmarks clearly visible indicates a blocked eustachian tube which is not an early sign of otitis media. A tympanic membrane that is flat, slightly pulled in at the center, and moves with insufflation is a normal eardrum, not a manifestation of otitis media.

An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. What do these findings suggest? a. Asthma b. Atelectasis c. Lobar pneumonia d. Heart failure

ANS: A Asthma is allergic hypersensitivity to certain inhaled particles that produces inflammation and a reaction of bronchospasm, which increases airway resistance, especially during expiration. An increased respiratory rate, the use of accessory muscles, a retraction of the intercostal muscles, prolonged expiration, decreased breath sounds, and expiratory wheezing are all characteristics of asthma. Atelectasis presents with decreased or absent breath sounds but no prolonged expiration or expiratory wheezing. Lobar pneumonia presents with tachycardia and loud bronchial breathing with patent bronchus but no prolonged expiration or expiratory wheezing. Heart failure can present with both crackles and wheezing but does not have a prolonged expiration, and based on this patient's history of allergies and the symptoms occurred when he was working in the yard, asthma is the most likely problem.

During an oral examination of a 4-year-old American-Indian child, the nurse notices that her uvula is partially split. Which of these statements is accurate? a. A bifid uvula may occur in some American-Indian groups. b. This condition is a cleft palate and is common in American Indians. c. A bifid uvula is torus palatinus, which frequently occurs in American Indians. d. This condition is due to an injury and should be reported to the authorities.

ANS: A Bifid uvula, a condition in which the uvula is split either completely or partially, occurs in some American-Indian groups. This finding is not a cleft palate, a torus palatinus (benign bony ridge running in the middle of the hard palate), or due to injury.

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? a. This decline in blood pressure is the result of peripheral vasodilatation and is an expected change. b. Because of increased cardiac output, the blood pressure should be higher at this time. c. This change in blood pressure is not an expected finding because it means a decrease in cardiac output. d. This decline in blood pressure means a decrease in circulating blood volume, which is dangerous for the fetus.

ANS: A Despite the increased cardiac output, arterial blood pressure decreases in pregnancy because of peripheral vasodilatatio n. The blood pressure drops to its lowest point during the second trimester and then rises after that.

While performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices the presence of bilateral pitting edema in the lower legs. The skin is puffy and tight but normal in color. No increased redness or tenderness is observed over his lower legs, and the peripheral pulses are equal and strong. In this situation, the nurse suspects that the likely cause of the edema is which condition? a. Heart failure b. Venous stasis c. Local inflammation d. Peripheral arterial insufficiency

ANS: A Bilateral edema or edema that is generalized over the entire body is caused by a central problem such as heart failure or kidney failure. Unilateral edema usually has a local or peripheral cause. Venous stasis is pooling of blood in the veins, usually in the lower extremities, and results in dusky rubor of dependent extremities. Localized inflammation produces redness and warmth of the affect area. Peripheral arterial insufficiency is decreased arterial blood flow to an area and can cause localized hypothermia and difficulty palpating a distal pulse.

The nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanism(s) by which venous blood returns to the heart? a. Intraluminal valves ensure unidirectional flow toward the heart. b. Contracting skeletal muscles milk blood distally toward the veins. c. High-pressure system of the heart helps facilitate venous return. d. Increased thoracic pressure and decreased abdominal pressure facilitate venous return to the heart.

ANS: A Blood moves through the veins by (1) contracting skeletal muscles that milk the blood proximally back toward the heart; (2) pressure gradients caused by breathing, during which inspiration makes the thoracic pressure decrease and the abdominal pressure increase; and (3) the intraluminal valves, which ensure unidirectional flow toward the heart.

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. What do these findings indicate? a. Candidiasis b. Leukoplakia c. Koplik spots d. Aphthous ulcers

ANS: A Candidiasis is a white, cheesy, curdlike patch on the buccal mucosa and tongue. It scrapes off, leaving a raw, red surface that easily bleeds. It also occurs after the use of antibiotics or corticosteroids and in people who are immunosuppressed. Leukoplakia appears as chalky white, thick, raised patches with well-defined borders on the buccal mucosa. Koplik spots are small blue-white spots with irregular red halo scattered over mucosa opposite the molars and is an early sign of measles. Aphthous ulcers, or canker sores, first appear as a vesicle and then a small, round, "punched out" ulcer with a white base surrounded by a red halo and are quite painful and last for 1-2 weeks. The findings for this patient indicate candidiasis.

While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would the nurse want to include in the history? a. "Does your baby seem to startle with loud noises?" b. "Has your baby had any surgeries on her ears?" c. "Have you noticed any drainage from her ears?" d. "How many ear infections has your baby had since birth?"

ANS: A Children exposed in utero to a variety of conditions, such as maternal rubella or to maternal ototoxic drugs are at risk for hearing deficits. Aspirin can be ototoxic, so the nurse should ask if the baby seems to startle with loud noises.

The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. What does the nurse suspect is the cause of these signs and symptoms? a. Chronic allergies b. Lymphadenopathy c. Nasal congestion d. Upper respiratory infection

ANS: A Chronic allergies often develop chronic facial characteristics and include blue shadows below the eyes, a double or single crease on the lower eyelids, open-mouth breathing, and a transverse line on the nose. Lymphadenopathy means enlargement of lymph nodes from infection, allergy, or neoplasm, it is a sign of allergies, not a cause. Although nasal congestion and upper respiratory infections may present with watery eyes and sneezing, people with nasal congestion usually state congestion or a pressure feeling in their head and people with upper respiratory infections often have a cough and/or sore throat and don't have a transverse line across the bridge of the nose, dark blue shadows under the eyes, or a double crease on the lower eyelids. The signs and symptoms of this patient are likely from chronic allergies.

The nurse just noted from the medical record that the patient has a lesion that is confluent in nature. What should the nurse expect to find upon examination? a. Lesions that run together b. Annular lesions that have grown together c. Lesions arranged in a line along a nerve route d. Lesions that are grouped or clustered together

ANS: A Confluent lesions (as with urticaria [hives]) run together. Annular lesions are circular in nature. Zosteriform lesions are arranged along a nerve route. Grouped lesions are clustered together. Annular lesions are circular in nature. Zosteriform lesions are arranged along a nerve route. Grouped lesions are clustered together. A lesion that is confluent runs together, as with urticaria (hives).

During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. What do these findings indicate? a. Dehydration b. A normal oral assessment c. Irritation from gastric juices d. Side effects from nausea medication

ANS: A Dehydration can cause dry mouth and deep vertical fissures in the tongue (due to reduced tongue volume). These finding are not normal and are not associated with irritation from gastric juices or from nausea caused by medications.

A 22-year-old woman comes to the clinic because of severe sunburn and states, "I was out in the sun for just a couple of minutes." The nurse begins a medication review with her, paying special attention to which medication class? a. Tetracyclines for acne b. Proton pump inhibitors for heartburn c. Nonsteroidal anti-inflammatory drugs for pain d. Thyroid replacement hormone for hypothyroidism

ANS: A Drugs that may increase sunlight sensitivity and give a burn response include sulfonamides, thiazide diuretics, oral hypoglycemic agents, and tetracycline. Proton pump inhibitors, nonsteroidal anti-inflammatories, and thyroid replacement hormone are not associated with skin sensitivities or sunburn.

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? a. Person who has been on bed rest for 4 days b. Older adult taking anticoagulant medication c. Woman in the second month of her first pregnancy d. Person with a 30-year, 1 pack per day smoking habit

ANS: A Efficient venous return depends on contracting skeletal muscles, competent valves in the veins, and a patent lumen. Problems with any of these three elements lead to venous stasis. People who undergo prolonged standing, sitting, or bed rest are at risk for venous disease because they do not benefit from the milking action to the veins that walking accomplishes. Hypercoagulable (not anticoagulated) states and vein wall trauma also place the person at risk for venous disease. Obesity and multiple pregnancies are also risk factors. Smoking is a risk factor for arterial disease, not venous disease

The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which one of these reflects the correct procedure? a. Pulling the pinna down b. Pulling the pinna up and back c. Slightly tilting the child's head toward the examiner d. Instructing the child to touch their chin to their chest

ANS: A For an otoscopic examination on an infant or a child under 3 years of age, the pinna is pulled down. The other responses are not part of the correct procedure. The pinna should be pulled up and back for an otoscopic exam of an adult, not a child under 3 years of age. The child's head should be tilted slightly away from the examiner towards the opposite shoulder, not towards the examiner or to their chin. For an otoscopic examination on an infant or on a child under 3 years of age, the pinna is pulled down.

During a well-baby checkup, a mother is concerned because her 2-month-old infant cannot hold her head up when she is pulled to a sitting position. Which response by the nurse is appropriate? a. "Head control is usually achieved by 4 months of age." b. "You shouldn't be trying to pull your baby up like that until she is older." c. "Head control should be achieved by this time." d. "This inability indicates possible nerve damage to the neck muscles."

ANS: A Head control is achieved by 4 months when the baby can hold the head erect and steady when pulled to a vertical position. The other responses are not appropriate.

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. Heart failure b. Fluid overload c. Atrial septal defect d. Myocardial infarction

ANS: A Heart failure causes decreased cardiac output when the heart fails as a pump and the circulation becomes backed up and congested. Signs and symptoms include dyspnea, orthopnea, paroxysmal nocturnal dyspnea, decreased blood pressure, dependent and pitting edema; anxiety; confusion; jugular vein distention; and fatigue. The S3 is associated with heart failure and is always abnormal after 35 years of age. The S3 may be the earliest sign of heart failure.

How should the nurse document mild, slight pitting edema the ankles of a pregnant patient? a. 1+/0-4+ b. 3+/0-4+ c. 4+/0-4+ d. Brawny edema

ANS: A If pitting edema is present, then the nurse should grade it on a scale of 1+ (mild) to 4+ (severe). Brawny edema appears as nonpitting edema and feels hard to the touch.

The nurse has palpated a lump in a female patient's right breast. The nurse documents this as a small, round, firm, distinct, lump located at 2 o'clock, 2 cm from the nipple. It is nontender and fixed. No associated retraction of the skin or nipple, no erythema, and no axillary lymphadenopathy are observed. What information is missing from the documentation? a. Size of the lump b. Shape of the lump c. Consistency of the lump d. Whether the lump is solitary or multiple

ANS: A If the nurse feels a lump or mass, then he or she should note these characteristics: (1) location, (2) size judge in centimeters in three dimensions: width × length × thickness, (3) shape, (4) consistency, (5) motility, (6) distinctness, (7) nipple, (8) the skin over the lump, (9) tenderness, and (10) lymphadenopathy.

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 "a couple of minutes"; then he is able to resume his activities. What do these symptoms suggest? a. Claudication b. Sore muscles c. Muscle cramps d. Venous insufficiency

ANS: A Intermittent claudication feels like a cramp and is usually relieved by rest within 2 minutes. The other responses are not correct. Sore muscles and muscle cramps do not usually occur while performing an activity, but afterwards, and are not relieved by resting for a couple of minutes. Venous insufficiency does not cause pain with walking or exercise that is relieved by rest, but rather presents with edema, thickened skin, and brown discoloration in lower legs. The symptoms this patient described suggest intermittent claudication.

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. Circumduction b. Flexion and extension c. Inversion and eversion d. Supination and pronation

ANS: B The knee is a hinge joint, permitting flexion and extension of the lower leg on a single plane. The knee is not capable of circumduction, inversion, eversion, supination, or pronation.

The nurse is performing an oral assessment on a 40-year-old black patient and notices the presence of a 1-cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of these statements is true about this lesion? a. It is leukoedema which is common in dark-pigmented people. b. It is indicative of cancer and should be immediately tested. c. It is the result of hyperpigmentation and is a normal finding. d. It is torus palatinus and would normally be found only in smokers.

ANS: A Leukoedema, which is a grayish-white benign lesion occurring on the buccal mucosa, is most often observed in blacks. The patient's 1 cm, nontender, grayish-white lesion on the left buccal mucosa is not indicative of cancer, a normal result of hyperpigmentation, or torus palatinus. Instead, it is leukoedema, which is a grayish-white benign lesion occurring on the buccal

The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect? a. Palpable superficial lymph nodes b. Excessive swelling of the lymph nodes c. No palpable nodes because of the immature immune system of a child d. Fewer and smaller sized lymph nodes compared with those of an adult

ANS: A Lymph nodes are relatively large in children, and the superficial ones are often palpable even when the child is healthy.

During an assessment, the nurse notices that a patient's left arm is swollen from the shoulder down to the fingers, with nonpitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. Based on these findings, what does the nurse suspect? a. Lymphedema b. Venous stasis c. Arteriosclerosis d. Deep-vein thrombosis

ANS: A Lymphedema after breast cancer causes unilateral swelling and nonpitting brawny edema, with overlying skin indurated. It is caused by the removal of lymph nodes with breast surgery or damage to lymph nodes and channels with radiation therapy for breast cancer, and lymphedema can impede drainage of lymph. The other responses are not correct. Venous stasis is the pooling of blood in the legs, not in the arms. Deep vein thrombosis is the development of a thrombus, or clot, in a deep vein, most commonly in the legs, not the arms. Arteriosclerosis is increased rigidity of the peripheral blood vessels that occurs with aging. The symptoms this patient is experiencing are from lymphedema.

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. What do these findings suggest? a. Macular degeneration b. Vision that is normal for someone her age c. The beginning stages of cataract formation d. Increased intraocular pressure or glaucoma

ANS: A Macular degeneration is characterized by the loss of central vision and is the most common cause of blindness. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision. These findings are not consistent with normal vision at this, or any, age. These findings are not consistent with normal vision at this, or any, age. The increased intraocular pressure of chronic open-angle glaucoterm-283ma, the most common type of glaucoma, involves a gradual loss of peripheral vision but not central vision. The symptoms this patient has suggest macular degeneration. Macular degeneration is characterized by the loss of central vision and is the most common cause of blindness.

When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? a. Between the scapulae b. Third intercostal space, MCL c. Over the lower lobes, posterior side d. Fifth intercostal space, midaxillary line (MAL)

ANS: A Normally fremitus is most prominent between the scapulae and around the sternum. These sites are where the major bronchi are closest to the chest wall. Fremitus normally decreases as one progresses down the chest because more tissue impedes sound transmission.

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o'clock in each eye. What should the nurse do regarding this finding? a. Record this as a normal finding. b. Refer the individual for further evaluation. c. Document this finding as an asymmetric light reflex. d. Perform the confrontation test to validate the findings

ANS: A Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetric. If asymmetry is noted, then the nurse should administer the cover test.

A patient has been admitted for severe psoriasis. The nurse expects to see what finding in the patient's fingernails? a. Pitting b. Paronychia c. Beau lines d. Splinter hemorrhages

ANS: A Sharply defined pitting and crumbling of the nails, each with distal detachment, characterize pitting nails and are associated with psoriasis. Paronychia is red, swollen, and tender inflammation of the nail folds. Beau lines are depressions across the nail that extends to the nail bed. Splinter hemorrhages are red-brown linear streaks from damage to nail bed capillaries.

The nurse is observing the auscultation technique of a student nurse. What is the correct method to use when progressing from one auscultatory site on the thorax to another? a. Side-to-side comparison b. Top-to-bottom comparison c. Posterior-to-anterior comparison d. Interspace-by-interspace comparison

ANS: A Side-to-side comparison is most important when auscultating the chest. The nurse should listen to at least one full respiration in each location. The other techniques are not correct.

A physician tells the nurse that a patient's vertebra prominens is tender and asks the nurse to reevaluate the area in 1 hour. What area of the body will the nurse assess? a. At the level of the C7 vertebra b. At the level of the T11 vertebra c. At the level of the L5 vertebra d. At the level of the S3 vertebra

ANS: A The C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the head is flexed.

A woman has just learned that she is pregnant. What should the nurse teach this patient about changes in her breasts? a. She can expect her areolae to become larger and darker in color. b. Breasts may begin secreting milk after the fourth month of pregnancy. c. She should inspect her breasts for visible veins and immediately report these. d. During pregnancy, breast changes are fairly uncommon; most of the changes occur after the birth.

ANS: A The areolae become larger and grow a darker brown as pregnancy progresses, and the tubercles become more prominent. (The brown color fades after lactation, but the areolae never return to their original color). A venous pattern is an expected finding and prominent over the skin surface and does not need to be reported. After the fourth month of pregnancy, colostrum, a thick, yellow fluid (precursor to milk), may be expressed from the breasts.

Which of the following statements is true regarding the internal structures of the breast? a. Fibrous, glandular, and adipose tissues b. Primarily muscle with very little fibrous tissue c. Primarily milk ducts, known as lactiferous ducts d. Glandular tissue, which supports the breast by attaching to the chest wall

ANS: A The breast is made up of glandular, fibrous (including the suspensory ligaments), and adipose tissues.

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? a. Tetralogy of Fallot b. Atrial septal defect c. Patent ductus arteriosus d. Ventricular septal defect

ANS: A The cause of these findings is tetralogy of Fallot.

The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true? a. The outer layer of the eye is very sensitive to touch. b. The outer layer of the eye is darkly pigmented to prevent light from reflecting internally. c. The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated when the outer surface of the eye is stimulated. d. The visual receptive layer of the eye in which light waves are changed into nerve impulses is located in the outer layer of the eye.

ANS: A The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch. The middle layer, the choroid, has dark pigmentation to prevent light from reflecting internally. The trigeminal nerve (CN V) and the facial nerve (CN VII), not the trochlear nerve (IV), are stimulated when the outer surface of the eye is stimulated. The retina, in the inner layer of the eye, is where light waves are changed into nerve impulses. The outer layer of the eye is not darkly pigmented, the sclera is white and the cornea is transparent. It is the middle layer, the choroid, that has dark pigmentation to prevent light from reflecting internally. The true statement about the outlayer of the eye is that it is made up of the cornea and the sclera.

The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct? a. Avoiding touching the nasal septum with the speculum b. Inserting the speculum at least 3 cm into the vestibule c. Gently displacing the nose to the side that is being examined d. Keeping the speculum tip medial to avoid touching the floor of the nares

ANS: A The correct technique for using an otoscope to examine the nasal cavity is to insert the apparatus into the nasal vestibule, avoiding pressure on the sensitive nasal septum. The tip of the nose should be lifted up before inserting the speculum.

When assessing the tongue of an adult, what finding would be considered abnormal? a. Smooth glossy dorsal surface b. Thin white coating over the tongue c. Raised papillae on the dorsal surface d. Visible venous patterns on the ventral surface

ANS: A The dorsal surface of the tongue is normally roughened from papillae. A thin white coating may be present. The ventral surface may show veins. Smooth, glossy areas are abnormal and may indicate atrophic glossitis

The nurse is examining a patient who tells the nurse, "I sure sweat a lot, especially on my face and feet but it doesn't have an odor." The nurse knows that this is likely r/t a disorder with what part of the body? a. Eccrine glands b. Apocrine glands c. Disorder of the stratum corneum d. Disorder of the stratum germinativum

ANS: A The eccrine glands are coiled tubules that directly open onto the skin surface and produce a dilute saline solution called sweat. Apocrine glands are primarily located in the axillae, anogenital area, nipples, and naval area and mix with bacterial flora to produce the characteristic musky body odor. The patient's statement is not r/t disorders of the stratum corneum or the stratum germinativum. Apocrine glands are primarily located in the axillae, anogenital area, nipples, and naval area and mix with bacterial flora to produce the characteristic musky body odor. The part of the body that produces sweat are the eccrine glands.

The nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. How should the nurse interpret this finding? a. Normal for this age b. Lower than expected c. Higher than expected, probably as a result of crying d. Higher than expected, reflecting persistent tachycardia

ANS: A The heart rate may range from 100 to 180 beats per minute immediately after birth and then stabilize to an average of 120 to 140 beats per minute. Infants normally have wide fluctuations with activity, from 170 beats per minute or more with crying or being active to 70 to 90 beats per minute with sleeping. Persistent tachycardia is greater than 200 beats per minute in newborns or greater than 150 beats per minute in infants.

When assessing a patient's lungs, what should the nurse recall about the left lung? a. Consists of two lobes. b. Is divided by the horizontal fissure. c. Primarily consists of an upper lobe on the posterior chest. d. Is shorter than the right lung because of the underlying stomach.

ANS: A The left lung has two lobes and is longer and narrower than the right lung. It is narrower than the right lung because the heart bulges to the left. The right lung has three lobes and is shorter than the left lung because of the underlying liver. The posterior chest is almost all lower lobes.

The nurse is reviewing the age-related changes in the eye for a class. Which of these physiologic changes is responsible for presbyopia? a. Loss of lens elasticity b. Degeneration of the cornea term-284 c. Decreased adaptation to darkness d. Decreased distance vision abilities

ANS: A The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This condition is called presbyopia.

What are the primary muscles of respiration? a. Diaphragm and intercostals b. Sternomastoids and scaleni c. Trapezii and rectus abdominis d. External obliques and pectoralis major

ANS: A The major muscle of respiration is the diaphragm. The intercostal muscles lift the sternum and elevate the ribs during inspiration, increasing the anteroposterior diameter. Expiration is primarily passive. Forced inspiration involves the use of other muscles, such as the accessory neck muscles—sternomastoid, scaleni, and trapezii muscles. Forced expiration involves the abdominal muscles.

When examining a patient's CN function, what muscles should the nurse assess to assess the function of CN XI? a. Sternomastoid and trapezius b. Spinal accessory and omohyoid c. Trapezius and sternomandibular d. Sternomandibular and spinal accessory

ANS: A The muscles innervated by CN XI are the sternomastoid and the trapezius muscles in the neck. Options B, C, and D are incorrect because the spinal accessory is not a muscle but the name of CN XI and there is no sternomandibular muscle.

The nurse is assisting with a BSE clinic. Which of these women reflects abnormal findings during the inspection phase of breast examination? a. Woman whose nipples are in different planes (deviated) b. Woman whose left breast is slightly larger than her right c. Nonpregnant woman whose skin is marked with linear striae d. Pregnant woman whose breasts have a fine blue network of veins visible under the skin

ANS: A The nipples should be symmetrically placed on the same plane on the two breasts. With deviation in pointing, an underlying cancer may cause fibrosis in the mammary ducts, which pulls the nipple angle toward it. The other examples are normal findings. A woman with a left breast that is slightly larger than her right, a nonpregnant woman whose skin is marked with linear striae, and a pregnant woman whose breasts have a fine blue network of vein visible under the skin are all normal findings. However, a woman whose nipples are in different planes, or deviate, is abnormal.

The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction? a. Air conduction is the normal pathway for hearing. b. Amplitude of sound determines the pitch that is heard. c. Vibrations of the bones in the skull cause air conduction. d. Loss of air conduction is called a conductive hearing loss.

ANS: A The normal pathway of hearing is air conduction, which starts when sound waves produce vibrations on the tympanic membrane. Conductive hearing loss results from a mechanical dysfunction of the external or middle ear. The other statements are not true concerning air conduction. The frequency of sound waves is what determines pitch, not the amplitude. Vibrations of the bones in the skull are bone conduction, not air conduction. Conductive hearing loss involves mechanical dysfunction of the external or middle ear and is caused by impacted cerumen, foreign bodies, a perforated tympanic membrane, pus or serum in the middle ear, and otosclerosis, not loss of air conduction.

The nurse is palpating a female patient's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation? a. Supine with the arms raised over her head b. Sitting with the arms relaxed at her sides c. Supine with the arms relaxed at her sides d. Sitting with the arms flexed and fingertips touching her shoulders

ANS: A The nurse should help the woman to a supine position, tuck a small pad under the side to be palpated, and help the woman raise her arm over her head. These maneuvers will flatten the breast tissue and medially displace it. Any significant lumps will then feel more distinct.

The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal? a. Optic disc that is a yellow-orange color. b. Presence of pigmented crescents in the macular area. c. Optic disc margins that are blurred around the edges. d. Presence of the macula located on the nasal side of the retina.

ANS: A The optic disc is located on the nasal side of the retina. Its color is a creamy yellow-orange to a pink, and the edges are distinct and sharply demarcated, not blurred. A pigmented crescent is black and is due to the accumulation of pigment in the choroid. Presence of pigmented crescents in the macular area is an abnormal finding. A pigmented crescent is black and is due to the accumulation of pigment in the choroid. The optic dish margins are normally distinct and sharply demarcated, not blurred around the edges. The macula is located on the temporal side of the fundus of the eye, not on the nasal side of the retina. The correct answer of a normal finding is that the optic disc is a yellow-orange color.

When examining the eye, the nurse notices that the patient's eyelid margins approximate completely. What does the nurse understand about this assessment finding? a. It is expected. b. It may result in problems with tearing. c. It indicates increased intraocular pressure. d. It may indicate a problem with extraocular muscles.

ANS: A The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins approximate completely, which is a normal finding. This is a normal finding and does not result in problems with tearing or indicate problems with increase intraocular pressure or extraocular muscles.

A patient is newly diagnosed with benign breast disease. The nurse recognizes which statement about benign breast disease to be true? a. It makes it more difficult to examine the breasts. b. It is easily reduced with hormone replacement therapy. c. It frequently turns into cancer in a woman's later years. d. It is usually diagnosed before a woman reaches childbearing age.

ANS: A The presence of benign breast disease (formerly fibrocystic breast disease) makes it hard to examine the breasts; the general lumpiness of the breast conceals a new lump. The other statements are not true. Benign breast disease is not treated with hormone replacement therapy and it does not usually turn into cancer, although the nodularity associated with benign breast disease makes it difficult to detect other cancerous lumps. It also is usually diagnosed between 30 and 55 years old (not before childbearing age).

During a breast examination on a female patient, the nurse notices that the nipple is flat, broad, and fixed. The patient states it "started doing that a few months ago." What does this finding suggest? a. Dimpling b. Retracted nipple c. Nipple inversion d. Deviation in nipple pointing

ANS: A The retracted nipple looks flatter and broader, similar to an underlying crater. A recent retraction suggests cancer, which causes fibrosis of the whole duct system and pulls in the nipple. It also may occur with benign lesions such as ectasia of the ducts. The nurse should not confuse retraction with the normal long-standing type of nipple inversion, which has no broadening and is not fixed.

When listening to heart sounds, which valve closures are heard best at the base of the heart? a. Aortic and pulmonic b. Mitral and pulmonic c. Mitral and tricuspid d. Tricuspid and aortic

ANS: A The second heart sound (S2) occurs with the closure of the semilunar (aortic and pulmonic) valves and signals the end of systole. Although it is heard over all the precordium, the S2 is loudest at the base of the heart.

Which of these statements is true regarding the vertebra prominens? a. It is the spinous process of C7. b. It is nonpalpable in most individuals. c. It is opposite the interior border of the scapula. d. It is located next to the manubrium of the sternum.

ANS: A The spinous process of C7 is the vertebra prominens and is the most prominent bony spur protruding at the base of the neck. Counting ribs and intercostal spaces on the posterior thorax is difficult because of the muscles and soft tissue. The vertebra prominens is easier to identify and is used as a starting point in counting thoracic processes and identifying landmarks on the posterior chest.

A new mother calls the clinic to report that part of her left breast is red, swollen, tender, very hot, and hard. She has a fever of 38.3° C. She also has had symptoms of influenza, such as chills, sweating, and feeling tired. The nurse notices that she has been breastfeeding for 1 month. From her description, what condition does the nurse suspect? a. Mastitis b. Paget disease c. Plugged milk duct d. Mammary duct ectasia

ANS: A The symptoms describe mastitis, which stems from an infection or stasis caused by a plugged duct. A plugged duct does not have infection present. Paget disease starts with a small crust on the nipple apex and then spreads to the areola. A plugged milk duct often presents as a tender lump that may be reddened and warm to touch but no infection is present. Mammary duct ectasia is caused by stagnation of cellular debris and secretions in the ducts, leading to obstruction, inflammation and infection. Itching, burning, or drawing pain occurs around the nipple with a sticky, purulent discharge that may be cream, green, or bloody. The symptoms this patient has described mastitis, which stems from an infection or stasis caused by a plugged duct. A plugged duct does not have infection present but a plugged duct with infection is mastitis.

A patient's laboratory data reveal an elevated thyroxine (T4) level. What gland should the nurse assess? a. Thyroid b. Parotid c. Adrenal d. Parathyroid

ANS: A The thyroid gland is a highly vascular endocrine gland that secretes T4 and triiodothyronine (T3). The other glands do not secrete T4. The parotid glands are salivary glands and secrete saliva. The adrenal glands secrete corticosteroids, not T4, and the parathyroid glands control the body's calcium. The gland that secretes thyroxine, or T4, is the thyroid gland. The thyroid gland is a highly vascular endocrine gland that secretes thyroxine (T4) and triiodothyronine (T3).

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? a. These findings can all be normal in a child. b. An S3 is indicative of heart disease in children. c. The venous hum most likely indicates an aneurysm. d. These findings are indicative of congenital problems.

ANS: A These are all commonly found in children. A physiologic S3, which occurs early in diastole just after S2, is common in children. A venous hum, caused by turbulence of blood flow in the jugular venous system, is common in healthy children and has no pathologic significance. Heart murmurs that are innocent (or functional) in origin are very common through childhood.

A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. What should the nurse do? a. Consider this a normal finding. b. Continue with the examination, and assess visual fields. c. Assess the pupillary light reflex for possible blindness. d. Expect that a 2-week-old infant should be able to fixate and follow an object.

ANS: A This is a normal finding. By 2 to 4 weeks an infant can fixate on an object. By the age of 1 month, the infant should fixate and follow a bright light or toy. This is a normal finding. The nurse cannot assess visual fields as the infant cannot follow instructions; assessing the pupillary light reflex does not assess for blindness; and the nurse should not expect the infant to be able follow an object. An infant can fixate on an object by 2 to 4 weeks and by the age of 1 month, should be able to fixate and follow a bright light or toy.

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 should the nurse do? a. Document this as a normal finding. b. Talk with the patient about his intake of caffeine. c. Perform an electrocardiogram after the examination. d. Refer the patient to a cardiologist for further testing.

ANS: A This is sinus dysrhythmia which occurs normally in young adults and children. With sinus dysrhythmia, the rhythm varies with the person's breathing, increasing at the peak of inspiration and slowing with expiration. The nurse should document this as a normal finding. This is a normal finding so there is no need to question the patient about his caffeine intake, perform an electrocardiogram, or refer to a cardiologist.

During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement? a. Using gentle pressure, palpate with both hands to compare the two sides. b. Using strong pressure, palpate with both hands to compare the two sides. c. Gently pinch each node between one's thumb and forefinger, and then move down the neck muscle. d. Using the index and middle fingers, gently palpate by applying pressure in a rotating pattern.

ANS: A Using gentle pressure is recommended because strong pressure can push the nodes into the neck muscles. Palpating with both hands to compare the two sides symmetrically is usually most efficient.

The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? a. Wheezes b. Bronchophony c. Bronchial sounds d. Whispered pectoriloquy

ANS: A Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema. Bronchophony and whispered pectoriloquy occur with pathologic conditions that increase lung density, such as pulmonary consolidation, which enhances the transmission of voice sounds. Asthma does not increase lung density. Instead, a patient with asthma has narrowed airways which results in wheezing.

When examining children affected with Down syndrome (trisomy 21), what should the nurse look for r/t this disorder? a. Ear dysplasia b. Long, thin neck c. Protruding thin tongue d. Narrow and raised nasal bridge

ANS: A With the chromosomal aberration trisomy 21, also known as Down syndrome, head and face characteristics may include upslanting eyes with inner epicanthal folds, a flat nasal bridge, a small broad flat nose, a protruding thick tongue, ear dysplasia, a short broad neck with webbing, and small hands with a single palmar crease. A short broad neck with webbing, rather than a long, thin neck; a protruding thick tongue, not a thin tongue; and a flat nasal bridge, not a raised nasal bridge are associated with Down syndrome.

During an examination, the nurse finds that a patient has excessive dryness of the skin. How should the nurse document this finding? a. Xerosis b. Pruritus c. Alopecia d. Seborrhea

ANS: A Xerosis is the term used to describe skin that is excessively dry. Pruritus refers to itching, alopecia refers to hair loss, and seborrhea refers to oily skin. Pruritus refers to itching, alopecia refers to hair loss, and seborrhea refers to oily skin. Xerosis is the term used to describe skin that is excessively dry.

During an assessment, a patient mentions that "I just can't smell like I used to. I can barely smell the roses in my garden. Why is that?" For which possible causes of changes in the sense of smell will the nurse assess? (Select all that apply.) a. Aging b. Chronic allergies c. Cigarette smoking d. Chronic alcohol use e. Herpes simplex virus I f. Frequent episodes of strep throat

ANS: A, B, C The sense of smell diminishes with cigarette smoking, chronic allergies, and aging. Chronic alcohol use, a history of strep throat, and herpes simplex virus I are not associated with changes in the sense of smell. Chronic alcohol use, herpes simplex virus I, and frequent episodes of strep throat do not common causes of a diminished sense of smell. The sense of smell diminishes with cigarette smoking, chronic allergies, and aging. Chronic alcohol use, a history of strep throat, and herpes simplex virus I are not associated with changes in the sense of smell.

When gathering information relative to a complete health assessment, the nurse should include which in the decision-making process? (Select all that apply.) a. Treat the health assessment as a legal document. b. Use line drawings to explain and record pertinent findings. c. Do not document findings on the computer while the patient is present. d. Gather needed equipment before the start of the health assessment. e. Write down "word for word" what the patient says as evidence of reliable documentation.

ANS: A, B, D A prudent nurse gathers all needed equipment before the start of a complete health assessment. Simple line drawings can be used as illustrations of findings as well as teaching purposes during the health assessment interaction. Data from the history and physical examination should be recorded as soon as possible as memory fades as the day progresses. Documenting as you move through the examination works well for many examiners, but you just need to make you do not ignore the patient as you focus on the computer. The health assessment record is considered to be a legal document, and a prudent nurse proceeds cautiously to ensure its integrity is maintained. Although it is important to be accurate, it is virtually impossible to write down "word for word" everything that the patient may say during the assessment.

A patient is recovering from several hours of orthopedic surgery. During an assessment of the patient's lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? (Select all that apply.) a. Sudden onset b. Warm, red, and swollen calf c. Pain that is worse at the end of the day d. Aching, tired pain, with a feeling of fullness e. Pain that is relieved with elevation of the leg. f. Intense, sharp pain, with the deep muscle tender to the touch

ANS: A, B, F Signs and symptoms of acute venous problems include pain in the calf that has a sudden onset and that is intense and sharp with tenderness in the deep muscle when touched. The calf is warm, red, and swollen. The other options are symptoms of chronic venous problems

A 16-year-old boy is brought to the clinic for a problem that he refused to let his mother see. The nurse examines him, and finds that he has scrotal swelling on the left side. He had the mumps the previous week, and the nurse suspects that he has orchitis. Which of the following assessment findings support this diagnosis? (Select all that apply.) a. Swollen testis b. Mass that transilluminates c. Scrotal skin that is reddened d. Mass that does not transilluminate e. Scrotum that is tender upon palpation f. Scrotum that is nontender upon palpation

ANS: A, C, D, E With orchitis, the testis is swollen, with a feeling of weight, and is tender or painful. The mass does not transilluminate, and the scrotal skin is reddened. Transillumination of a mass occurs with a hydrocele, not orchitis.

A patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings? (Select all that apply.) a. Skin of the patient is pale and cool. b. His ankles have two small, weeping ulcers. c. He states that the pain gets worse when walking. d. Patient works long hours sitting at a computer desk. e. Patient has a history of diabetes and cigarette smoking. f. Patient states that the pain is worse at the end of the day

ANS: A, C, E Patients with chronic arterial symptoms often have a history of smoking and diabetes (among other risk factors). The pain has a gradual onset with exertion and is relieved with rest or dangling. The skin appears cool and pale. The other responses reflect chronic venous problems. Weeping ulcers on ankles, a job involving sitting for long periods of time, and pain that is worse at the end of the day are associated with venous ulcers, not arterial ulcers.

The nurse is testing the hearing of a 78-year-old man and is reminded of the changes in hearing that occur with aging that include which of the following? (Select all that apply.) a. Progression of hearing loss is slow. b. The aging person has low-frequency tone loss. c. Sounds may be garbled and difficult to localize. d. Hearing loss r/t aging begins in the mid-40s. e. Hearing loss reflects nerve degeneration of the middle ear. f. The aging person may find it harder to hear consonants than vowels.

ANS: A, C, F Presbycusis is a type of hearing loss that occurs with aging and is found in 60% of those older than 65 years. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve, and it slowly progresses after the age of 50 years. The person first notices a high-frequency tone loss; it is harder to hear consonants (high-pitched components of speech) than vowels, which makes words sound garbled. The ability to localize sound is also impaired.

The nurse is 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. Regular border c. Hard, dense, and immobile d. Rubbery texture and mobile e. Dull, heavy pain on palpation f. Irregular, poorly delineated border

ANS: A, F Cancerous breast masses are solitary, unilateral, and nontender. They are solid, hard, dense, and fixed to underlying tissues or skin as cancer becomes invasive. Their borders are irregular and poorly delineated. They are often painless, although the person may experience pain. They are most common in the upper outer quadrant. A dull, heavy pain on palpation and a mass with a rubbery texture and a regular border are characteristics of benign breast disease.

The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear? a. Tympany b. Dullness c. Resonance d. Hyperresonance

ANS: B Abdominal percussion is performed to assess the relative density of abdominal contents, locate organs, and screen for abnormal fluid or masses in the abdomen. The liver is a solid organ which is located in the right upper quadrant and would elicit a dull percussion note. Tympany is heard over air-filled organs such as the stomach and intestines. It is the predominant sound that should be heard over the intestines because air in the intestines rises to the surface when the person is supine. Resonance is a low-pitched, clear, hollow sound that predominates in health lung tissue. Hyperresonance is a lower-pitched, booming sound found when too much air is present such as with gaseous distention of the intestines in the abdomen or emphysema

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. How long should the nurse listen before reporting absent bowel sounds? a. 1 minute b. 5 minutes c. 10 minutes d. 2 minutes in each quadrant

ANS: B Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding that bowel sounds are completely absent.

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, how should the nurse proceed? a. Squeeze the glans to check for the presence of discharge. b. Consider this finding as normal, and proceed with the examination. c. Assess the testicles for the presence of masses or painless lumps. d. Obtain a more detailed history, focusing on any scrotal abnormalities the patient has noticed.

ANS: B After adolescence, the scrotal skin is deeply pigmented and has large sebaceous follicles and appears corrugated.

If an imaginary line were drawn connecting the highest point on each iliac crest. What vertebra would that line cross? a. First sacral b. Fourth lumbar c. Seventh cervical d. Twelfth thoracic

ANS: B An imaginary line connecting the highest point on each iliac crest crosses the fourth lumbar vertebra. The other options are not correct.

The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? a. "We need to determine the areas of tenderness before using percussion and palpation." b. "Auscultation prevents distortion of bowel sounds that might occur after percussion and palpation." c. "Auscultation allows the patient more time to relax and therefore be more comfortable with the physical examination." d. "Auscultation prevents distortion of vascular sounds, such as bruits and hums, that might occur after percussion and palpation."

ANS: B Auscultation is performed first (after inspection) because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.

The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? a. Sound like two pieces of leather being rubbed together b. Are usually high-pitched, gurgling, and irregular sounds c. Are usually loud, high-pitched, rushing, and tinkling sounds d. Originate from the movement of air and fluid through the large intestine

ANS: B Bowel sounds are high-pitched, gurgling, and cascading sounds that irregularly occur from 5 to 30 times per minute. They originate from the movement of air and fluid through the small intestine.

The nurse is assessing the cranial nerves. To assess cranial nerve XII, what should the nurse ask the patient to do? a. Say "ahh". b. Stick out tongue. c. Smile and then frown. d. Follow the nurses fingers through the six cardinal positions of gaze.

ANS: B Cranial nerve XII is the hypoglossal nerve. To assess its function, the nurse should ask the patient to stick out his or her tongue and observe for the location (midline is normal) and any fasiculations. Having the patient say "ahh" assesses cranial nerve IX, having the patient smile and frown is assessing cranial nerve VII, and having the patient follow the nurses fingers through the six cardinal positions of gaze assesses cranial nerves III, IV, and VI.

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. "You can continue with hormone replacement therapy as it actually decreases your risk for breast cancer." b. "You should be aware that you're at increased risk for dyspareunia because of decreased vaginal secretions." c. "You have only stopped menstruating and there are not really any other changes that you need to be concerned about." d. "You likely may have difficulty with sexual pleasure as a result of drastic changes in the female sexual response cycle."

ANS: B Decreased vaginal secretions leave the vagina dry and at risk for irritation and pain with intercourse (dyspareunia). Hormone replacement therapy increases, not decreases, the risk for breast cancer. In addition to cessation of menses, there are several other changes that occur with menopause. The female's hormonal milieu decreases rapidly, the uterus shrinks, the ovaries atrophy, the pelvic musculature weakens, the cervix shrinks, and the vagina becomes shorter, narrower, less elastic, and vaginal epithelium atrophies, becoming thinner, drier, and itchy. However, these physical changes need not affect sexual pleasure and function.

A patient has hypoactive bowel sounds. What is a possible cause of this finding? a. Diarrhea b. Peritonitis c. Laxative use d. Gastroenteritis

ANS: B Diminished or absent bowel sounds signal decreased gastrointestinal motility which can be caused from inflammation from peritonitis, a paralytic ileus after abdominal surgery, or with a bowel obstruction. Diarrhea, laxative use, and gastroenteritis cause hyperactive, not hypoactive, bowel sounds.

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. What do these findings suggest? a. A varicocele b. Epididymitis c. A spermatocele d. Testicular torsion

ANS: B Epididymitis presents as severe pain of sudden onset in the scrotum that is somewhat relieved by elevation. On examination, the scrotum is enlarged, reddened, and exquisitely tender. The epididymis is enlarged and indurated and may be hard to distinguish from the testis. The overlying scrotal skin may be thick and edematous. A varicocele can present with either a dull pain, constant pulling or dragging sensation, or be asymptomatic. Appearance upon inspection may be normal or the lighter scrotal skin may have a bluish color and the testis on side of varicocele may be smaller due to impaired circulation. When standing a soft irregular mass posterior to and above testis which feels like a "bag of worms" may be palpable and collapses when supine and then refills when upright. A spermatocele is usually a painless, round, freely movable mass lying above and behind testis and if large may feel like a third testis. Testicular torsion presents with sudden onset of excruciating unilateral pain in testicle; red, swollen scrotum with one testes (usually the left) higher owing to rotation of shortening; and extremely tender to palpation and difficult to distinguish epididymis from testis.

The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? a. Musical in quality b. Expected near the major airways c. Usually caused by a pathologic disease d. Similar to bronchial sounds except shorter in duration

ANS: B Bronchovesicular breath sounds are moderate in pitch and amplitude and are equal in length in inspiration and expiration. They are heard over major bronchi where fewer alveoli are located posteriorly—between the scapulae, especially on the right; and anteriorly, around the upper sternum in the first and second intercostal spaces. The other responses are not correct.

A woman who has had rheumatoid arthritis for years is starting to notice that her fingers are drifting to the side. What is term commonly used for this condition? a. Radial drift b. Ulnar deviation c. Swan-neck deformity d. Dupuytren contracture

ANS: B Fingers drift to the ulnar side because of stretching of the articular capsule and muscle imbalance caused by chronic rheumatoid arthritis. A radial drift is not observed. Swan-neck deformity is a flexion contracture in the metacarpophalangeal joint, then hyperextension of the PIP joint, and flexion of the DIP joint which resembles the curve of a swan's neck. Dupuytren contracture is a flexion contracture of the digits. It first affects the fourth digit, then the fifth digit, and then third digit.

The nurse is preparing to examine the external genitalia of a school-age girl. Which position would be most appropriate in this situation? a. In the parent's lap b. In a frog-leg position on the examining table c. In the lithotomy position with the feet in stirrups d. Lying flat on the examining table with legs extended

ANS: B For school-age children, placing them on the examining table in a frog-leg position is best. With toddlers and preschoolers, having the child on the parent's lap in a frog-leg position is best.

An older patient has been diagnosed with pernicious anemia. This disorder could be r/t what condition? a. Increased gastric acid secretion b. Decreased gastric acid secretion c. Delayed gastrointestinal emptying time d. Increased gastrointestinal emptying time

ANS: B Gastric acid secretion decreases with aging and may cause pernicious anemia (because it interferes with vitamin B12 absorption), iron deficiency anemia, and malabsorption of calcium.

A patient's vision is recorded as 20/80 in each eye. How does the nurse interpret this finding? a. Patient has presbyopia. b. Patient as poor vision. c. Patient has acute vision. d. Patient has normal vision.

ANS: B Normal visual acuity is 20/20 in each eye; the larger the denominator, the poorer the vision. Presbyopia is a decrease in accommodation which is observed by convergence (motion toward) of the axes of the eyeballs and pupillary constriction and is tested by having the person focus on a distant object.

During a genital examination, the nurse notices that a male patient has clusters of small vesicles on the glans, surrounded by erythema. What does this finding suggest? a. Genital warts b. Genital herpes c. Peyronie disease d. Syphilitic chancres

ANS: B Genital herpes, or herpes simplex virus 2 (HSV-2), infections present as clusters of small vesicles with surrounding erythema, which are often painful and erupt on the glans or foreskin. The lesions of genital warts are soft, pointed, moist, fleshy, painless papules that may be single or multiple in a cauliflower-like patch. They occur on the shaft of the penis, behind the corona, or around the anus, where they may grow into large grapelike clusters. Peyronie disease presents as subcutaneous plaques on the penis and is associated with painful bending of the penis during erection. Its cause is trauma to the penis with resulting scar, deformity, and often erectile dysfunction. Syphilitic chancres begin within 2 to 4 weeks of infection as a small, solitary, silvery papule that erodes to a red, round or oval, superficial ulcer with a yellowish serous discharge. The symptoms this patient is presenting with are those of genital herpes.

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 what type of cancer? a. Uterine b. Cervical c. Ovarian d. Endometrial

ANS: B HPV is the virus responsible for most cases of cervical cancer, not the other options.

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. What do these findings likely indicate? a. Syphilitic chancre b. HPV or genital warts c. Pediculosis pubis (crab lice) d. Herpes simplex virus type 2 (herpes genitalis)

ANS: B HPV lesions are painless, warty growths that the woman may not notice. Lesions are pink or flesh colored, soft, pointed, moist, warty papules that occur in single or multiple cauliflower-like patches around the vulva, introitus, anus, vagina, or cervix. Herpetic lesions are painful clusters of small, shallow vesicles with surrounding erythema. Syphilitic chancres begin as a solitary silvery papule that erodes into a red, round or oval superficial ulcer with a yellowish discharge. Pediculosis pubis causes severe perineal itching and excoriations and erythematous areas.

While conducting a musculoskeletal assessment the nurse stands behind the patient and has the patient bend over and touch his or her toes. What is the nurse assessing? a. Balance b. The spine c. Cervical range of motion d. External rotation of hips

ANS: B Having a patient bend over and touch his or her toes while standing behind himself or herself, the nurse is observing the ROM of the spine and inspecting whether the spine is straight. This position does not assess balance, cervical range of motion, or external hip rotation.

A 30-year-old woman is visiting the clinic because of "pain in my bottom when I have a bowel movement." The nurse should assess for which problem? a. Pinworms b. Hemorrhoids c. Colon cancer d. Fecal incontinence

ANS: B Having painful bowel movements, known as dyschezia, may be attributable to a local condition (hemorrhoid or fissure) or constipation. Pinworms cause acute pain, itching, and a papular rash. Colon cancer often presents with occult blood in the stool. Fecal incontinence is leaking of solid or liquid stool involuntarily.

An older man is concerned about his sexual performance. In addition to a disease, what else should the nurse explain can cause a withdrawal from sexual activity later in life? a. Decreased sperm production b. Side effects of medications c. Decreased libido with aging d. Decreased pleasure from sexual intercourse

ANS: B In the absence of disease, a withdrawal from sexual activity may be attributable to side effects of medications such as antihypertensives, antidepressants, sedatives, psychotropics, antispasmotics, tranquilizers or narcotics, and estrogens; loss of spouse; depression; preoccupation with work; marital or family conflict; heavy use of alcohol; lack of privacy (living with adult children or in nursing home); economic or emotional stress; poor nutrition; or fatigue. Although there is a decrease in sperm production and other physical changes with aging, they need not interfere with the libido and pleasure from sexual intercourse.

The nurse is assessing the abdomen of an older adult. Which statement regarding the older adult and abdominal assessment is true? a. Abdominal tone is increased. b. Abdominal musculature is thinner. c. Abdominal rigidity with an acute abdominal condition is more common. d. The older adult with an acute abdominal condition complains more about pain than the younger person.

ANS: B In the older adult, the abdominal musculature is thinner and has less tone than that of the younger adult, and abdominal rigidity with an acute abdominal condition is less common in the aging person. The older adult with an acute abdominal condition often complains less about pain than the younger person.

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? a. Ascertain whether either of them has been using broad-spectrum antibiotics. b. Explain that couples are considered infertile after 1 year of unprotected intercourse. c. Immediately refer the woman to an expert in pelvic inflammatory disease—the most common cause of infertility. d. Explain that couples are considered infertile after 3 months of engaging in unprotected intercourse and that they will need a referral to a fertility expert.

ANS: B Infertility is considered after 1 year of engaging in unprotected sexual intercourse without conceiving. The other actions are not appropriate.

What are the functional units of the musculoskeletal system? a. Bones b. Joints c. Muscles d. Tendons

ANS: B Joints are the functional units of the musculoskeletal system because they permit the mobility needed to perform the activities of daily living. The skeleton (bones) is the framework of the body. There are three types of muscles: skeletal, smooth, and cardiac and they produce movement when they contract. Tendons are strong fibrous cords that attach skeletal muscles to the bones. The other options are not correct.

An 80-year-old woman is visiting the clinic for a checkup. She states, "I can't walk as much as I used to." What should the nurse have the patient do to observe for motor dysfunction in her hip? a. Internally rotate her hip while she is sitting. b. Abduct her hip while she is lying on her back. c. Adduct her hip while she is lying on her back. d. Externally rotate her hip while she is standing.

ANS: B Limited abduction of the hip while supine is the most common motion dysfunction found in hip disease. The other options are not correct.

The nurse has just completed an inspection of a nulliparous woman's external genitalia. Which of these would be a description of a finding within normal limits? a. Redness of the labia majora b. Multiple nontender sebaceous cysts c. Gaping and slightly shriveled labia majora d. Discharge that is foul smelling and irritating

ANS: B No lesions should be noted, except for the occasional sebaceous cysts, which are yellowish 1-cm nodules that are firm, nontender, and often multiple. The labia majora are dark pink, moist, and symmetric; redness indicates inflammation or lesions. Discharge that is foul smelling and irritating may indicate infection. In the nulliparous woman, the labia majora meet in the midline, are symmetric and plump.

When performing a scrotal assessment, the nurse notices that the scrotal contents show a red glow with transillumination. How should the nurse proceed? a. Assess the patient for the presence of a hernia. b. Suspect the presence of serous fluid in the scrotum. c. Refer the patient for evaluation of a mass in the scrotum. d. Consider this finding normal and proceed with the examination.

ANS: B Normal scrotal contents do not allow light to pass through the scrotum. However, serous fluid does transilluminate and shows as a red glow. Neither a mass nor a hernia would transilluminate.

A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? a. Obturator test b. Test for Murphy sign c. Iliopsoas muscle test d. Assess for rebound tenderness

ANS: B Normally palpating the liver causes no pain. In a person with inflammation of the gallbladder, or cholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration (Murphy test). The person feels sharp pain and abruptly stops midway during inspiration. The obturator and iliopsoas muscle tests assess for an inflamed appendix. Although a patient with cholecystitis may have rebound tenderness, the presence of rebound tenderness indicates peritoneal inflammation which could be caused by several things so it is not specific to cholecystitis.

The nurse is palpating a female patient's adnexa. The findings include a firm, smooth uterine wall; the ovaries are palpable and feel smooth and firm. The fallopian tube is firm and pulsating. How should the nurse proceed? a. Tell the patient that her examination is normal. b. Give her an immediate referral to a gynecologist. c. Suggest that she return in a month for a recheck to verify the findings. d. Tell the patient that she may have an ovarian cyst that should be evaluated further.

ANS: B Normally the uterine wall feels firm and smooth, with the contour of the fundus rounded. Ovaries are not often palpable, but when they are, they normally feel smooth, firm, and almond shaped and are highly movable, sliding through the fingers. The fallopian tube is not normally palpable. No other mass or pulsation should be felt. Pulsation or palpable fallopian tube suggests ectopic pregnancy, which warrants immediate referral.

A hospitalized patient does not require a full neurologic examination during every shift assessment. What is a method of assessing the neurologic status of a patient without performing a full neurological examination? a. Palpate the carotid pulse. b. Offer the patient a glass of water. c. Look at the significant other throughout the examination. d. Assign the nursing assistant to ask the patient questions and report the findings.

ANS: B Offering the patient water is not only a courtesy but also an opportunity for the nurse to note the following physical data: the patient's ability to hear, follow directions, cross the midline, and swallow. Palpating the carotid pulse is a cardiovascular assessment. The nurse should make eye contact with the patient during assessments. Assessments are not within the scope of practice of a nursing assistant; the nurse cannot delegate assessments to a nursing assistant.

During the health history of a patient who reports chronic constipation, the patient asks the nurse about foods to eat to avoid constipation. What should the nurse include as an example of an appropriate food? a. Yogurt b. Broccoli c. Ground beef d. Iceberg lettuce

ANS: B Patients with constipation should be encouraged to eat foods high in fiber. High-fiber foods are either soluble type (e.g., beans, prunes, barley, broccoli) or insoluble type (e.g., cereals, wheat germ). The other examples are not considered high-fiber foods.

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? a. The nurse should screen for monthly breast tenderness. b. The nurse should ask a postmenopausal woman if she has ever had vaginal bleeding. c. Once a woman reaches menopause, the nurse does not need to ask any history questions. d. Postmenopausal women are not at risk for contracting STIs; therefore, these questions can be omitted.

ANS: B Postmenopausal bleeding warrants further workup and referral. The other statements are not true.

The mother of a 10-year-old boy asks the nurse about the recognition of puberty. How should the nurse reply? a. "Puberty usually begins around 15 years of age." b. "The first sign of puberty is an enlargement of the testes." c. "The penis size does not increase until about 16 years of age." d. "The development of pubic hair precedes testicular or penis enlargement."

ANS: B Puberty begins sometime between age 9 for African Americans and age 10 for Caucasians and Hispanics. The first sign is an enlargement of the testes. Pubic hair appears next, and then penis size increases.

While examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. What does the nurse suspect? a. Pulsations of the renal arteries b. Normal abdominal aortic pulsations c. Pulsations of the inferior vena cava d. Increased peristalsis from a bowel obstruction

ANS: B Pulsations from the aorta are normally observed beneath the skin in the epigastric area, particularly in thin people who have good muscle wall relaxation. Pulsations of the renal arteries are not visible. The vena cava is a vein, not an artery, and does not have pulsations. Waves of peristalsis are sometimes visible in very thin people and appear as a slow ripple moving obliquely across the abdomen

The nurse is assessing the abdomen of a pregnant woman who states she has been having "acid indigestion" all the time. What does the nurse know that esophageal reflux during pregnancy can cause? a. Diarrhea b. Pyrosis c. Dysphagia d. Constipation

ANS: B Pyrosis, or heartburn, is caused by esophageal reflux during pregnancy. The other options are not correct.

When assessing the scrotum of a male patient, the nurse notices the presence of multiple firm, nontender, yellow 1-cm nodules. What does this finding indicate? a. Urethritis b. Sebaceous cysts c. Subcutaneous plaques d. Due to an inflammation of the epididymis

ANS: B Sebaceous cysts are commonly found on the scrotum. These yellowish 1-cm nodules are firm, nontender, and often multiple. Urethritis is infection of the urethra which causes painful, burning urination or pruritis. Meatus edges are reddened, everted, and swollen with purulent drainage. Subcutaneous plaque on the penis is called Peyronie disease and is associated with painful bending of the penis during erection. Its cause is trauma to the penis with resulting scar, deformity, and often erectile dysfunction. Inflammation of the epididymis (epididymitis) causes swelling and severe pain of sudden onset in the scrotum, which is relieved by elevation. The multiple yellowish 1 cm nodules this patient has are sebaceous cysts. Sebaceous cysts are commonly found on the scrotum. These yellowish 1-cm nodules are firm, nontender, and often multiple.

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. How should the nurse respond? a. "HRT is at such a low dose that side effects are very unusual." b. "HRT has several side effects, including fluid retention, breast tenderness, and vaginal bleeding." c. "Vaginal bleeding with HRT is very unusual; I suggest you come into the clinic immediately to have this evaluated." d. "It sounds as if your dose of estrogen is too high; I think you may need to decrease the amount you are taking and then call back in a week."

ANS: B Side effects of HRT include fluid retention, breast pain, and vaginal bleeding. The other responses are not correct.

The nurse is performing an examination of the anus and rectum. Which of these statements is correct and important to remember during this examination? a. The rectum is approximately 8 cm long. b. The anorectal junction cannot be palpated. c. Above the anal canal, the rectum turns anteriorly. d. There are no sensory nerves in the anal canal or rectum.

ANS: B The anal columns are folds of mucosa that extend vertically down from the rectum and end in the anorectal junction. This junction is not palpable but is visible on proctoscopy. The rectum is 12 cm long; just above the anal canal, the rectum dilates and turns posteriorly.

During an interview the patient states, "I can feel this bump on the top of both of my shoulders—it doesn't hurt but I am curious about what it might be." What should the nurse tell this patient? a. "That is the subacromial bursa." b. "That is the acromion process." c. "That is the glenohumeral joint." d. "That is the greater tubercle of the humerus."

ANS: B The bump of the scapula's acromion process is felt at the very top of the shoulder. The other options are not correct

Which statement is true regarding the recording of data from the history and physical examination? a. Use long, descriptive sentences to document findings. b. Record the data as soon as possible after the interview and physical examination. c. The examiner should avoid taking any notes during the history and examination because of the possibility of decreasing the rapport with the patient. d. If the information is not documented, then it can be assumed that it was done as a standard of care.

ANS: B The data from the history and physical examination should be recorded as soon after the event as possible. From a legal perspective, if it is not documented, then it was not done. Brief notes should be taken during the examination. When documenting, the nurse should use short, clear phrases and avoid redundant phrases and descriptions.

What should the examiner do during auscultation of breath sounds? a. Listen with the bell of the stethoscope. b. Compare sounds on the left and right sides. c. Listen only to the posterior chest for adventitious sounds. d. Instruct the patient to breathe in and out through the nose.

ANS: B The examiner should auscultate the lungs from side to side to compare the breath sounds. The diaphragm of the stethoscope is used to assess lung sounds. The patient should be instructed to take deep breaths through the mouth during auscultation. Breath sounds should be auscultated on the anterior, lateral, and posterior chest.

During an internal examination of a woman's genitalia, the nurse will use which technique for proper insertion of the speculum? a. The woman is instructed to bear down, the speculum blades are opened and applied in a swift, upward movement. b. The woman is instructed to bear down, the width of the blades is horizontally turned, and the speculum is inserted downward at a 45-degree angle toward the small of the woman's back. c. The blades of the speculum are inserted on a horizontal plane, turning them to a 30-degree angle while continuing to insert them. The woman is asked to bear down after the speculum is inserted. d. The blades are locked open by turning the thumbscrew. Once the blades are open, pressure is applied to the introitus and the blades are inserted downward at a 45-degree angle to bring the cervix into view.

ANS: B The examiner should instruct the woman to bear down, turn the width of the blades horizontally, and insert the speculum at a 45-degree angle downward toward the small of the woman's back.

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? a. "It is okay that you have become sexually active." b. "Girls your age often have questions about sexual activity. Do you have any questions?" c. "If it is okay with you, I'd like to ask you some questions about your sexual history." d. "Girls your age often engage in sexual activities. It is okay to tell me if you have had intercourse."

ANS: B The examiner should start with a permission statement such as, "Girls your age often experience..." A permission statement conveys the idea that it is normal to think or feel a certain way, and implying that the topic is normal and unexceptional is important.

Which is a structure of the external male genital? a. Testis b. Scrotum c. Epididymis d. Vas deferens

ANS: B The external male genital structures include the penis and scrotum. The testis, epididymis, and vas deferens are internal structures.

Which statement concerning the sphincters is correct? a. The internal sphincter is under voluntary control. b. The external sphincter is under voluntary control. c. Both sphincters remain slightly relaxed at all times. d. The internal sphincter surrounds the external sphincter.

ANS: B The external sphincter not only surrounds the internal sphincter but also has a small section overriding the tip of the internal sphincter at the opening. The external sphincter is under voluntary control. Except for the passing of feces and gas, the sphincters keep the anal canal tightly closed.

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. What does this finding suggest? a. Carcinoma b. Genital warts c. Genital herpes d. Syphilitic chancres

ANS: B The lesions of genital warts are soft, pointed, moist, fleshy, painless papules that may be single or multiple in a cauliflower-like patch. They occur on the shaft of the penis, behind the corona, or around the anus, where they may grow into large grapelike clusters. Genital carcinoma begins as red, raised, warty growth or as an ulcer with watery discharge which almost always occur on the glans or inner lip of foreskin. Genital herpes (HSV-2 infection) appears as clusters of small vesicles with surrounding erythema which are often painful and erupt on the glans, foreskin, or anus. Syphilitic chancres begin within 2 to 4 weeks of infection as a small, solitary, silvery papule that erodes to a red, round or oval, superficial ulcer with a yellowish serous discharge. The symptoms this patient is experiencing are those of genital warts.

When auscultating heart sounds, which technique should the nurse use? a. Listen with the bell. b. Listen with the diaphragm. c. Listen with both the diaphragm and bell working from apex to base in a Z pattern. d. Listen with both the bell and diaphragm comparing sides of the heart as progress from apex to base.

ANS: B The nurse should auscultate the heart with the diaphragm of the stethoscope to study heart sounds, inching from the apex up to the base or vice versa in a rough "Z" pattern and then auscultate with the bell of the stethoscope again inching through all locations, noting any murmurs or abnormal sounds. The nurse should not be comparing "sides" but the sounds at the different sites (aortic, pulmonic, Erb's point, tricuspid, and mitral).

During the examination portion of a patient's 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? a. Ask her to place her hands and arms over her head. b. Elevate her head and shoulders to maintain eye contact. c. Allow her to choose to have her feet in the stirrups or have them resting side by side on the edge of the table. d. Allow her to keep her buttocks approximately 6 inches from the edge of the table to prevent her from feeling as if she will fall off.

ANS: B The nurse should elevate her head and shoulders to maintain eye contact. The patient's arms should be placed at her sides or across the chest. Placing her hands and arms over her head only tightens the abdominal muscles. The feet should be placed into the stirrups, knees apart, and buttocks at the edge of the examining table. The stirrups are placed so that the legs are not abducted too far.

A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate? a. "No need to worry. Most men your age develop hernias." b. "A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles." c. "A hernia is the result of prenatal growth abnormalities that are just now causing problems." d. "I'll have to have your physician explain this to you."

ANS: B The nurse should explain that a hernia is a protrusion of the abdominal viscera through an abnormal opening in the muscle wall. The nurse should acknowledge the patient's concerns and not tell him not to worry about it or refer him to his physician to explain it. It is not a result of prenatal growth abnormalities.

The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? a. Examine the tender area first. b. Examine the tender area last. c. Avoid palpating the tender area. d. Palpate the tender area first, and then auscultate for bowel sounds.

ANS: B The nurse should save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination. Auscultation is performed before percussion and palpation because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.

During an abdominal assessment, the nurse would consider which of these findings as normal? a. Presence of a bruit in the femoral area b. Tympanic percussion note in the umbilical region c. Dull percussion note in the left upper quadrant at the midclavicular line d. Palpable spleen between the ninth and eleventh ribs in the left midaxillary line

ANS: B Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not usually present. Normally the spleen is not palpable. Dullness would not be found in the area of lung resonance (left upper quadrant at the midclavicular line).

During an examination of an aging man, what finding would the nurse expect? a. Change in scrotal color b. Decrease in the size of the penis c. Enlargement of the testes and scrotum d. Increase in the number of rugae over the scrotal sac

ANS: B When assessing the genitals of an older man, the nurse may notice thinner, graying pubic hair and a decrease in the size of the penis. The size of the testes may be decreased, they may feel less firm, and the scrotal sac is pendulous with less rugae. No change in scrotal color is observed.

While assessing a hospitalized patient who is jaundiced, the nurse notices that the patient has been incontinent of stool. The stool is loose and gray-tan in color. What does this finding indicate? a. Occult blood b. Inflammation c. Absent bile pigment d. Ingestion of iron preparations

ANS: C The presence of gray-tan stool indicates the absence of bile pigment, which can occur with obstructive jaundice. The ingestion of iron preparations and the presence of occult blood turn the stools to a black color. Jellylike mucus shreds mixed in the stool would indicate inflammation.

A patient calls the clinic for instructions before having a Papanicolaou (Pap) smear. What is an appropriate response by the nurse? a. "If you are menstruating, please use pads to avoid placing anything into the vagina." b. "Avoid intercourse, inserting anything into the vagina, or douching within 24 hours of your appointment." c. "We would like you to use a mild saline douche before your examination. You may pick this up in our office." d. "If you suspect that you have a vaginal infection, please gather a sample of the discharge to bring with you."

ANS: B When instructing a patient before Pap smear is obtained, the nurse should follow these guidelines: Do not obtain during the woman's menses or if a heavy infectious discharge is present. Instruct the woman not to douche, have intercourse, or put anything into the vagina within 24 hours before collecting the specimens. Any specimens will be obtained during the visit, not beforehand.

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. What does this finding indicate? a.Valvular disorder b. Blood flow turbulence c. Fluid volume overload d. Ventricular hypertrophy

ANS: B A blowing, swishing sound heard over the carotid artery is a bruit. This sound indicates blood flow turbulence; normally none is present. It does not indicate a valvular disorder (that would be heard when auscultating the heart not the carotid artery), fluid volume overload or ventricular hypertrophy.

A patient comes to the clinic reporting a cough that is worse at night but not as bad during the day. What does the nurse suspect? a. Pneumonia b. Postnasal drip or sinusitis c. Exposure to irritants at work d. Chronic bronchial irritation from smoking

ANS: B A cough that primarily occurs at night may indicate postnasal drip or sinusitis. Exposure to irritants at work causes an afternoon or evening cough. Smokers experience early morning coughing. Coughing associated with acute illnesses such as pneumonia is continuous throughout the day.

The nurse is percussing over the lungs of a patient with pneumonia. If the patient has atelectasis, what sound will the nurse hear? a. Tympany b. Dullness c. Resonance d. Hyperresonance

ANS: B A dull percussion note signals an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or a tumor. Tympany is a hollow drum-like sound normally found with percussion over the intestines in the abdomen. Resonance is a low-pitched, clear, hollow sound that predominates in healthy lung tissue. Hyperresonance is a lower-pitched, booming sound found when too much air is present such as in emphysema or pneumothorax. An abnormal density in the lungs, such as atelectasis, pneumonia, pleural effusion, or a tumor would produce a dull note when percussed.

A patient comes into the clinic reporting pain in her O.D. On examination, the nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. What is the correct term for this finding? a. Chalazion b. Hordeolum c. Blepharitis d. Dacryocystitis

ANS: B A hordeolum, or stye, is a painful, red, and swollen pustule at the lid margin. A chalazion is a nodule protruding on the lid, toward the inside, and is nontender, firm, with discrete swelling. Dacryocystitis is an inflammation of the lacrimal sac. Blepharitis is inflammation of the eyelids. The painful, red, swollen pustule at the lid margin on this patient's eyelid is a hordeolum or stye.

The nurse is performing the diagnostic positions test. Which result is a normal finding? a. Convergence of the eyes b. Parallel movement of both eyes c. Nystagmus in extreme superior gaze d. Slight amount of lid lag when moving the eyes from a superior to an inferior position

ANS: B A normal response for the diagnostic positions test is parallel tracking of the object with both eyes. Eye movement that is not parallel indicates a weakness of an extraocular muscle or dysfunction of the CN that innervates it. The diagnostic positions test assesses for any muscle weakness during movement of the eye by leading the eyes through the six cardinal positions of gaze. It is not assessing the ability of the eyes to converge, or move toward each other. Nystagmus with an extreme superior gaze is normal, but not in any other position and lid lag is not normal.

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. Based on these findings and the patient's history, the nurse should recognize this extra heart sound is most likely what? a. Split S1 b. Atrial gallop c. Diastolic murmur d. Summation sound

ANS: B A pathologic S4 is termed an atrial gallop or an S4 gallop. It occurs with decreased compliance of the ventricle and with systolic overload (afterload), including outflow obstruction to the ventricle (aortic stenosis) and systemic hypertension. A left-sided S4 occurs with these conditions and is heard best at the apex with the patient in the left lateral position.

During a breast health interview, a patient states that she has noticed pain in her left breast. Which statement by the nurse is most appropriate? a. "Don't worry about the pain; breast cancer is not painful." b. "I would like some more information about the pain in your left breast." c. "Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct." d. "Breast pain is almost always the result of benign breast disease."

ANS: B Although breast cancer usually occurs from trauma, inflammation, infection, or benign breast disease, rather than cancer, the nurse should gather more information about the patient's pain. The nurse should not belittle the patient's feelings by using statements like "don't worry" or by sharing personal experiences.

When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect? a. Crepitus palpated at the costochondral junctions b. Presence of bronchovesicular breath sounds in the peripheral lung fields c. No diaphragmatic excursion as a result of a child's decreased inspiratory volume d. Irregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest

ANS: B Bronchovesicular breath sounds in the peripheral lung fields of the infant and young child up to age 5 or 6 years are normal findings. Their thin chest walls with underdeveloped musculature do not dampen the sound, as do the thicker chest walls of adults; therefore, breath sounds are loud and harsh. Crepitus is not a normal or expected finding in a child or any age patient.

When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. Based on this data, what does the nurse conclude? a. An acute purulent otitis externa b. Most likely a serous otitis media c. Evidence of a resolving cholesteatoma d. Experiencing the early stages of perforation

ANS: B An amber-yellow color to the tympanic membrane suggests serum or pus in the middle ear. Air or fluid or bubbles behind the tympanic membrane are often visible. The patient may have feelings of fullness, transient hearing loss, and a popping sound with swallowing. These findings most likely suggest that the child has serous otitis media. The other responses are not correct. The manifestation of otitis externa is a sticky, yellow discharge (not an amber-yellow tympanic membrane). Cholesteatoma is an overgrowth of epidermal tissue in the middle ear or temporal bone that has a pearly white, cheesy appearance (not an amber-yellow color). A perforation typically begins with ear pain and stops with a popping sensation and then drainage occurs. This patient's amber-yellow color to the tympanic membrane suggests serum or pus in the middle ear. Air or fluid or bubbles behind the tympanic membrane are often visible.

Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient? a. Increased night vision b. Dark retinal background c. Increased photosensitivity d. Narrowed palpebral fissures

ANS: B An ethnically based variability in the color of the iris and in retinal pigmentation exists, with darker irides having darker retinas behind them.

A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, "I don't know what is the matter. All of a sudden I can't hear you out of my left ear!" What should the nurse do next? a. Irrigate the ear with rubbing alcohol. b. Notify the patient's health care provider. c. Prepare to remove cerumen from the patient's ear. d. Make note of this finding for the report to the next shift.

ANS: B Any sudden loss of hearing in one or both ears that is not associated with an upper respiratory infection needs to be reported at once to the patient's health care provider. Hearing loss associated with trauma is often sudden. Irrigating the ear or removing cerumen is not appropriate at this time. This is not a normal finding.

The nurse is assessing for inflammation in a dark-skinned person. Which technique is the best? a. Assessing the skin for cyanosis and swelling b. Palpating the skin for edema and increased warmth c. Assessing the oral mucosa for generalized erythema d. Palpating for tenderness and local areas of ecchymosis

ANS: B Because inflammation cannot be seen in dark-skinned people, palpating the skin for increased warmth, for taut or tightly pulled surfaces that may be indicative of edema, and for a hardening of deep tissues or blood vessels is often necessary

A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately 1 2 to 2 hours, occurring once or twice each day. What should the nurse suspect? a. Hypertension b. Cluster headaches c. Tension headaches d. Migraine headaches

ANS: B Cluster headaches produce pain around the eye, temple, forehead, and cheek and are unilateral and always on the same side of the head. They are excruciating and occur once or twice per day and last 1 2 to 2 hours each. Although hypertension may cause headaches, the blood pressure needs to be severely elevated and would likely not occur once or twice a day and last for 1 2 to 2 hours. Tension headaches are occipital, frontal, or with bandlike tightness. Migraine headaches are supraorbital, retro-orbital, or frontotemporal.

During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation? a. When adventitious sounds are present b. When the bronchial tree is obstructed c. In conjunction with whispered pectoriloquy d. In conditions of consolidation, such as pneumonia

ANS: B Decreased or absent breath sounds occur when the bronchial tree is obstructed, as in emphysema, and when sound transmission is obstructed, as in pleurisy, pneumothorax, or pleural effusion. Although there may be decreased breath sounds when adventitious sounds are heard or with consolidation, it is not expected. Decreased breath sounds are also not expected with whispered pectoriloquy.

The nurse has discovered decreased skin turgor in a patient and knows that this finding is expected in which condition? a. Severe obesity b. Severe dehydration c. Childhood growth spurts d. Connective tissue disorders such as scleroderma

ANS: B Decreased skin turgor is associated with severe dehydration or extreme weight loss.

The nurse is performing a middle ear assessment on a 15-year-old patient who has had a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and landmarks visible. What should the nurse do? a. Refer the patient for the possibility of a fungal infection. b. Recognize that these are scars caused from frequent ear infections. c. Consider that these findings may represent the presence of blood in the middle ear. d. Be concerned about the ability to hear because of this abnormality on the tympanic membrane.

ANS: B Dense white patches on the tympanic membrane are sequelae of repeated ear infections. They do not necessarily affect hearing. A fungal infection manifests as a colony of black or white dots on the eardrum or canal walls (not dense white patch). Blood behind the tympanic membrane would cause the tympanic membrane to appear blue or dark red.

During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition? a. Rickets b. Dehydration c. Mental retardation d. Increased intracranial pressure

ANS: B Depressed and sunken fontanels occur with dehydration or malnutrition. Mental retardation and rickets have no effect on the fontanels. Increased intracranial pressure would cause tense or bulging and possibly pulsating fontanels.

The nurse notices that a patient's palpebral fissures are not symmetric. On examination, the nurse may find that damage has occurred to which cranial nerve (CN)? a. V b. VII c. XI d. XIII

ANS: B Facial muscles are mediated by CN VII; asymmetry of palpebral fissures may be attributable to damage to CN VII (Bell palsy). Cranial nerve V, the trigeminal nerve, mediates facial sensations of pain and touch. Cranial nerve XI is the spinal accessory nerve that innervates the sternomastoid and trapezius muscles of the neck. There is no cranial nerve XIII (only 12 cranial nerves).

The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? a. "Is caused by moisture in the alveoli." b. "Is caused by sounds generated from the larynx." c. "Reflects the blood flow through the pulmonary arteries." d. "Indicates that air is present in the subcutaneous tissues."

ANS: B Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall where they are felt as vibrations. Crepitus is the term for air in the subcutaneous tissues.

During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notices the presence of blood in the anterior chamber of the eye. What does this finding indicate? a. Hypopyon b. Hyphema c. Pterygium d. A corneal abrasion

ANS: B Hyphema is the term for blood in the anterior chamber and is a serious result of blunt trauma (a fist or a baseball) or spontaneous hemorrhage and may indicate scleral rupture or major intraocular trauma. Hypopyon is the term for lager of white blood cells in the anterior chamber and often cause pain, red eye, and possibly decreased vision. Pterygium is the term for a triangular opaque wing of bulbar conjunctive overgrows toward the center of the cornea. It looks membranous, translucent, and yellow to white. A corneal abrasion is the term for damage or removal of the top layer of corneal epithelium, usually a result of scratches or poorly fitting or overworn contact lenses. The person with a corneal abrasion usually feels intense pain; a foreign body sensation; and lacrimation, redness, and photophobia. The presence of blood in the anterior chamber that this patient has is hyphema.

A patient has been admitted to the emergency department for a suspected drug overdose. His respirations are shallow, with an irregular pattern, at a rate of 12 respirations per minute. The nurse interprets this respiration pattern as which of the following? a. Bradypnea b. Hypoventilation c. Cheyne-Stokes respirations d. Chronic obstructive breathing

ANS: B Hypoventilation is characterized by an irregular, shallow pattern, and can be caused by an overdose of narcotics or anesthetics. Bradypnea is slow breathing, with a rate less than 10 respirations per minute. Cheyne-Stokes respirations are a cycle in which respirations gradually wax and wane in a regular pattern, increasing in rate and depth and then decreasing. Chronic obstructive breathing is characterized by normal inspiration and prolonged expiration to overcome increased airway resistance. This patient's breathing is hypoventilation.

A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correct regarding the significance of this in relation to the infant's hearing? a. Rubella may affect the mother's hearing but not the infant's. b. Rubella can damage the infant's organ of Corti, which will impair hearing. c. Rubella can impair the development of cranial nerve VIII and thus affect hearing. d. Rubella is especially dangerous to the infant's hearing in the second trimester of pregnancy.

ANS: B If maternal rubella infection occurs during the first trimester, then it can damage the organ of Corti and impair hearing. Maternal rubella can affect the infant's hearing, not the mother's hearing, if it occurs in the first trimester of pregnancy. Hearing is impaired due to damage to the organ of Corti, not cranial nerve VIII. Rubella does not impair the development of cranial nerve VIII.

A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. What technique should the nurse use to assess for a bruit. a. Palpate the thyroid while the patient is swallowing. b. Auscultate the thyroid with the bell of the stethoscope. c. Palpate the thyroid while the patient holds their breath. d. Auscultate the thyroid with the diaphragm of the stethoscope.

ANS: B If the thyroid gland is enlarged, then the nurse should auscultate it for the presence of a bruit, which is a soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope. A bruit is a soft, pulsatile, whooshing, blowing sound. A bruit occurs with accelerated or turbulent blood flow. It is not able to be palpated. A bruit is heard best with the bell, not the diaphragm of the stethoscope.

A patient states during the interview that she noticed a new lump in the shower a few days ago. It was on her left breast near her axilla. How should the nurse proceed? a. Palpate the lump first. b. Palpate the unaffected breast first. c. Avoid palpating the lump because it could be a cyst, which might rupture. d. Palpate the breast with the lump first but plan to palpate the axilla last.

ANS: B If the woman mentions a breast lump she has discovered herself, then the nurse should examine the unaffected breast first to learn a baseline of normal consistency for this individual.

A mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base. What does the nurse suspect? a. Eczema b. Impetigo c. Herpes zoster d. Diaper dermatitis

ANS: B Impetigo is moist, thin-roofed vesicle with a thin erythematous base and is a contagious bacterial infection of the skin and most common found in infants and children. Eczema is characterized by erythematous papules and vesicles with weeping, oozing, and crusts. Herpes zoster (i.e., chickenpox or varicella) is characterized by small, tight vesicles that are shiny with an erythematous base. Diaper dermatitis is characterized by red, moist maculopapular patches with poorly defined borders. The moist, thin vesicles that look like blisters and scabs on the buttocks are likely impetigo.

A 35-year-old pregnant woman comes to the clinic for a monthly appointment. During the assessment, the nurse notices that she has a brown patch of hyperpigmentation on her face. The nurse continues the skin assessment. What other finding should the nurse expect? a. Xerosis b. Chloasma c. Keratoses d. Acrochordons

ANS: B In pregnancy, skin changes can include striae, linea nigra (a brownish-black line down the midline), chloasma (brown patches of hyperpigmentation), and vascular spiders. Xerosis is dry skin and keratoses are raised, thickened areas of pigmentation that look crusted, scaly, and warty; neither of which are common in pregnancy. Acrochordons are skin tags, and these often occur in the aging adult.

When examining the mouth of an older patient, the nurse recognizes which finding is due to the aging process? a. Teeth appearing shorter b. Tongue that looks smoother in appearance c. Buccal mucosa that is beefy red in appearance d. Small, painless lump on the dorsum of the tongue

ANS: B In the aging adult, the tongue looks smoother because of papillary atrophy. The teeth are slightly yellowed and appear longer because of the recession of gingival margins.

During an assessment, the nurse elevated a patient's legs 12 inches off the table and 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, what should the nurse expect for a normal finding? a. Significant elevational pallor b. Venous filling within 15 seconds c. No change in the coloration of the skin d. Color returning to the feet within 20 seconds of assuming a sitting position

ANS: B In this test, it normally takes 10 seconds or less for the color to return to the feet and 15 seconds for the veins of the feet to fill. Significant elevational pallor, as well as delayed venous filling, occurs with arterial insufficiency.

During a skin assessment, the nurse notices that a Mexican-American patient has skin that is yellowish-brown; however, the skin on the hard and soft palate is pink and the patient's scleras are white. From these findings, what can the nurse rule out? a. Pallor b. Jaundice c. Cyanosis d. Iron deficiency

ANS: B Jaundice is exhibited by a yellow color of the skin and mucous membranes, which indicates rising levels of bilirubin in the blood. Jaundice is first noticed in the junction of the hard and soft palate in the mouth and in the scleras. Pallor occurs when the red-pink tones from oxygenated Hb are lost and the skin takes on the color of the connective tissue (collagen) which is mostly white. Cyanosis is a bluish-gray color of the skin. Iron deficiency can cause nails with a concave (spoon-like) shape.

A 54-year-old man comes to the clinic with a "horrible problem." He tells the nurse that he has just discovered a lump on his breast and is fearful of cancer. The nurse knows which statement about breast cancer in men is true? a. Breast cancer in men rarely spreads to the lymph nodes. b. Less than one percent of all breast cancers occurs in men. c. Most breast masses in men are diagnosed as gynecomastia. d. Breast masses in men are difficult to detect because of minimal breast tissue.

ANS: B Less than one percent of all breast cancers occur in men. The early spreading to axillary lymph nodes is attributable to minimal breast tissue. Breast cancer in men often spreads to the axillary lymph nodes because of the minimal breast tissue in men. Breast masses in men are not typically diagnosed as gynecomastia or more difficult to detect, but they are diagnosed 10 years later than women because of lack of screening and general awareness. The correct option is that less than one percent of all breast cancers occur in men.

The nurse has just completed a lymph node assessment on a 60-year-old healthy female patient. When palpating the nodes on this healthy 60-year-old adult, how did the lymph nodes feel? a. Fixed b. Nonpalpable c. Rubbery, discrete, and mobile d. Large, firm, and fixed to the tissue

ANS: B Most lymph nodes are nonpalpable in adults. The palpability of lymph nodes decreases with age. Normal nodes feel movable, discrete, soft, and nontender.

During ocular examinations, what should the nurse keep in mind regarding the movement of the extraocular muscles? a. Is decreased in the older adult. b. Is stimulated by CNs III, IV, and VI. c. Is impaired in a patient with cataracts. d. Is stimulated by cranial nerves (CNs) I and II.

ANS: B Movement of the extraocular muscles is stimulated by three CNs: III, IV, and VI. Aging and cataracts do not affect the extraocular movements. Movement of the extraocular muscles is not stimulated by CNs I and II but by CNs III, IV, and VI.

A woman comes to the clinic and states, "I've been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." For what condition should the nurse assess for other signs and symptoms? a. Cachexia b. Myxedema c. Graves disease d. Parkinson syndrome

ANS: B Myxedema (hypothyroidism) is a deficiency of thyroid hormone that, when severe, causes a nonpitting edema or myxedema. The patient will have a puffy edematous face, especially around the eyes (periorbital edema); coarse facial features; dry skin; and dry, coarse hair and eyebrows. Cachexia, or cachectic appearance, accompanies chronic wasting diseases such as cancer, dehydration, and starvation. Features included sunken eyes, hollow cheeks, and exhausted, defeated expression. Graves disease is an autoimmune disease with increased production of thyroid hormones which is manifested by goiter, eyelid retraction, and exophthalmos (bulging eyeballs) and other symptoms. The facial features characteristic of Parkinson syndrome are a flat and expressionless, "masklike," with elevated eyebrows, staring gaze, oily skin, and drooling. The signs and symptoms of this patient are characteristic of myxedema, or hypothyroidism.

While inspecting a patient's breasts, the nurse finds that the left breast is slightly larger than the right with the bilateral presence of Montgomery glands. How should the nurse proceed? a. Palpate over the Montgomery glands, checking for drainage. b. Consider these findings as normal, and proceed with the examination. c. Ask extensive health history questions regarding the woman's breast asymmetry. d. Continue with the examination, and then refer the patient for further evaluation of the Montgomery glands.

ANS: B Normal findings of the breast include one breast (most often the left) slightly larger than the other and the presence of Montgomery glands across the areola. These are normal findings so there is no need to palpate the Montgomery glands and checking for drainage, asking extensive health history questions, or referring the patient for further evaluation of the Montgomery glands.

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include which findings? a. Adventitious sounds and limited chest expansion b. Muffled voice sounds and symmetric tactile fremitus c. Increased tactile fremitus and dull percussion tones d. Absent voice sounds and hyperresonant percussion tones

ANS: B Normal lung findings include symmetric chest expansion, resonant percussion tones, vesicular breath sounds over the peripheral lung fields, muffled voice sounds, and no adventitious sounds.

What is the normal splitting of the S2 is associated with? a. Expiration b. Inspiration c. Exercise state d. Low resting heart rate

ANS: B Normal or physiologic splitting of the S2 is associated with inspiration because of the increased blood return to the right side of the heart, delaying closure of the pulmonic valve.

During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding? a. Yellow fatty deposits over the cornea b. Presence of small brown macules on the sclera c. Pallor near the outer canthus of the lower lid d. Yellow color of the sclera that extends up to the iris

ANS: B Normally in dark-skinned people, small brown macules may be observed in the sclera. Blacks may have yellowish fatty deposits beneath the eyelids, away from the cornea, not over the cornea or extending up to the iris. Pallor near the outer canthus is not normal, but may indicate anemia.

A woman is leaving on a trip to Hawaii and has come in for a checkup. During the examination the nurse learns that she has diabetes and is prescribed oral hypoglycemic agents. What should the nurse include in this patient's teaching? a. Increased possibility of bruising b. Importance of sunscreen and avoiding direct sunlight c. Lack of availability of glucose-monitoring equipment d. Skin sensitivity as a result of exposure to salt water

ANS: B Oral hypoglycemic agents may increase sunlight sensitivity and could result in sunburn. Other drugs that increase sunlight sensitivity include sulfonamides, thiazide diuretics, and tetracycline. Oral hypoglycemic agents are not associated with increased bruising. Glucose-monitoring equipment is readily available in retail stores. Exposure to salt water does not typically cause skin sensitivity. However, oral hypoglycemic agents and other drugs such as sulfonamides, thiazide diuretics, and tetracycline may increase sunlight sensitivity and cause sunburn.

A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of a television or radio. What is the most likely cause of this hearing loss? a. Presbycusis b. Otosclerosis c. Trauma to the bones d. Frequent ear infections

ANS: B Otosclerosis is a common cause of conductive hearing loss in young adults between the ages of 20 and 40 years. Presbycusis is a type of hearing loss that occurs with aging. Trauma and frequent ear infections are not a likely cause of his hearing loss. Instead, a common cause of conductive hearing loss (mechanical dysfunction of the external or middle ear which causes partial hearing loss that can be compensated for with an increase in amplitude) in young adults between the ages of 20 and 40 years is otosclerosis.

A patient says that she has recently noticed a lump in the front of her neck below her "Adam's apple" that seems to be getting bigger. During the assessment, what finding would lead the nurse to suspect that this may not be a cancerous thyroid nodule? a. It is tender. b. It is mobile and soft. c. It disappears when the patient smiles. d. It is hard and fixed to the surrounding structures.

ANS: B Painless, rapidly growing nodules may be cancerous, especially the appearance of a single nodule in a young person. However, cancerous nodules tend to be hard and fixed to surrounding structures, not mobile.

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal? a. Decrease in tear production b. Unequal pupillary constriction in response to light c. Presence of arcus senilis observed around the cornea d. Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles

ANS: B Pupils are small in the older adult, and the pupillary light reflex may be slowed, but pupillary constriction should be symmetric. The assessment findings in the other responses are considered normal in older people. Decrease in tear production, presence of arcus senilis around the cornea, and loss of outer hair on the eyebrows are normal findings in the aging adult. Although pupils are small in the older adult, and the pupillary light reflex may be slowed, the pupillary constriction should be symmetric. Therefore, unequal pupillary constriction in response to light is an abnormal finding.

The direction of blood flow through the heart is best described by which of these? a. Vena cava → right atrium → right ventricle → lungs → pulmonary artery → left atrium → left ventricle b. Right atrium → right ventricle → pulmonary artery → lungs → pulmonary vein→ left atrium → left ventricle c. Aorta → right atrium → right ventricle → lungs → pulmonary vein → left atrium→ left ventricle → vena cava d. Right atrium → right ventricle → pulmonary vein → lungs → pulmonary artery→ left atrium → left ventricle

ANS: B Returning blood from the body empties into the right atrium and flows into the right ventricle and then goes to the lungs through the pulmonary artery. The lungs oxygenate the blood, and it is then returned to the left atrium through the pulmonary vein. The blood goes from there to the left ventricle and then out to the body through the aorta.

A man has come in to the clinic for a skin assessment because he is worried he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on" his skin. Which is the best description of these? a. Senile lentigines, which do not become cancerous b. Seborrheic keratoses, which do not become cancerous c. Acrochordons, which are precursors to squamous cell carcinoma d. Actinic keratoses, which are precursors to basal cell carcinoma

ANS: B Seborrheic keratoses appear like dark, greasy, "stuck-on" lesions that primarily develop on the trunk. These lesions do not become cancerous. Senile lentigines are commonly called liver spots and are not precancerous. Acrochordons are skin tags and are not precancerous. Actinic (senile or solar) keratoses are lesions that are red-tan scaly plaques that increase over the year s to become raised and roughened. They may have a silvery-white scale adherent to the plaque. They occur on sun-exposed surfaces and are directly r/t sun exposure. They are premalignant and may develop into squamous cell carcinoma.

During a visit to the clinic, a woman in her seventh month of pregnancy states 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? a. Lymphedema b. Varicose veins c. Raynaud phenomenon d. Deep vein thrombophlebitis

ANS: B Superficial varicose veins are caused by incompetent distant valves in the veins, which results in the reflux of blood, producing dilated, tortuous veins. Varicose veins are more common in women, and pregnancy can also be a cause. Symptoms include aching, heaviness in the calf, easy fatigability, and night leg or foot cramps. Dilated, tortuous veins are observed on assessment. Lymphedema is the accumulation of protein-rich fluid in the interstitial spaces in the arm, not the leg. Raynaud phenomenon presents as episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress. The symptoms of deep vein thrombophlebitis are warmth, swelling, redness, tender to palpation, and may have dependent cyanosis. This patient is experiencing superficial varicose veins which are caused by incompetent distant valves in the veins, which results in the reflux of blood, producing dilated, tortuous veins.

A patient has come in for an examination and states, "I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is?" The nurse notes swelling below the angle of the jaw. What does the nurse suspect? a. Inflammation of the thyroid gland b. Inflammation of the parotid gland c. Infection in the occipital lymph node d. Infection in the submental lymph node

ANS: B Swelling of the parotid gland is evident below the angle of the jaw and is most visible when the head is extended. Painful inflammation occurs with mumps, and swelling also occurs with abscesses or tumors. Swelling occurs anterior to the lower ear lobe.

The nurse suspects that a patient has hyperthyroidism, and the laboratory data indicate that the patient's T4 and T3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination? a. Dyspnea b. Tachycardia c. Constipation d. Atrophied nodular thyroid gland

ANS: B T4 and T3 are thyroid hormones that stimulate the rate of cellular metabolism, resulting in tachycardia. With an enlarged thyroid gland as in hyperthyroidism, the nurse might expect to find diffuse enlargement (goiter) or a nodular lump but not an atrophied gland. Dyspnea and constipation are not findings associated with hyperthyroidism

A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. What is the best response by the nurse? a. Tell the patient to watch the lesion and report back in 2 months. b. Refer the patient because of the suggestion of melanoma on the basis of her symptoms. c. Ask additional questions regarding environmental irritants that may have caused this condition. d. Tell the patient that these signs suggest a compound nevus, which is very common in young to middle-aged adults.

ANS: B The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, the development of itching, burning, and bleeding, or a new-pigmented lesion. Any one of these signs raises the suggestion of melanoma and warrants immediate referral.

What is the best description of the S1 heart sound? a. Indicates the beginning of diastole. b. Coincides with the carotid artery pulse. c. Louder than the S2 at the base of the heart. d. Is caused by the closure of the semilunar valves.

ANS: B The S1 coincides with the carotid artery pulse, is the start of systole, and is louder than the S2 at the apex of the heart; the S2 is louder than the S1 at the base. The nurse should gently feel the carotid artery pulse while auscultating at the apex of the heart; the sound heard as each pulse is felt is the S1.

4. Which statement about the apices of the lungs is true? a. Are at the level of the second rib anteriorly. b. Extend 3 to 4 cm above the inner third of the clavicles. c. Are located at the sixth rib anteriorly and the eighth rib laterally. d. Rest on the diaphragm at the fifth intercostal space in the midclavicular line (MCL).

ANS: B The apex of the lung on the anterior chest is 3 to 4 cm above the inner third of the clavicles. On the posterior chest, the apices are at the level of C7.

If a patient reports a recent breast infection, then the nurse should expect to find what type of node enlargement? a. Nonspecific b. Ipsilateral axillary c. Inguinal and cervical d. Contralateral axillary

ANS: B The breast has extensive lymphatic drainage. Most of the lymph, more than 75%, drains into the ipsilateral, or same side, axillary nodes. If there was a recent breast infection, then the same side (ipsilateral) axillary nodes will likely be enlarged. A recent breast infection would not cause enlargement of the inguinal or cervical lymph nodes or lymph nodes on the opposite (contralateral) side. Instead, since the breast has extensive lymphatic drainage with most of the lymph (more than 75%) drains into the ipsilateral, or same side, axillary nodes. If there was a recent breast infection, then the same side (ipsilateral) axillary nodes will likely be enlarged.

During an assessment, the nurse notices that an older adult patient has tears rolling down his face from his O.S. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling "dry and itchy." Which action by the nurse is correct? a. Documenting the finding as ptosis b. Assessing for other signs of ectropion c. Assessing the eye for a possible foreign body d. Contacting the prescriber; these are signs of basal cell carcinoma

ANS: B The condition described is known as ectropion, and it occurs in older adults and is attributable to atrophy of the elastic and fibrous tissues. The lower lid does not approximate to the eyeball, and, as a result, the puncta cannot effectively siphon tears; excessive tearing results. Ptosis is a drooping of the upper eyelid. These signs do not suggest the presence of a foreign body in the eye or basal cell carcinoma.

A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient? a. Hard and fixed cervical nodes b. Enlarged and tender inguinal nodes c. Bilateral enlargement of the popliteal nodes d. Pelletlike nodes in the supraclavicular region

ANS: B The inguinal nodes in the groin drain most of the lymph of the lower extremities. With local inflammation, the nodes in that area become swollen and tender. Since it is the inguinal nodes that drain the lymph from the lower extremities, the cervical and supraclavicular lymph nodes would not be affected and there are no popliteal lymph nodes.

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. What does the nurse suspect? a. Lymphedema b. Raynaud phenomenon c. Deep-vein thrombosis d. Chronic arterial insufficiency

ANS: B The condition with episodes of abrupt, progressive tricolor changes of the fingers in response to cold, vibration, or stress is known as Raynaud phenomenon. Lymphedema is an accumulation of protein-rich fluid in the interstitial spaces in the arm that may occur with breast cancer. Lymphedema after breast cancer causes unilateral swelling and nonpitting brawny edema, with overlying skin indurated. It is caused by the removal of lymph nodes with breast surgery or damage to lymph nodes and channels with radiation therapy for breast cancer. Lymphedema can impede drainage of lymph. Deep vein thrombosis is the development of a thrombus, or clot, in a deep vein, most commonly in the legs, not the arms. Symptoms of chronic arterial insufficiency are significant elevational pallor and delayed venous filling in the legs.

Which is a normal finding when assessing the respiratory system of an older adult? a. Increased thoracic expansion b. Decreased mobility of the thorax c. Decreased anteroposterior diameter d. Bronchovesicular breath sounds throughout the lungs

ANS: B The costal cartilages become calcified with aging, resulting in a less mobile thorax. Chest expansion may be somewhat decreased, and the chest cage commonly shows an increased anteroposterior diameter. The costal cartilages become calcified with aging, resulting in a less mobile thorax and thus also a slight decrease, not increase, in thoracic expansion. The chest cage commonly shows an increased, not a decreased, anteroposterior diameter and bronchovesicular breath sounds are not found throughout the lungs.

The nurse is teaching a review class on the lymphatic system. Which statement by a class participant indicates correct understanding of the material? a. "Lymph flow is propelled by the contraction of the heart." b. "The flow of lymph is slow, compared with that of the blood." c. "One of the functions of the lymph is to absorb lipids from the biliary tract." d. "Lymph vessels have no valves; therefore, lymph fluid flows freely from the tissue spaces into the bloodstream."

ANS: B The flow of lymph is slow, compared with flow of the blood. Lymph flow is not propelled by the heart but rather by contracting skeletal muscles, pressure changes secondary to breathing, and contraction of the vessel walls. Lymph does not absorb lipids from the biliary tract. The vessels do have valves; therefore, flow is one way from the tissue spaces to the bloodstream.

A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. Which is the best response by the nurse? a. "How many teeth did you have at this age?" b. "This is a normal number of teeth for an 18 month old." c. "Normally, by age 21 2 years, 16 deciduous teeth are expected." d. "All 20 deciduous teeth are expected to erupt by age 4 years."

ANS: B The guidelines for the number of teeth for children younger than 2 years old are as follows: the child's age in months minus the number 6 should be equal to the expected number of deciduous teeth. Normally all 20 teeth are in by 21 2 years old. In this instance, the child is 18 months old, minus 6, equals 12 deciduous teeth expected.

A 55-year-old postmenopausal woman is being seen in the clinic for her annual examination. She is concerned about changes in her breasts that she has noticed over the past 5 years. She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem "flat and flabby." Which is the best reply by the nurse? a. "This change occurs most often because of long-term use of bras that do not provide enough support to the breast tissues." b. "Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast and is a normal process of aging." c. "This is a normal change that occurs as women get older and is due to the increased levels of progesterone during the aging process." d. "Postural changes in the spine make it appear that your breasts have changed in shape. Exercises to strengthen the muscles of the upper back and chest wall will help prevent the changes in elasticity and size."

ANS: B The hormonal changes of menopause cause the breast glandular tissue to atrophy, making the breasts more pendulous, flattened, and sagging. This change in the breasts is not due to long-term use of unsupportive bras, increased levels of progesterone with aging, or postural changes in the spine. Rather, the hormonal changes of menopause cause the breast glandular tissue to atrophy, making the breasts more pendulous, flattened, and sagging.

The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true? a. The right side of the brain interprets the vision for the O.D. b. The image formed on the retina is upside down and reversed from its actual appearance in the outside world. c. Light rays are refracted through the transparent media of the eye before striking the pupil. d. Light impulses are conducted through the optic nerve to the temporal lobes of the brain.

ANS: B The image formed on the retina is upside down and reversed from its actual appearance in the outside world. The light rays are refracted through the transparent media of the eye before striking the retina, and the nerve impulses are conducted through the optic nerve tract to the visual cortex of the occipital lobe of the brain. The left side of the brain interprets vision for the O.D.

The nurse is preparing for a class on breast cancer. Which statement is true with regard to cultural differences in breast cancer in the United States? a. Black women have a lower incidence of aggressive, triple negative breast cancer. b. The relative 5-year survival rate for black women is lower than that for Caucasian women. c. For every stage of breast cancer, Asian/Pacific Islander women have the lowest rate of survival. d. Ashkenazi Jewish women have a significantly lower prevalence of BRCA1 and BRCA2 gene mutations.

ANS: B The incidence of breast cancer and survival rates varies between different cultural groups. The relative 5-year survival rate is 83% for black women and 92% for white women. Survival varies by the stage of cancer when it is diagnosed and black women are diagnosed at a later stage and have higher rates of the aggressive, triple negative breast cancer. The incidence of breast cancer and survival rates varies between different cultural groups. The relative 5-year survival rate for black women is lower (not higher) than Caucasian women (83% to 92%). Survival varies by the stage of cancer when it is diagnosed and black women are diagnosed at a later stage and have higher rates (not lower incidence) of the aggressive, triple negative breast cancer. For every stage of breast cancer, Asian/Pacific Islander women have the highest (not lowest) rate of survival and Ashkenazi Jewish women have a significantly higher (not lower) prevalence of BRCA1 and BRCA2 gene mutations.

A mother brings her newborn in for an assessment and asks, "Is there something wrong with my baby? His head seems so big." Which statement is true regarding the relative proportions of the head and trunk of the newborn? a. At birth, the head is one fifth the total length. b. Head circumference should be greater than chest circumference at birth. c. The head size reaches 90% of its final size when the child is 3 years old. d. When the anterior fontanel closes at 2 months, the head will be more proportioned to the body.

ANS: B The nurse recognizes that during the fetal period, head growth predominates. Head size is greater than chest circumference at birth, and the head size grows during childhood, reaching 90% of its final size when the child is age 6 years.

During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding? a. Asymmetry of the breasts is unusual and the patient should be referred to physician. b. Asymmetry of the breasts is common, but the nurse should verify that this finding is not new. c. Asymmetry of breast size and shape is very unusual and means she may have an inflammation or growth. d. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about.

ANS: B The nurse should notice symmetry of size and shape of the breasts. It is common to have a slight asymmetry in size; often the left breast is slightly larger than the right. However, a sudden increase in the size of one breast signifies inflammation or new growth. The nurse should verify that this asymmetry is not new.

A male patient with a history of acquired immunodeficiency syndrome (AIDS) has come in for an examination and states, "I think that I have the mumps." What should the nurse examine first? a. Thyroid gland b. Parotid gland c. Cervical lymph nodes d. Mouth and skin for lesions

ANS: B The parotid gland may become swollen with the onset of mumps, and parotid enlargement has been found with HIV.

What is the sac that surrounds and protects the heart is called? a. Myocardium b. Pericardium c. Endocardium d. Pleural space

ANS: B The pericardium is a tough, fibrous double-walled sac that surrounds and protects the heart. It has two layers that contain a few milliliters of serous pericardial fluid. The myocardium is the muscular wall of the heart. The endocardium is the thin layer of endothelial tissue that lines the inner surface of the heart chambers and valves. The pleural space is the space between the visceral and parietal pleura of each lung. The sac that surrounds and protects the heart is the pericardium.

The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation? a. No sensation b. Firm pressure c. Pain during palpation d. Pain sensation behind eyes

ANS: B The person should feel firm pressure but no pain. Sinus areas are tender to palpation in persons with chronic allergies or an acute infection (sinusitis). A normal finding when palpating the sinus areas is for the patient to feel firm pressure, not no sensation at all, pain during palpation, or pain behind the eyes. Sinus areas that are tender to palpation may indicate chronic allergies or an acute infection (sinusitis). Feeling firm pressure but no pain is a normal finding.

The nurse uses the profile sign during an assessment. What does this technique detect? a. Barrel chest b. Early clubbing c. Symmetry of the fingers d. Insufficient capillary refill

ANS: B The profile sign involves viewing the finger from the side. This is done to detect early clubbing.

The nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. When assessing this patient's pulse, what should the nurse expect? a. Normal b. Bounding c. Weak, thready d. Unpalpable pedal pulse

ANS: B The pulses of a patient with untreated hyperthyroidism are expected to be full or bounding (easily palpable, pounds under your fingertips). Bounding pulses occur with hyperkinetic states (e.g., exercise, anxiety, fever), anemia, and hyperthyroidism. The pedal pulse is likely to be easier to palpate, not unpalpable. An absent pulse occurs with an arterial occlusion and a weak, thready pulse occurs with shock and peripheral artery disease

Which statement is true regarding the arterial system? a. Arteries are large-diameter vessels. b. The arterial system is a high-pressure system. c. The walls of arteries are thinner than those of the veins. d. Arteries can greatly expand to accommodate a large blood volume increase.

ANS: B The pumping heart makes the arterial system a high-pressure system.

The nurse keeps in mind that a thorough skin assessment is extremely important. What can the skin provide important information about? a. Support systems b. Circulatory status c. Socioeconomic status d. Psychological wellness

ANS: B The skin holds information about the body's circulation, nutritional status, and signs of systemic diseases, as well as topical data on the integumentary system itself. Assessment of the skin does not typically provide information on support systems, socioeconomic status, or psychological wellness.

Where does the trachea bifurcate on the anterior chest? a. Costal angle b. Sternal angle c. Xiphoid process d. Suprasternal notch

ANS: B The sternal angle marks the site of tracheal bifurcation into the right and left main bronchi; it corresponds with the upper borders of the atria of the heart, and it lies above the fourth thoracic vertebra on the back.

In assessing the tonsils of a 30-year-old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is the correct response to these findings? a. Refer the patient to a throat specialist. b. No response is needed; this appearance is normal for the tonsils. c. Continue with the assessment, looking for any other abnormal findings. d. Obtain a throat culture on the patient for possible streptococcal (strep) infection.

ANS: B The tonsils are the same color as the surrounding mucous membrane, although they look more granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes. There is no need to refer the patient to a throat specialist, obtain a throat culture, or look for other abnormal findings because the findings in this question are normal. Although the tonsils look more granular and their surface shows deep crypts, they are the same color as the surrounding mucous membrane and tonsillar tissue enlarges during childhood until puberty and then involutes.

A patient's vision is recorded as 20/30 when the Snellen eye chart is used. How should the nurse interpret these results? a. At 30 feet the patient can read the entire chart. b. The patient can read at 20 feet what a person with normal vision can read at 30 feet. c. The patient can read the chart from 20 feet in the O.S. and 30 feet in the O.D. d. The patient can read from 30 feet what a person with normal vision can read from 20 feet.

ANS: B The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see.

When examining the face of a patient, what are the two pairs of salivary glands that are accessible for examination? a. Occipital; submental b. Parotid; submandibular c. Submandibular; occipital d. Sublingual; parotid

ANS: B The two pairs of salivary glands accessible to examination on the face are the parotid glands, which are in the cheeks over the mandible, anterior to and below the ear; and the submandibular glands, which are beneath the mandible at the angle of the jaw. The parotid glands are normally nonpalpable. The occipital and submental are lymph nodes, not glands and the sublingual glands lie on the floor of the mouth, so are not readily accessible for examination. The two pairs of salivary glands that are accessible for examination on the face are the parotid glands, which are in the cheeks over the mandible, anterior to and below the ear; and the submandibular glands, which are beneath the mandible at the angle of the jaw.

When examining the ear with an otoscope, how should the tympanic membrane look? a. Light pink with a slight bulge b. Pearly gray and slightly concave c. Whitish with black flecks or dots d. Pulled in at the base of the cone of light

ANS: B The tympanic membrane is a translucent membrane with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The tympanic membrane is oval and slightly concave, pulled in at its center by the malleus, which is one of the middle ear ossicles. A light pink color and a slight bulge of the tympanic membrane indicate otitis media. It should not look white and if there are tiny black flecks or dots, that is indicative of a fungal infection, or otomycosis. The tympanic membrane does not appear pulled in at the base of the cone of light, but should instead appear flat and slightly pulled in at the center. A normal tympanic membrane should appear a pearly gray color and have a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light. The tympanic membrane is oval and slightly concave, pulled in at its center by the malleus, which is one of the middle ear ossicles.

In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. What is the reason for this? a. It is the largest quadrant of the breast. b. It is the most common location of breast tumors. c. It is where the majority of suspensory ligaments attach. d. It is more prone to injury and calcifications than other locations in the breast.

ANS: B The upper outer quadrant is the site of most breast tumors. In the upper outer quadrant, the nurse should notice the axillary tail of Spence, the cone-shaped breast tissue that projects up into the axilla, close to the pectoral group of axillary lymph nodes. The other options are incorrect.

The nurse is assessing a patient with liver disease for jaundice. Which of these assessment findings is indicative of true jaundice? a. Yellow patches in the outer sclera b. Yellow color of the sclera that extends up to the iris c. Skin that appears yellow when examined under low light d. Yellow deposits on the palms and soles of the feet where jaundice first appears

ANS: B The yellow sclera of jaundice extends up to the edge of the iris. Calluses on the palms and soles of the feet often appear yellow but are not classified as jaundice. Scleral jaundice should not be confused with the normal yellow subconjunctival fatty deposits that are common in the outer sclera of dark-skinned people. Signs of jaundice should be assessed with adequate lighting.

A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. His hair seems to be breaking off in patches, and he notices some scaling on his head. What does the nurse suspect? a. Folliculitis b. Tinea capitis c. Toxic alopecia d. Seborrheic dermatitis

ANS: B Tinea capitis is rounded patchy hair loss on the scalp, leaving broken-off hairs, pustules, and scales on the skin, and is caused by a fungal infection. Lesions are fluorescent under a Wood light and are usually observed in children and farmers; tinea capitis is highly contagious. Folliculitis is inflammation of hair follicles which causes a pustule with a hair visible in the center. Toxic alopecia is patchy, asymmetric balding that accompanies severe illness or chemotherapy. Seborrheic dermatitis (cradle cap) is thick, yellow-to-white, greasy adherent scales with mild erythema on the scalp and forehead which is very common in early infancy. The patchy hair loss and scales on the scalp that this patient is experiencing is tinea capitis.

The nurse is attempting to assess the femoral pulse in a patient who is obese. Which of these actions would be most appropriate? a. Ask the patient to assume a prone position. b. Ask the patient to bend his or her knees to the side in a froglike position. c. The nurse firmly presses against the bone with the patient in a semi-Fowler position. d. The nurse listens with a stethoscope for pulsations; palpating the pulse in an obese person is extremely difficult.

ANS: B To help expose the femoral area, particularly in obese people, the nurse should ask the person to bend his or her knees to the side in a froglike position. This will make accessing the femoral artery easier. The femoral artery is located in the groin area and can be especially difficult to assess in an obese patient. Having the patient assume a prone or Semi-fowler's positions does not help to expose the femoral area and the pulse will unlikely be heard with a stethoscope

During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation? a. In an obese patient b. When part of the lung is obstructed or collapsed c. When bulging of the intercostal spaces is present d. When accessory muscles are used to augment respiratory effort

ANS: B Unequal chest expansion occurs when part of the lung is obstructed or collapsed, as with pneumonia, or when guarding to avoid postoperative incisional pain. Chest expansion is still expected to be equal in obese patients, when there is bulging of intercostal spaces, and when accessory muscles are used in breathing.

A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. When interpreting these findings, what should the nurse recall? a. Alterations in arterial function will cause edema. b. Nonpitting, hard edema occurs with lymphatic obstruction. c. Phlebitis of a superficial vein will cause bilateral edema. d. Long-standing arterial obstruction will cause pitting edema.

ANS: B Unilateral edema occurs with occlusion of a deep vein or with unilateral lymphatic obstruction and causes edema that is nonpitting and feels hard to the touch (brawny edema). Alterations in arterial function or long-standing arterial obstruction do not cause lower leg edema nor does phlebitis of a superficial vein. Instead, lower leg edema is caused by problems with the heart or deep veins, lymphatic system, or kidneys.

The nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, then the nurse should recognize which finding while pushing on the right upper quadrant of the patient's abdomen, just below the rib cage? a. The jugular veins will not be detected during this maneuver. b. The jugular veins will remain elevated as long as pressure on the abdomen is maintained. c. An impulse will be visible at the fourth or fifth intercostal space at or inside the midclavicular line. d. The jugular veins will rise for a few seconds and then recede back to the previous level if the heart is properly working.

ANS: B When performing hepatojugular reflux, the jugular veins will rise for a few seconds and then recede back to the previous level if the heart is able to pump the additional volume created by the pushing. However, with heart failure, the jugular veins remain elevated as long as pressure on the abdomen is maintained.

When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard? a. Low humming sound b. Swishing, whooshing sound c. Regular "lub, dub" pattern d. Steady, even, flowing sound

ANS: B When using the Doppler ultrasonic stethoscope, the pulse site is found when one hears a swishing, whooshing sound.

While obtaining a health history, a patient tells the nurse that he has frequent nosebleeds and asks the best way to get them to stop. What would be the nurse's best response? a. "While sitting up, place a cold compress over your nose." b. "Sit up with your head tilted forward and pinch your nose." c. "Allow the bleeding to stop on its own, but don't blow your nose." d. "Lie on your back with your head tilted back and pinch your nose."

ANS: B With a nosebleed, the person should sit up with the head tilted forward and pinch the nose between the thumb and forefinger for 5 to 15 minutes.

A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. What do these findings suggest? a. Bronchitis b. Pneumothorax c. Acute pneumonia d. Asthmatic attack

ANS: B With a pneumothorax, free air in the pleural space causes partial or complete lung collapse. If the pneumothorax is large, then tachypnea and cyanosis are evident. Unequal chest expansion, decreased or absent tactile fremitus, tracheal deviation to the unaffected side, decreased chest expansion, hyperresonant percussion tones, and decreased or absent breath sounds are found with the presence of pneumothorax.

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 the expected hemodynamic changes r/t age? a. Increase in resting heart rate b. Increase in systolic blood pressure c. Decrease in diastolic blood pressure d. Increase in diastolic blood pressure

ANS: B With aging, an increase in systolic blood pressure occurs. No significant change in diastolic pressure and no change in the resting heart rate occur with aging. Cardiac output at rest does not changed with aging.

A 10-year-old is at the clinic for "a sore throat that has lasted 6 days." Which of these findings would be consistent with an acute infection? a. Tonsils 3+/1-4+ with pale coloring b. Tonsils 3+/1-4+ with large white spots c. Tonsils 2+/1-4+ with small plugs of white debris d. Tonsils 1+/1-4+ and pink; the same color as the oral mucosa

ANS: B With an acute infection, tonsils are bright red and swollen and may have exudate or large white spots. Tonsils are enlarged to 2+, 3+, or 4+ with an acute infection.

While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess? a. Nutritional status b. When the patient first noticed the lesion c. Whether the patient has had a recent cold d. Whether the patient has had any recent exposure to sick animals

ANS: B With carcinoma, the initial lesion is round and indurated, but then it becomes crusted and ulcerated with an elevated border. Most cancers occur between the outer and middle thirds of the lip. Any lesion that is still unhealed after 2 weeks should be referred. Therefore, the nurse should try to establish how long the lesion has been there and ask the patient when the patient first noticed the lesion.

A 17-year-old student is a swimmer on her high school's swim team. She has had three bouts of otitis externa this season and wants to know what to do to prevent it. What should the nurse include in the instructions? a. Use a cotton-tipped swab to dry ear canals thoroughly after each swim. b. Use rubbing alcohol or 2% acetic acid eardrops after every swim. c. Irrigate the ears with warm water and a bulb syringe after each swim. d. Rinse the ears with a warmed solution of mineral oil and hydrogen peroxide.

ANS: B With otitis externa (swimmer's ear), swimming causes the external canal to become waterlogged and swell; skinfolds are set up for infection. The rubbing alcohol and acetic acid mix with the water in the ear and then evaporate. The use of cotton-tip swabs in the ears is not recommended as cotton can be left in the ear and it can also impact cerumen. Irrigating the ears is done to clean the ears, not prevent otitis externa. Otitis externa can be prevented by using rubbing alcohol or 2% acetic acid eardrops after every swim.

In performing a voice test to assess hearing, which of these actions would the nurse perform? a. Shield the lips so that the sound is muffled. b. Whisper a set of random numbers and letters, and then ask the patient to repeat them. c. Ask the patient to place his or her finger in their ear to occlude outside noise. d. Stand approximately 4 feet away to ensure that the patient can really hear at this distance.

ANS: B With the examiner's head 30 to 60 cm (1 to 2 feet) from the patient's ear, have the patient place one finger on the tragus of the ear and push it in and out of the auditory meatus. While the patient is doing this, the examiner exhales and slowly whispers a set of random numbers and letters, such as "5, B, 6." Normally the patient is asked to repeat each number and letter correctly after hearing the examiner say them. Shielding the lips to muffle the sound, asking the patient to place a finger in their ear to occlude outside noise, and the examiner standing 4 feet away from the patient are not techniques used to perform the voice test. The voice test is performed with the examiner's head 30 to 60 cm (1 to 2 feet) from the patient's ear and having the patient place one finger on the tragus of the ear and push it in and out of the auditory meatus. While the patient is doing this, the examiner exhales and slowly whispers a set of random numbers and letters, such as "5, B, 6." Normally, the patient is asked to repeat each number and letter correctly after hearing the examiner say them and then exhaling and slowly whispering a set of random numbers and letters, such as "5, B, 6." Normally the patient is asked to repeat each number and letter correctly after hearing the examiner say them.

The nurse is assessing the joints of a woman who has stated, "I have a long family history of arthritis, and my joints hurt." The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? (Select all that apply.) a. Symmetric joint involvement b. Asymmetric joint involvement c. Pain with motion of affected joints d. Affected joints may have heat, redness, and swelling e. Affected joints are swollen with hard, bony protuberances

ANS: B, C, E In osteoarthritis, asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. Affected joints have stiffness, swelling with hard bony protuberances, pain with motion, and limitation of motion. The other options reflect the signs of rheumatoid arthritis.

The nurse is examining a 62-year-old man and notes that he has bilateral gynecomastia. The nurse should explore his health history for which related conditions? (Select all that apply.) a. Malnutrition b. Liver disease c. Hyperthyroidism d. Type 2 diabetes mellitus e. History of alcohol abuse

ANS: B, C, E Gynecomastia occurs with Cushing syndrome, liver cirrhosis, adrenal disease, hyperthyroidism, and numerous drugs, such as alcohol and marijuana use, estrogen treatment for prostate cancer, antibiotics (metronidazole, isoniazid), digoxin, angiotensin-converting enzyme (ACE) inhibitors, diazepam, and tricyclic antidepressants.

During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? (Select all that apply.) a. Immediate treatment is needed. b. Virtually no symptoms are exhibited. c. Vision loss begins with peripheral vision. d. Patient may experience sensitivity to light, nausea, and halos around lights. e. Patient experiences tunnel vision in the late stages. f. Open-angle glaucoma causes sudden attacks of increased pressure that cause blurred vision.

ANS: B, C, E Open-angle glaucoma is the most common type of glaucoma; virtually no symptoms are exhibited. Vision loss begins with the peripheral vision, which often goes unnoticed because individuals learn to compensate intuitively by turning their heads. The other characteristics are those of closed angle glaucoma.

The nurse is assessing a 1-month-old infant at his well-baby checkup. Which assessment findings are appropriate for this age? (Select all that apply.) a. Absent tonic neck reflex b. Nonpalpable cervical lymph nodes c. Fontanels firm and slightly concave d. Head circumference equal to chest circumference e. Head circumference less than chest circumference f. Head circumference greater than chest circumference

ANS: B, C, F An infant's head circumference is larger than the chest circumference. At age 2 years, both measurements are the same. During childhood, the chest circumference grows to exceed the head circumference by 5 to 7 cm. The fontanels should feel firm and slightly concave in the infant, and they should close by age 9 months. The tonic neck reflex is present until between 3 and 4 months of age, and cervical lymph nodes are normally nonpalpable in an infant.

After completing an assessment of a 60-year-old white male with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. What should the nurse include in the instructions? a. Annual proctoscopy b. Annual PSA blood test c. Colonoscopy every 10 years d. Fecal occult blood test every 6 months

ANS: C Early detection measures for colon cancer include an annual fecal occult blood test after age 50 years (after age 45 for African Americans), a colonoscopy every 10 years after age 50, and a PSA blood test annually for men over 50 years old (45 years for African Americans).

The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? (Select all that apply). a.As the patient says a long "ee-ee-ee" sound, the examiner hears a long "aaaaaa" sound. b. As the patient says a long "ee-ee-ee" sound, the examiner also hears a long "ee-ee-ee" sound. c.As the patient repeatedly says "ninety-nine," the examiner clearly hears the words "ninety-nine." d. Voice sounds are faint, muffled, and almost inaudible when the patient whispers "one, two, three" in a very soft voice. e. When the patient speaks in a normal voice, the examiner can hear a sound but cannot exactly distinguish what is being said.

ANS: B, D, E As a patient repeatedly says "ninety-nine," normally the examiner hears voice sounds but cannot distinguish what is being said. If a clear "ninety-nine" is auscultated, then it could indicate increased lung density, which enhances the transmission of voice sounds, which is a measure of bronchophony. When a patient says a long "ee-ee-ee" sound, normally the examiner also hears a long "ee-ee-ee" sound through auscultation, which is a measure of egophony. If the examiner hears a long "aaaaaa" sound instead, this sound could indicate areas of consolidation or compression. With whispered pectoriloquy, as when a patient whispers a phrase such as "one-two-three," the normal response when auscultating voice sounds is to hear sounds that are faint, muffled, and almost inaudible. If the examiner clearly hears the whispered voice, as if the patient is speaking through the stethoscope, then consolidation of the lung fields may exist.

The nurse is preparing for a certification course on skin care and needs to be familiar with the various lesions that may be identified on assessment of the skin. Which of the following definitions are correct? (Select all that apply.) a. Papule: Hypertrophic scar. b. Vesicle: Known as a friction blister. c. Bulla: Elevated, circumscribed lesion filled with turbid fluid (pus). d. Nodule: Solid, elevated, and hard or soft growth that is larger than 1 cm. e. Petechiae: Tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color.

ANS: B, D, E Vesicles are also known as a friction blister; nodules are solid, elevated, and hard or soft growth that is larger than 1 cm.; and petechiae are tiny punctate hemorrhages, 1 to 3 mm, round and discrete, dark red, purple, or brown in color. A hypertrophic scar is a keloid, not a papule. A papule is solid and elevated but measures less than 1 cm. An elevated, circumscribed lesion filled with turbid fluid (pus) is a pustule, no a bulla. A bulla is larger than 1 cm and contains clear fluid.

During a digital examination of the rectum, the nurse notices that the patient has hard feces in the rectum. The patient complains of feeling "full," has a distended abdomen, and states that she has not had a bowel movement "for several days." The nurse suspects which condition? a. Rectal polyp b. Rectal abscess c. Fecal impaction d. Fecal incontinence

ANS: C A fecal impaction is a collection of hard, desiccated feces in the rectum. The obstruction often results from decreased bowel motility, in which more water is reabsorbed from the stool. Rectal polyps are protruding growths from the rectal mucous membrane. They are usually asymptomatic and are fairly common. A rectal abscess starts from an infected anorectal gland and the infection channels through the perianal tissues to form a fistula (connection between the infected gland and the outside perineum). Symptoms include persistent pain and swelling and may drain purulent or serosanguineous matter. Fecal incontinence is the leaking of solid or liquid stool involuntarily.

A teenage girl has arrived reporting pain in her left wrist. She was playing basketball when she fell and landed on her left hand. The nurse examines her hand. Which finding would lead the nurse to expect a fracture? a. Dull ache b. Deep pain in her wrist c. Sharp pain that increases with movement d. Dull throbbing pain that increases with rest

ANS: C A fracture causes sharp pain that increases with movement. The other types of pain do not occur with a fracture.

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. How should the nurse proceed? a. Document the presence of hepatomegaly. b. Ask additional health history questions regarding his alcohol intake. c. Consider this finding as normal, and proceed with the examination. d. Describe this dullness as indicative of an enlarged liver, and refer him to a physician.

ANS: C A liver span of 10.5 cm is the mean for males and 7 cm for females. Men and taller individuals are at the upper end of this range. Women and shorter individuals are at the lower end of this range. A liver span of 11 cm is within normal limits for this individual.

The nurse is providing patient education for a man who has been diagnosed with a rotator cuff injury. When explaining the structures involved in his injury, what should the nurse include? a. Nucleus pulposus b. Medial epicondyle c. Glenohumeral joint d. Articular processes

ANS: C A rotator cuff injury involves the glenohumeral joint, which is enclosed by a group of four powerful muscles and tendons that support and stabilize it. The other options are not in or near the rotator cuff or shoulder. The nucleus pulposus is located in the center of each intervertebral disk. The articular processes are projections in each vertebral disk that lock onto the next vertebra, thereby stabilizing the spinal column. The medial epicondyle is located at the elbow.

A 40-year-old black man is in the office for his annual physical examination. Which statement regarding the PSA blood test is true? a. Should be performed at age 50 years. b. Should be performed with this visit. c. Should be performed at age 45 years. d. Is only necessary if a family history of prostate cancer exists.

ANS: C According to the American Cancer Society, the PSA blood test should be performed annually for black men beginning at age 45 years and annually for all other men over age 50 years.

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. What does the nurse suspect? a. A fractured clavicle b. Possible deformity of the spine c. Weakness of the shoulder muscles d. This is a normal finding for an infant at this age

ANS: C An infant who starts to "slip" between the nurse's hands shows weakness of the shoulder muscles. An infant with normal muscle strength wedges securely between the nurse's hands. The other responses are not correct.

What usually occurs to the cells in the reproductive tract to cause the changes normally associated with menopause? a. Aging b. Becoming fibrous c. Estrogen dependent d. Able to respond to progesterone

ANS: C Because cells in the reproductive tract are estrogen dependent, decreased estrogen levels during menopause bring dramatic physical changes. The other options are not correct.

The physician comments that a patient has abdominal borborygmi. What is the best description of this term? a. Hypoactive bowel sounds b. A peritoneal friction rub c. Loud gurgling bowel sounds d. Loud continual humming bowel sounds

ANS: C Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling. Upon auscultation borborygmi sounds like loud gurgling bowel sounds.

A patient who has had rheumatoid arthritis for years comes to the clinic to ask about changes in her fingers. The nurse will assess for signs of what problems? a. Heberden nodes b. Bouchard nodules c. Swan-neck deformities d. Dupuytren contractures

ANS: C Changes in the fingers caused by chronic rheumatoid arthritis include swan-neck and boutonniere deformities. Heberden nodes and Bouchard nodules are associated with osteoarthritis. Dupuytren contractures of the digits occur because of chronic hyperplasia of the palmar fascia.

A patient states, "I can hear a crunching or grating sound when I kneel." She also states that "it is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problem? a. Bone spur b. Tendonitis c. Crepitation d. Fluid in the knee joint

ANS: C Crepitation is an audible and palpable crunching or grating that accompanies movement and occurs when articular surfaces in the joints are roughened, as with rheumatoid arthritis. A bone spur is a bony projection (osteophyte) that develops along a bone edge, usually where bones meet at a joint. They often do not cause pain, but when they do, it is usually pain with movement in the specific joint with the bone spur. Tendonitis is an inflammation of a tendon and produces a swelling and tenderness to that one spot in the joint and affects only certain planes of ROM, especially during active ROM. Excess fluid in the knee can cause swelling and difficulty moving the knee, but usually does not cause pain, although the disease process causing the fluid (e.g. rheumatoid arthritis, osteoarthritis) may cause pain. The symptoms this patient is experiencing (audible and palpable crunching when kneeling indicates crepitation. Crepitation is an audible and palpable crunching or grating that accompanies movement and occurs when articular surfaces in the joints are roughened, as with rheumatoid arthritis.

The 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. What type of hernia do these findings suggest? a. Scrotal b. Femoral c. Direct inguinal d. Indirect inguinal

ANS: C Direct inguinal hernias occur most often in men over the age of 40 years. It is an acquired weakness brought on by heavy lifting, obesity, chronic cough, or ascites. The direct inguinal hernia is usually a painless, round swelling close to the pubis in the area of the internal inguinal ring that is easily reduced when the individual is supine. A scrotal hernia appears with an enlarged testis that does not transilluminate and may reduce when supine. It may be painful with straining. Upon palpation a soft, mushy mass which is distinct from the normal testis can be palpated and the palpating fingers cannot get above the mass. A femoral hernia usually presents with pain that is constant and may be severe and become strangulated. With indirect inguinal hernias, pain occurs with straining and a soft swelling increases with increased intra-abdominal pressure, which may decrease when the patient lies down.

A woman states that 2 weeks ago she had a urinary tract infection that was treated with an antibiotic. What should the nurse ask the woman? a. "Have you had excessive vaginal bleeding?" b. "Have you experienced changes in your urination patterns?" c. "Do you have any unusual vaginal discharge or itching?" d. "Have you noticed any changes in your desire for intercourse?"

ANS: C Several medications may increase the risk for vaginitis. Broad-spectrum antibiotics alter the balance of normal flora, which may lead to the development of vaginitis. The other questions are not appropriate.

The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen test. What instructions should the nurse give the patient to perform this test? a. Dorsiflex the foot. b. Plantarflex the foot. c. Hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. d. Hyperextend the wrists with the palmar surface of both hands touching, and wait for 60 seconds.

ANS: C For the Phalen test, the nurse should ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. The Phalen test reproduces numbness and burning in a person with carpal tunnel syndrome. The other actions are not correct when testing for carpal tunnel syndrome.

A patient's annual physical examination reveals a lateral curvature of the thoracic and lumbar segments of his spine; however, this curvature disappears with forward bending. What is this abnormality called? a. Dislocated hip b. Structural scoliosis c. Functional scoliosis d. Herniated nucleus pulposus

ANS: C Functional scoliosis is flexible and apparent with standing but disappears with forward bending. Structural scoliosis is fixed; the curvature shows both when standing and when bending forward. These findings are not indicative of a herniated nucleus pulposus or dislocated hip.

A patient tells the nurse that, "All my life I've been called 'knock knees'." What is medical term for this condition? a. Genu varum b. Pes planus c. Genu valgum d. Metatarsus adductus

ANS: C Genu valgum is also known as knock knees and is present when more than 2.5 cm is between the medial malleoli when the knees are together. Pes planus, or flat foot, is pronation, or turning in, of the medial side of the foot. Metatarsus adductus is adduction, or turning inward, of the front half of the foot. The term used to describe knock knees is genu valgum. Genu valgum is present when more than 2.5 cm is between the medial malleoli when the knees are together

Which is an accessory glandular structure for the male genital organs? a. Testis b. Scrotum c. Prostate d. Vas deferens

ANS: C Glandular structures accessory to the male genital organs are the prostate, seminal vesicles, and bulbourethral glands.

A patient has had three pregnancies and two live births. How should the nurse record this information? a. G2; P2; AB1 b. G3; P2; AB0 c. G3; P2; AB1 d. G3; P3; AB1

ANS: C Gravida (G) is the number of pregnancies. Para (P) is the number of births. Abortions (AB) are interrupted pregnancies, including elective abortions and spontaneous miscarriages.

During the interview with a female patient, the nurse gathers data that indicates the patient is perimenopausal. Which of these statements made by this patient leads to this conclusion? a. "I have noticed that my muscles ache at night when I go to bed." b. "I will be very happy when I can stop worrying about having a period." c. "I have been noticing that I sweat a lot more than I used to, especially at night." d. "I have only been pregnant twice, but both times I had breast tenderness as my first symptom."

ANS: C Hormone shifts occur during the perimenopausal period, and associated symptoms of menopause may occur, such as hot flashes, night sweats, numbness and tingling, headache, palpitations, drenching sweats, mood swings, vaginal dryness, and itching. Muscle aches at night and breast tenderness as the first sign of pregnancy are not perimenopausal symptoms and the patient stating they will be happy to not have to worry about periods also does not indicate perimenopause.

The nurse is examining only the rectal area of a woman and should place the woman in what position? a. Prone b. Lithotomy c. Left lateral decubitus d. Bending over the table while standing

ANS: C The left lateral decubitus position is used when examining only the rectal area. If the genitalia are also going to be examined, the nurse should place the female patient in the lithotomy.

The nurse is describing how to perform a testicular self-examination to a patient. Which statement is most appropriate? a. "A good time to examine your testicles is just before you take a shower." b. "The testicle is egg shaped and movable. It feels firm and has a lumpy consistency." c. "If you notice an enlarged testicle or a painless lump, call your health care provider." d. "Perform a testicular examination at least once a week to detect the early stages of testicular cancer."

ANS: C If the patient notices a firm painless lump, a hard area, or an overall enlarged testicle, then he should call his health care provider for further evaluation. The testicle normally feels rubbery with a smooth surface. A good time to examine the testicles is during the shower or bath, when one's hands are warm and soapy and the scrotum is warm. Testicular self-examination should be performed once a month.

A 2-month-old uncircumcised infant has been brought to the clinic for a well-baby checkup. How would the nurse proceed with the genital examination? a. Elicit the cremasteric reflex. b. The glans is assessed for redness or lesions. c. Retracting the foreskin should be avoided until the infant is 3 months old. d. Any dirt or smegma that has collected under the foreskin should be noted.

ANS: C If uncircumcised, then the foreskin is normally tight during the first 3 months and should not be retracted because of the risk for tearing the membrane attaching the foreskin to the shaft. The cremasteric reflex (retracting the scrotal contents) is strong in infants and care should be taken not to elicit it. Since retracting the foreskin on an uncircumcised infant is not recommended until the infant is 3 months old, the glans and dirt and smegma under the foreskin cannot be assessed.

When performing a health history, the nurse would note immunizations under which category? a. Family history b. Personal history c. Past medical history d. History of present illness

ANS: C Immunizations would be included in the past medical or health history. Immunizations would not be included in a family medical history, the personal/social history, or the history of present illness unless there was a health issue that included this type of medication administration.

What structure secretes a thin, milky alkaline fluid to enhance the viability of sperm? a. Cowper gland b. Median sulcus c. Prostate gland d. Bulbourethral gland

ANS: C In men, the prostate gland secretes a thin milky alkaline fluid that enhances sperm viability. The Cowper glands (also known as bulbourethral glands) secrete a clear, viscid mucus. The median sulcus is a groove that divides the lobes of the prostate gland and does not secrete fluid.

During an examination of an aging man, the nurse recognizes that which finding is an expected or normal change? a. Enlarged scrotal sac b. Increased pubic hair c. Decreased penis size d. Increased rugae over the scrotum

ANS: C In the aging man, the amount of pubic hair decreases, the penis size decreases, and the rugae over the scrotal sac decreases. The scrotal sac does not enlarge.

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 states pain going down his buttock into his leg. What does the nurse suspect? a. Scoliosis b. Meniscus tear c. Herniated nucleus pulposus d. Spasm of paravertebral muscles

ANS: C Lateral tilting and sciatic pain with straight leg raising are findings that occur with a herniated nucleus pulposus. The other options are not correct.

A 2-year-old boy has been diagnosed with physiologic cryptorchidism. Considering this diagnosis, what will the nurse most likely observe during the assessment? a. Testes that are hard and painful to palpation b. Atrophic scrotum and a bilateral absence of the testis c. Absence of the testis in the scrotum, but the testis can be milked down d. Testes that migrate into the abdomen when the child squats or sits cross-legged

ANS: C Migratory testes (physiologic cryptorchidism) are common because of the strength of the cremasteric reflex and the small mass of the prepubertal testes. The affected side has a normally developed scrotum and the testis can be milked down. The other responses are not correct.

The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm? a. A bruit is absent. b. Femoral pulses are increased. c. A pulsating mass is usually present. d. Most are located below the umbilicus

ANS: C Most aortic aneurysms are palpable during routine examination and feel like a pulsating mass. A bruit will be audible, and femoral pulses are present but decreased. Such aneurysms are located in the upper abdomen just to the left of midline.

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. What is this movement called? a. Flexion b. Abduction c. Adduction d. Extension

ANS: C Moving a limb toward the midline of the body is called adduction; moving a limb away from the midline of the body is called abduction. Flexion is bending a limb at a joint; and extension is straightening a limb at a joint.

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? a. Nabothian cysts are present. b. The cervical os is a horizontal slit. c. The cervical surface is granular and red. d. Stringy and opaque secretions are present.

ANS: C Normal findings: Nabothian cysts may be present on the cervix after childbirth. The cervical os is a horizontal, irregular slit in the parous woman. Secretions vary according to the day of the menstrual cycle, and may be clear and thin or thick, opaque, and stringy. The surface is normally smooth, but cervical eversion, or ectropion, may occur where the endocervical canal is rolled out. Abnormal finding: The cervical surface should not be reddened or granular, which may indicate a lesion.

When the nurse is interviewing a preadolescent girl, which opening question would be least threatening? a. "Do you have any questions about growing up?" b. "What has your mother told you about growing up?" c. "When did you notice that your body was changing?" d. "I remember being very scared when I got my period. How do you think you'll feel?"

ANS: C Open-ended questions such as, "When did you...?" rather than "Do you...?" should be asked. Open-ended questions are less threatening because they imply that the topic is normal and unexceptional

A 14-year-old boy who has been diagnosed with Osgood-Schlatter disease reports painful swelling just below the knee for the past 5 months. Which response by the nurse is appropriate? a. "If these symptoms persist, you may need arthroscopic surgery." b. "You are experiencing degeneration of your knee, which may not resolve." c. "Your disease is due to repeated stress on the patellar tendon. It is usually self-limited, and your symptoms should resolve with rest." d. "Increasing your activity and performing knee-strengthening exercises will help decrease the inflammation and maintain mobility in the knee."

ANS: C Osgood-Schlatter disease is a painful swelling of the tibial tubercle just below the knee and most likely due to repeated stress on the patellar tendon. It is usually self-limited, occurring during rapid growth and most often in boys. The symptoms resolve with rest. The other responses are not appropriate.

During a bimanual examination, the nurse detects a solid tumor on the ovary that is heavy and fixed, with a poorly defined mass. What does this finding suggest? a. Ovarian cyst b. Endometriosis c. Ovarian cancer d. Ectopic pregnancy

ANS: C Ovarian tumors that are solid, heavy, and fixed, with poorly defined mass are suggestive of malignancy. Benign masses may feel mobile and solid. An ovarian cyst may feel smooth, round, fluctuant, mobile, and nontender. With an ectopic pregnancy, the examiner may feel a palpable, tender pelvic mass that is solid, mobile, and unilateral. Endometriosis may have masses (in various locations in the pelvic area) that are small, firm, nodular, and tender to palpation, with enlarged ovaries.

During a health history, the patient tells the nurse, "I have pain all the time in my stomach. It's 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? a. Appendicitis b. Gastric ulcer c. Duodenal ulcer d. Cholecystitis

ANS: C Pain associated with duodenal ulcers occurs 2 to 3 hours after a meal; it may be relieved by eating more food. Chronic pain associated with gastric ulcers usually occurs on an empty stomach. Severe, acute pain would occur with appendicitis and cholecystitis.

The nurse is performing an abdominal assessment. What types of percussion notes can be heard during abdominal assessment? a. Flatness, resonance, and dullness b. Resonance, dullness, and tympany c. Tympany, hyperresonance, and dullness d. Resonance, hyperresonance, and flatness

ANS: C Percussion notes normally heard during the abdominal assessment may include tympany, which should predominate because air in the intestines rises to the surface when the person is supine; hyperresonance, which may be present with gaseous distention; and dullness, which may be found over a distended bladder, adipose tissue, fluid, or a mass. Flatness is not a term used to describe a percussed sound. Resonance is a low-pitched, clear, hollow sound that predominates in healthy lung tissue but not in the abdomen.

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. Assessing bone density annually b. Taking medications to prevent osteoporosis c. Performing physical activity, such as fast walking d. Taking 800 mg calcium and 200 IU vitamin D supplements dail

ANS: C Physical activity, such as fast walking, delays or prevents bone loss in perimenopausal women. The faster the pace of walking, the higher the preventive effect is on the risk for hip fracture. The other options are not correct. Annually assessing bone density does not prevent or delay bone loss, it just monitors it. There are no medications to prevent osteoporosis, but to treat it. Taking 800 mg calcium and 200 IU vitamin D supplements daily is not enough to meet the recommended daily doses for a perimenopausal woman. The best way to prevent or delay bone loss is exercise.

During a neonatal examination, the nurse notices that the newborn infant has six toes. How should the nurse document this finding? a. Unidactyly b. Syndactyly c. Polydactyly d. Multidactyly

ANS: C Polydactyly is the presence of extra fingers or toes. Syndactyly is webbing between adjacent fingers or toes. The other terms are not correct

During the interview, a patient reveals that she has some vaginal discharge. She is worried that it may be a sexually transmitted infection. What would be the most appropriate response by the nurse? a. "Oh, don't worry. Some cyclic vaginal discharge is normal." b. "Have you been engaging in unprotected sexual intercourse?" c. "I'd like more information about the discharge. What color is it?" d. "Have you had any urinary incontinence associated with the discharge?"

ANS: C Questions that help the patient reveal more information about her symptoms should be asked in a nonthreatening manner. Asking about the amount, color, and odor of the vaginal discharge provides the opportunity for further assessment. Normal vaginal discharge is small, clear or cloudy, and always nonirritating.

A patient is reporting 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

ANS: C Rheumatoid arthritis pain is worse in the morning when a person arises and then improves with movement. Movement increases most other types of joint pain.

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. What does the nurse suspect? a. Crepitation b. Rheumatoid arthritis c. Rotator cuff lesions d. A dislocated shoulder

ANS: C Rotator cuff lesions may limit range of motion and cause pain and muscle spasms during abduction, whereas forward flexion remains fairly normal. Crepitation is an audible and palpable crunching or grating that accompanies movement and occurs when articular surfaces in the joints are roughened, as with rheumatoid arthritis. Rheumatoid arthritis is a chronic inflammatory pain condition in the joints. Joint involvement is symmetric and bilateral, with heat, redness, swelling, and painful motion of affected joints. A dislocated shoulder shows an obvious deformity and severe pain with movement. Crepitation is an audible and palpable crunching or grating that accompanies movement and occurs when articular surfaces in the joints are roughened, as with rheumatoid arthritis. Rheumatoid arthritis is a chronic inflammatory pain condition in the joints. Joint involvement is symmetric and bilateral (not just one side as in this patient), with heat, redness, swelling, and painful motion of affected joints. A dislocated shoulder shows an obvious deformity and severe pain with movement (not just with certain movements as with this patient). The symptoms this patient is experiencing are that of rotator cuff lesions.

A 35-year-old recent immigrant is being seen in the clinic for symptoms of a cough associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. Based on these findings, what is the most likely cause? a. Pneumonia b. Bronchitis c. Tuberculosis d. Pulmonary edema

ANS: C Sputum is not diagnostic alone, but some conditions have characteristic sputum production. Tuberculosis often produces rust-colored sputum in addition to other symptoms of night sweats and low-grade afternoon fevers. Pneumonia typically presents with yellow-green sputum and pink, frothy sputum is characteristic of pulmonary edema. Bronchitis alone usually has a dry, not productive, cough.

The nurse notices that a patient has had a pale, yellow, greasy stool, or steatorrhea. What is the cause of this finding? a. Occult bleeding b. Absent bile pigment c. Increased fat content d. Ingestion of bismuth preparations

ANS: C Steatorrhea (pale, yellow, greasy stool) is caused by increased fat content in the stools, as in malabsorption syndrome. Occult bleeding and ingestion of bismuth products cause a black stool, and absent bile pigment causes a gray-tan stool.

The nurse notices that a patient has had a black, tarry stool. What should the nurse recognize may cause this finding? a. Gallbladder disease b. Overuse of laxatives c. Gastrointestinal bleeding d. Localized bleeding around the anus

ANS: C Stools may be black and tarry (melena) as a result of bleeding in the upper gastrointestinal tract. Red blood in stools occurs with localized bleeding in the rectal or anal areas.

When the nurse is performing a testicular examination on a 25-year-old man, which finding is considered normal? a. Nontender subcutaneous plaques b. Scrotal area that is dry, scaly, and nodular c. Testes that feel oval and movable and are slightly sensitive to compression d. Single, hard, circumscribed, movable mass, less than 1 cm under the surface of the testes

ANS: C Testes normally feel oval, firm and rubbery, smooth, and bilaterally equal and are freely movable and slightly tender to moderate pressure. The scrotal skin should not be dry, scaly, or nodular or contain subcutaneous plaques. Any mass would be an abnormal finding.

During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse recognizes this finding could indicate a problem with what structure? a. Spleen b. Sigmoid c. Appendix d. Gallbladder

ANS: C The appendix is located in the right lower quadrant. When the iliopsoas muscle is inflamed, which occurs with an inflamed or perforated appendix, pain is felt in the right lower quadrant. The spleen is in the left upper quadrant; the sigmoid is in the left lower quadrant; and the gallbladder is in the right upper quadrant.

What is the articulation of the mandible and the temporal bone called? a. Intervertebral foramen b. Condyle of the mandible c. Temporomandibular joint d. Zygomatic arch of the temporal bone

ANS: C The articulation of the mandible and the temporal bone is the temporomandibular joint. The other responses are not correct.

During an examination, how would the nurse expect the cervical os of a woman who has never had children to appear? a. Everted b. Stellate c. Small and round d. As a horizontal irregular slit

ANS: C The cervical os in a nulliparous woman is small and round. In the parous woman, it is a horizontal, irregular slit that also may show healed lacerations on the sides. It does not appear stellate (resembling a star shape) or everted (rolled out).

A 62-year-old man is experiencing fever, chills, malaise, urinary frequency, and urgency. He also reports urethral discharge and a dull aching pain in the perineal and rectal area. These symptoms are most consistent with which condition? a. BPH b. Polyps c. Prostatitis d. Carcinoma of the prostate

ANS: C The common presenting symptoms of prostatitis are fever, chills, malaise, and urinary frequency and urgency. The individual may also have dysuria, urethral discharge, and a dull aching pain in the perineal and rectal area. The signs and symptoms of benign prostatic hypertrophy (BPH) include urinary frequency, urgency, hesitancy, straining to urinate, weak stream, intermittent stream, sensation of incomplete emptying, and nocturia. The prostate surface feels smooth, rubbery, or firm (like the consistency of the nose), with the median sulcus obliterated. A rectal polyp is a protruding growth from the rectal mucous membrane and is fairly common. Rectal polyps are difficult to palpate and are found on examination with a scope. The signs and symptoms of carcinoma of the prostate include frequency, nocturia, hematuria, weak stream, hesitancy, pain or burning on urination, and continuous pain in lower back, pelvis, and thighs. It often starts as a single hard nodule on the posterior surface of the prostate and as it invades normal tissue, multiple hard nodules appear, or the entire gland feels stone-hard and fixed and the median sulcus obliterated.

The nurse is preparing for an internal genitalia examination of a woman. Which order of the examination is correct? a. Bimanual, speculum, and rectovaginal b. Speculum, rectovaginal, and bimanual c. Speculum, bimanual, and rectovaginal d. Rectovaginal, bimanual, and speculum

ANS: C The correct sequence is speculum examination, then bimanual examination after removing the speculum, and then rectovaginal examination. The examiner should change gloves before performing the rectovaginal examination to avoid spreading any possible infection.

The nurse is examining the glans and knows which finding is normal for this area? a. Hair is without pest inhabitants. b. The skin is wrinkled and without lesions. c. Smegma may be present under the foreskin of an uncircumcised male. d. The meatus may have a slight discharge when the glans is compressed.

ANS: C The glans looks smooth and without lesions and does not have hair. The meatus should not have any discharge when the glans is compressed. Some cheesy smegma may have collected under the foreskin of an uncircumcised male.

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. What is the nurse palpating? a. Iliac crest b. Ischial tuberosity c. Greater trochanter d. Gluteus maximus muscle

ANS: C The greater trochanter of the femur is palpated when the person is standing, and it appears as a flat depression on the upper lateral side of the thigh. The iliac crest is the upper part of the hip bone; the ischial tuberosity lies under the gluteus maximus muscle and is palpable when the hip is flexed; and the gluteus muscle is part of the buttocks. The iliac crest is the upper part of the hip bone (not lateral); the ischial tuberosity lies under the gluteus maximus muscle and is palpable when the hip is flexed (not standing); and the gluteus muscle is part of the buttocks. The flat depression in the upper lateral side of the thigh that the nurse is palpating is the greater trochanter.

An 18-year-old patient is having her first pelvic examination. Which action by the nurse is appropriate? a. Inviting her mother to be present during the examination. b. Avoiding the lithotomy position for this first time because it can be uncomfortable and embarrassing. c. Raising the head of the examination table and giving her a mirror so that she can view the examination. d. Fully draping her, leaving the drape between her legs elevated to avoid embarrassing her with eye contact.

ANS: C The techniques of the educational or mirror pelvic examination should be used. This is a routine examination with some modifications in attitude, position, and communication. First, the woman is considered an active participant, one who is interested in learning and in sharing decisions about her own health care. The woman props herself up on one elbow, or the head of the table is raised. Her other hand holds a mirror between her legs, above the examiner's hands. The young woman can see all that the examiner is doing and has a full view of her genitalia. The mirror works well for teaching normal anatomy and its relationship to sexual behavior. The examiner can ask her if she would like to have a family member, friend, or chaperone present for the examination. The drape should be pushed down between the patient's legs so that the nurse can see her face.

To palpate the temporomandibular joint, where should the nurse place his or her fingers? a. The depression inferior to the tragus of the ear b. The depression superior to the tragus of the ear c. The depression anterior to the tragus of the ear d. The depression posterior to the tragus of the ear

ANS: C The temporomandibular joint can be felt in the depression anterior to the tragus of the ear. The other locations are not correct.

During an assessment, the nurse notices that a patient's 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? a. Constipation b. Abdominal tumor c. Umbilical hernia d. Intra-abdominal bleeding

ANS: C The umbilicus is normally midline and inverted with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect.

The nurse is conducting a hearing screening. Which technique will the nurse use during the whisper test? a. The nurse pulls the pinna up and back. b. The nurse covers their lips to obscure them from view. c. The nurse asks the patient to repeat 3 letters or numbers. d. The nurse stands 4 feet away from the patient and whispers three different words.

ANS: C To assess hearing using the whisper test, the nurse should stand at arm's length (2 feet) behind the person and test one ear at a time while masking hearing in the other ear. This is done by having the patient place one finger on the tragus and pushing it in and out of the auditory meatus. While the patient is doing this, the nurse should move their head about 2 feet away from the person's ear and slowly whisper a set of 3 random numbers and letters. The nurse does not need to pull the pinna up and back or cover their lips as they should be standing behind the patient's field of vision. The nurse should only stand 1 to 2 feet away, not 4 feet.

During an assessment of the newborn, the nurse expects to see which finding when the anal area is slightly stroked? a. Jerking of the legs b. Flexion of the knees c. Quick contraction of the sphincter d. Relaxation of the external sphincter

ANS: C To assess sphincter tone, the nurse should check the anal reflex by gently stroking the anal area and noticing a quick contraction of the sphincter. The other responses are not correct.

The nurse is examining a 2-month-old infant and notices asymmetry of the infant's gluteal folds. The nurse should assess for other signs of what disorder? a. Spina bifida b. Down syndrome c. Hip dislocation d. Fractured clavicle

ANS: C Unequal gluteal folds may accompany hip dislocation after 2 to 3 months of age, but some asymmetry may occur in healthy children. Further assessment is needed. The other responses are not correct.

The nurse is assessing a patient in the hospital who has received numerous antibiotics for a lung infection and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? a. "We will need to get a biopsy to determine the cause." b. "This is an overgrowth of hair and will go away in a few days." c. "Black, hairy tongue is a fungal infection caused by all the antibiotics you have received." d. "This is probably caused by the same bacteria you had in your lungs."

ANS: C A black, hairy tongue is not really hair but the elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue. It occurs after the use of antibiotics, which inhibit normal bacteria and allow a proliferation of fungus. It is not caused by the same bacteria as his lung infection but occurred after the use of antibiotics, which inhibit normal bacteria and allow a proliferation of fungus. There is no need to get a biopsy.

The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. The mother tells the nurse that she noticed the lump approximately 8 hours after her baby's birth and that it seems to be getting bigger. What is a possible explanation for this? a. Hydrocephalus b. Craniosynostosis c. Cephalhematoma d. Caput succedaneum

ANS: C A cephalhematoma is a subperiosteal hemorrhage that is the result of birth trauma. It is soft, fluctuant, and well defined over one cranial bone. It appears several hours after birth and gradually increases in size. Hydrocephalus is enlarged head due to increased cerebral spinal fluid. Craniosynostosis is a severe deformity of the head with marked asymmetry caused by premature closure of the sutures. Caput succedaneum is edematous swelling and ecchymosis of the presenting part of the head caused by birth trauma that usually causes the skull to look markedly asymmetric.

A patient comes in for a physical examination in late July and states that she was "freezing to death" while waiting for her examination. The nurse notes that her skin is pale and cool. What should the nurse understand is the likely cause? a. Venous pooling b. Peripheral vasodilation c. Peripheral vasoconstriction d. Decreased arterial perfusion

ANS: C A chilly or air-conditioned environment causes vasoconstriction, which results in false pallor and coolness. Venous pooling and peripheral vasodilation do not cause pale or cool skin. Although decreased arterial perfusion can cause pale, cool skin, it is usually in the distal lower extremities and not generalized feeling cold.

A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her? a. Diets low in protein and high in carbohydrates may cause enhanced facial bones. b. Bones can become more noticeable if the person does not use a dermatologically approved moisturizer. c. More noticeable facial bones are probably due to a combination of factors r/t aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin. d. Facial skin becomes more elastic with age. This increased elasticity causes the skin to be more taught, drawing attention to the facial bones.

ANS: C A low protein, high carbohydrate diet do not enhance facial bones; although aging adults have diminished moisture in their skin, the bones do not become more noticeable; and the elasticity of the skin decreases, not increases, with aging. The facial bones and orbits appear more prominent in the aging adult and the facial skin sags, which is attributable to decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin.

The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test? a. To measure the rate of lymphatic drainage b. To evaluate the adequacy of capillary patency before venous blood draws c. To evaluate the adequacy of collateral circulation before cannulating the radial artery d. To evaluate the venous refill rate that occurs after the ulnar and radial arteries are temporarily occluded

ANS: C A modified Allen test is used to evaluate the adequacy of collateral circulation before the radial artery is cannulated. The other responses are not reasons for a modified Allen test.

During cardiac auscultation, the nurse hears a sound immediately occurring after the S2 at the second left intercostal space. What should the nurse do to further assess this sound? a. Ask the patient to hold his or her breath while the nurse listens again. b. No further assessment is needed because the nurse knows this sound is an S3. c. Watch the patient's respirations while listening for the effect on the sound. d. Have the patient turn to the left side while the nurse listens with the bell of the stethoscope.

ANS: C A split S2 is a normal phenomenon that occurs toward the end of inspiration in some people. A split S2 is heard only in the pulmonic valve area, the second left interspace. When the split S2 is first heard, the nurse should not be tempted to ask the person to hold his or her breath so that the nurse can concentrate on the sounds. Breath holding will only equalize ejection times in the right and left sides of the heart and cause the split to go away. Rather, the nurse should concentrate on the split while watching the person's chest rise up and down with breathing.

The nurse is describing a weak, thready pulse on the documentation flow sheet. Which statement is correct? a. "Easily palpable; pounds under the fingertips." b. "Greater than normal force that suddenly collapses." c. "Hard to palpate, may fade in and out, and is easily obliterated by pressure." d. "Rhythm is regular, but force varies with alternating beats of large and small amplitude."

ANS: C A weak, thready pulse is hard to palpate (not easy), may fade in and out, and is easily obliterated by pressure. It is associated with decreased cardiac output and peripheral arterial disease.

While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. What do these findings indicate? a. Cholesteatoma b. A fungal infection c. An acute otitis media d. A perforation of the eardrum

ANS: C Absent or distorted light reflex and a bright red color of the eardrum are indicative of acute otitis media. Cholesteatoma is an overgrowth of epidermal tissue in the middle ear or temporal bone that has a pearly white, cheesy appearance (not bright red). A fungal infection manifests as a colony of black or white dots on the eardrum or canal walls (not bright red). A perforated eardrum usually appears as a round or oval darkened area on the drum. This patient's absent light reflex and bright red color indicate acute otitis media.

During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. How do acutely infected lymph nodes typically appear? a. Clumped b. Unilateral c. Firm but freely movable d. Soft and nontender

ANS: C Acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely movable. Unilaterally enlarged nodes that are firm and nontender may indicate cancer.

During an examination of a 7-year-old girl, the nurse notices that the girl is showing breast budding. What should the nurse do next? a. Nothing; breast budding is a normal finding. b. Ask the young girl if her periods have started. c. Assess the girl's weight and body mass index (BMI). d. Ask the girl's mother at what age she started to develop breasts.

ANS: C Adolescent breast development usually begins between 8 and 10 years of age. However, research has shown that girls with overweight or obese BMI levels have a higher occurrence of early onset of breast budding (before age 8 years for black girls and age 10 years for white girls) and early menarche. Thus, the nurse should assess the patient's BMI. This is not a normal finding. Adolescent breast development usually begins between 8 and 10 years of age and precedes menarche by about 2 years. However, research has shown that girls with overweight or obese BMI levels have a higher occurrence of early onset of breast budding (before age 8 years for black girls and age 10 years for white girls) and early menarche. Thus, the nurse should assess the patient's BMI rather than asking her when she started developing breasts or if she has started having periods

A patient with a middle ear infection asks the nurse, "What does the middle ear do?" Which is the best response by the nurse? a. It helps maintain balance. b. It interprets sounds as they enter the ear. c. It conducts vibrations of sounds to the inner ear. d. It increases the amplitude of sound for the inner ear to function.

ANS: C Among its other functions, the middle ear conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear. The other responses are not functions of the middle ear. The inner ear, not the middle ear, helps with balance. Sound is interpreted in the cerebral cortex, not the middle ear. The middle ear reduces the amplitude of loud sounds, not increase them, to protect the inner year. The functions of the middle ear are to conduct sound vibrations from the outer ear to the central hearing apparatus in the inner ear; protect the inner ear by reducing the amplitude of loud sounds; and allow equalization of air pressure on each side of the tympanic membrane via the eustachian tubes so that the membrane does not rupture.

When performing a cardiovascular assessment, what should the nurse understand about an S4 heart sound? a. Heard at the onset of atrial diastole b. Often a normal finding in the older adult c. Heard at the end of ventricular diastole d. Heard best over the second left intercostal space with the individual sitting upright

ANS: C An S4 heart sound is heard at the end of diastole when the atria contract (atrial systole) and when the ventricles are resistant to filling. The S4 occurs just before the S1. It is heard best at the apex with the patient in the left lateral position.

The nurse is performing an assessment on a 65-year-old man. He reports a crusty nodule behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. Based on these findings, what does the nurse suspect? a. Most likely a keloid b. Probably a benign sebaceous cyst c. Could be a potential carcinoma, and the patient should be referred for a biopsy d. A tophus, which is common in the older adult and is a sign of gout

ANS: C An ulcerated crusted nodule with an indurated base that fails to heal is characteristic of a carcinoma. These lesions fail to heal and intermittently bleed. Individuals with such symptoms should be referred for a biopsy. The other responses are not correct. A keloid is an overgrowth of scar tissue which in the ear is common at lobule at the site of a pierced ear. A sebaceous cyst is a nodule filled with waxy sebaceous material, is painful if it becomes infected, and is often multiple of them. A tophus is a hard uric acid deposit under the skin. The ulcerated crusted nodule with an indurated base that fails to heal that this patient has is characteristic of a carcinoma

A 13-year-old girl is interested in obtaining information about the cause of her acne. What should the nurse include in the information about acne? a. It is contagious. b. It has no known cause. c. It is caused by increased sebum production. d. It has been found to be r/t poor hygiene.

ANS: C Approximately 90% of males and 80% of females will develop acne; causes are increased sebum production and epithelial cells that do not desquamate normally. Acne is not contagious or r/t poor hygiene. The cause is not unknown, but is caused by increased sebum production and epithelial cells that do not desquamate normally.

During a routine office visit, a patient takes off his shoes and shows the nurse "this awful sore that won't heal." On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. Based on these findings, what does the nurse suspect? a. Varicosities b. Venous stasis ulcer c. Arterial ischemic ulcer d. Deep vein thrombophlebitis

ANS: C Arterial ischemic ulcers occur at the toes, metatarsal heads, heels, and lateral ankle and are characterized by a pale ischemic base, well-defined edges, and no bleeding. Varicosities, or varicose veins, are caused by incompetent distant valves in the veins which produce dilated, tortuous veins. Venous (stasis) ulcers occur at the medial malleolus (not the great toe) and are characterized by bleeding and uneven edges. Deep vein thrombosis is the development of a thrombus, or clot, in a deep vein, most commonly in the legs, that may present with swelling, pain, redness, and warmth. The signs and symptoms this patient has are characteristic of an arterial ischemic ulcer

During an assessment of a 20-year-old Asian patient, the nurse notices that he has dry, flaky, white cerumen in his canal. What is the significance of this finding? a. It represents poor hygiene. b. It is probably the result of lesions from eczema in his ear. c. It is a normal finding, and no further follow-up is necessary. d. It could be indicative of change in cilia; the nurse should assess for hearing loss.

ANS: C Asians and American Indians are more likely to have dry cerumen, which appears white and flaky, whereas blacks and whites usually have wet cerumen that appears honey-brown. Dry, flaky cerumen in an Asian patient is not a result of poor hygiene, lesions from eczema, or change in cilia.

A 52-year-old woman has a papule on her nose that has rounded, pearly borders and a central red ulcer. She said she first noticed it several months ago and that it has slowly grown larger. The nurse suspects which condition? a. Acne b. Melanoma c. Basal cell carcinoma d. Squamous cell carcinoma

ANS: C Basal cell carcinoma usually starts as a skin-colored papule that develops rounded, pearly borders with a central red ulcer. It is the most common form of skin cancer and grows slowly. Acne presents as pustules (turbid fluid filled cavities) that are circumscribed and elevated. Melanoma usually presents as brown (but can be other colors) lesions with irregular or notched borders and may have a flaking, scaling, or oozing texture. Squamous cell carcinoma present as an erythematous scaly patch with sharp margins, 1 cm or more. This description does not fit acne lesions. (See Table 12-11 for descriptions of melanoma and squamous cell carcinoma.)

A 65-year-old patient with a history of heart failure comes to the clinic stating "I keep waking up from sleep with shortness of breath." Which action by the nurse is most appropriate? a. Obtain a detailed health history of the patient's allergies and a history of asthma. b. Tell the patient to sleep on his or her right side to facilitate ease of respirations. c. Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. d. Assure the patient that paroxysmal nocturnal dyspnea is normal and will probably resolve within the next week.

ANS: C Being awakened from sleep with shortness of breath is a symptom of paroxysmal nocturnal dyspnea. The nurse should assess for other signs and symptoms of paroxysmal nocturnal dyspnea. Paroxysmal nocturnal dyspnea is usually relieved by sitting upright.

A woman is in the family planning clinic seeking birth control information. She states that her breasts "change all month long" and that she is worried that this is unusual. What is the best response by the nurse? a. "Continual changes in your breasts are unusual. The breasts of nonpregnant women usually stay pretty much the same all month long." b. "Breast changes in response to stress are very common and you should assess your life for stressful events." c. "Because of the changing hormones during the monthly menstrual cycle, cyclic breast changes are common." d. "Breast changes normally occur only during pregnancy. You should get a pregnancy test done as soon as possible."

ANS: C Breasts of the nonpregnant woman change with the ebb and flow of hormones during the monthly menstrual cycle. During the 3 to 4 days before menstruation, the breasts feel full, tight, heavy, and occasionally sore. The breast volume is smallest on days 4 to 7 of the menstrual cycle.

During an examination of a 3-year-old child, the nurse notices a bruit over the left temporal area. What should the nurse do? a. Check for the bruit again in 1 hour. b. Stop the examination, and notify the physician. c. Continue the examination because a bruit is a normal finding for this age. d. Notify the parents that a bruit has been detected in their child and requires further evaluation.

ANS: C Bruits are common in the skull in children under 4 or 5 years of age and in children with anemia. They are systolic or continuous and are heard over the temporal area. There is no need to stop the examination and notify the physician, check the bruit in an hour, or further evaluation as bruits are common in the skull in children under 4 or 5 years of age and in children with anemia. They are systolic or continuous and are heard over the temporal area.

A 42-year-old woman states that she has noticed several small, slightly raised, bright red dots on her chest. On examination, the nurse confirms the presence of these "dots." How should the nurse document these findings? a. Anasarca b. Scleroderma c. Senile angiomas d. Latent myeloma

ANS: C Cherry (senile) angiomas are small, smooth, slightly raised bright red dots that commonly appear on the trunk of adults over 30 years old. Anasarca is bilateral or generalized edema all over the body. Scleroderma is tight, "hard" skin that causes problems with mobility. Myeloma is cancer of plasma cells. The small, smooth, slightly raised bright red dots this patient has are cherry (senile) angiomas. These commonly appear on the trunk of adults over 30 years old.

The nurse is assessing a 3-year-old for "drainage from the nose." On assessment, a purulent drainage that has a very foul odor is noted from the left naris and no drainage is observed from the right naris. The child is afebrile with no other symptoms. What should the nurse do next? a. Refer to the physician for an antibiotic order. b. Have the mother bring the child back in 1 week. c. Perform an otoscopic examination of the left nares. d. Tell the mother that this drainage is normal for a child of this age.

ANS: C Children are prone to put an object up the nose, producing unilateral purulent drainage with a foul odor. Because some risk for aspiration exists, removal should be prompt.

During an assessment of a 26-year-old for "a spot on my lip I think is cancer," the clinic nurse notices a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What is the most appropriate action by the nurse? a. Tell the patient she needs to see a skin specialist. b. Discuss the benefits of having a biopsy performed on any unusual lesion. c. Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and that they will heal in 4 to 10 days. d. Tell the patient that these vesicles are most likely the result of a riboflavin deficiency and discuss nutrition.

ANS: C Cold sores are groups of clear vesicles with a surrounding erythematous base. These evolve into pustules or crusts and heal in 4 to 10 days. The most likely site is the lip-skin junction. Infection often recurs in the same site. Recurrent herpes infections may be precipitated by sunlight, fever, colds, or allergy.

Immediately after birth, the nurse is unable to suction the nares of a crying newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next? a. Attempt to suction again with a bulb syringe. b. Wait a few minutes, and try again once the infant stops crying. c. Recognize that this situation requires immediate intervention. d. Contact the physician to schedule an appointment for the infant at his or her next hospital visit.

ANS: C Determining the patency of the nares in the immediate newborn period is essential because most newborns are obligate nose breathers. Nares blocked with amniotic fluid are gently suctioned with a bulb syringe. If obstruction is suspected, then a small lumen (5 to 10 Fr) catheter is passed down each naris to confirm patency. The inability to pass a catheter through the nasal cavity indicates choanal atresia, which requires immediate intervention.

A woman in her 26th week of pregnancy states that she is "not really short of breath" but feels that she is aware of her breathing and the need to breathe. What is the best reply by the nurse? a. "The diaphragm becomes fixed during pregnancy, making it difficult to take in a deep breath." b. "The increase in estrogen levels during pregnancy often causes a decrease in the diameter of the rib cage and makes it difficult to breathe." c. "What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong." d. "This increased awareness of the need to breathe is normal as the fetus grows because of the increased oxygen demand on the mother's body, which results in an increased respiratory rate."

ANS: C During pregnancy, the woman may develop an increased awareness of the need to breathe. Some women may interpret this as dyspnea, although structurally nothing is wrong. Increases in estrogen relax the chest cage ligaments, causing an increase in the transverse diameter. Although the growing fetus increases the oxygen demand on the mother's body, this increased demand is easily met by the increasing tidal volume (deeper breathing). Little change occurs in the respiratory rate.

During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate? a. Normal nipple inversion is usually bilateral. b. Unilateral inversion of a nipple is always a serious sign. c. Whether the inversion is a recent change should be determined. d. Nipple inversion is not significant unless accompanied by an underlying palpable mass

ANS: C The nurse should distinguish between a recently retracted nipple from one that has been inverted for many years or since puberty. Normal nipple inversion may be unilateral or bilateral and usually can be pulled out; that is, if it is not fixed. Recent nipple retraction signifies acquired disease (see Table 17-3).

The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement is true regarding this examination? a. An injected membrane may indicate an infection. b. The eardrum will appear in the oblique position. c. The normal membrane may appear thick and opaque. d. The appearance of the membrane is identical to that of an adult.

ANS: C During the first few days after the birth, the tympanic membrane of a newborn often appears thickened and opaque. It may look injected and have a mild redness from increased vascularity. The eardrum of a neonated is more horizontal, making it more difficult to see completely. By one month of age the drum is in the oblique (more vertical) position as in the adult. During the first few days after the birth, the tympanic membrane of a newborn often appears thickened and opaque. It may look injected and have a mild redness from increased vascularity, but it is not due to infection. The eardrum of a neonated is more horizontal (not oblique), making it more difficult to see completely. By one month of age the drum is in the oblique (more vertical) position as in the adult.

A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings? a. Epistaxis b. Rhinorrhea c. Dysphagia d. Xerostomia

ANS: C Dysphagia is difficulty with swallowing and may occur with a variety of disorders, including stroke and other neurologic diseases. Rhinorrhea is a runny nose, epistaxis is a bloody nose, and xerostomia is a dry mouth. Rhinorrhea is a runny nose, epistaxis is a bloody nose, and xerostomia is a dry mouth; none of which are expected findings in a patient who had a stroke with drooping on the right side of the face. Dysphagia is difficulty with swallowing and may occur with a variety of disorders, including stroke and other neurologic diseases.

A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. How should the nurse proceed that would allow the patient to feel more comfortable with the nurse examining his thyroid gland? a. Behind with the nurse's hands placed firmly around his neck b. The side with the nurse's eyes averted toward the ceiling and thumbs on his neck c. The front with the nurse's thumbs placed on either side of his trachea and his head tilted forward d. The front with the nurse's thumbs placed on either side of his trachea and his head tilted backward

ANS: C Examining this patient's thyroid gland from the back may be unsettling for him. It would be best to examine his thyroid gland using the anterior approach, asking him to tip his head forward and to the right and then to the left.

A mother asks when her newborn infant's eyesight will be developed. What is the best response by the nurse? a. "Vision is not totally developed until 2 years of age." b. "Infants develop the ability to focus on an object at approximately 8 months of age." c. "By approximately 3 months of age, infants develop more coordinated eye movements and can fixate on an object." d. "Most infants have uncoordinated eye movements for the first year of life."

ANS: C Eye movements may be poorly coordinated at birth, but by 3 to 4 months of age, the infant should establish binocularity and should be able to fixate simultaneously on a single image with both eyes.

A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition? a. Absent or decreased breath sounds b. Productive cough with thin, frothy sputum c. Chest pain that is worse on deep inspiration and dyspnea d. Diffuse infiltrates with areas of dullness upon percussion

ANS: C Findings for pulmonary embolism include chest pain that is worse on deep inspiration, dyspnea, apprehension, anxiety, restlessness, partial arterial pressure of oxygen (PaO2) less than 80 mm Hg, diaphoresis, hypotension, crackles, and wheezes. Thin, frothy sputum is characteristic of pulmonary edema and diffuse infiltrates with areas of dullness upon percussion are characteristic of pneumonia or some type of lung consolidation.

The nurse would most likely hear fine crackles in which patient or situation? a. A pregnant woman b. A healthy 5-year-old child c. The immediate newborn period d. A patient with a pneumothorax

ANS: C Fine crackles are commonly heard in the immediate newborn period as a result of the opening of the airways and a clearing of fluid. Persistent fine crackles would be noticed with pneumonia, bronchiolitis, or atelectasis. Fine crackles would not be expected in the other options.

The nurse is auscultating the chest in an adult. Which technique is correct? a. Instructing the patient to take deep, rapid breaths b. Instructing the patient to breathe in and out through his or her nose c. Firmly holding the diaphragm of the stethoscope against the skin of the chest d. Lightly holding the bell of the stethoscope against the skin on the chest to avoid friction

ANS: C Firmly holding the diaphragm of the stethoscope against the chest is the correct way to auscultate breath sounds. The patient should be instructed to breathe through his or her mouth, a little deeper than usual, but not to hyperventilate. The patient should be instructed to take breaths a little deeper than usual but not to hyperventilate and to breathe through his or her mouth, not nose. The diaphragm not the bell should be used to auscultate breath sounds and holding the diaphragm of the stethoscope firmly against the chest is the correct way to auscultate breath sounds.

The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent motor vehicle accident. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal? a. The auditory canal may be occluded from increased cerumen. b. If the drum has ruptured, then purulent drainage will result. c. Bloody or clear watery drainage can indicate a basal skull fracture. d. Foreign bodies from the accident may cause occlusion of the ear canal.

ANS: C Frank blood or clear watery drainage (cerebrospinal fluid) after a trauma suggests a basal skull fracture and warrants immediate referral. Purulent drainage indicates otitis externa or otitis media. An ear canal occluded from cerumen would not be draining, purulent drainage indicates otitis externa or otitis media, and it is not likely a foreign body from an accident would cause occlusion of the ear canal.

In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse's best course of action? a. Recommend that he make an appointment with his physician for a mammogram. b. Acknowledge it as benign breast enlargement which is not unusual in men. c. Explain that this condition may be the result of hormonal changes, and recommend that he see his physician. d. Explain that gynecomastia in men is usually associated with prostate enlargement and recommend that he be thoroughly screened.

ANS: C Gynecomastia may reappear in the aging man and may be attributable to a testosterone deficiency. The patient should see a physician to determine the cause and possible treatment. This is not considered a normal finding and a patient should see a physician to determine the cause and possible treatment. A mammogram is likely not necessary and it is not associated with prostate enlargement

During a well-baby checkup, the nurse notices that a 1-week-old infant's face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notices dilated scalp veins and downcast or "setting sun" eyes. The nurse suspects which condition? a. Craniotabes b. Microcephaly c. Hydrocephalus d. Caput succedaneum

ANS: C Hydrocephalus occurs with the obstruction of drainage of cerebrospinal fluid that results in excessive accumulation, increasing intracranial pressure, and an enlargement of the head. The face looks small, compared with the enlarged cranium, and dilated scalp veins and downcast or "setting sun" eyes are noted. Craniotabes is a softening of the skull's outer layer. Microcephaly is an abnormally small head. A caput succedaneum is edematous swelling and ecchymosis of the presenting part of the head caused by birth trauma. The signs and symptoms of the infant in this question are those of hydrocephalus.

What should the nurse do when assessing the carotid arteries of an older patient with cardiovascular disease? a. Palpate the artery in the upper one-third of the neck. b. Simultaneously palpate both arteries to compare amplitude. c. Listen with the bell of the stethoscope to assess for bruits. d. Instruct the patient to take slow deep breaths during auscultation.

ANS: C If cardiovascular disease is suspected, then the nurse should auscultate each carotid artery for the presence of a bruit. The nurse should avoid compressing the artery, which could create an artificial bruit and compromise circulation if the carotid artery is already narrowed by atherosclerosis. Excessive pressure on the carotid sinus area high in the neck should be avoided, and excessive vagal stimulation could slow down the heart rate, especially in older adults. Palpating only one carotid artery at a time will avoid compromising arterial blood to the brain. The carotid pulse should be palpated medial to the sternomastoid muscle near the base of the neck (not the upper third).

During an interview, the patient states he has the sensation that "everything around him is spinning." What part of the ear should the nurse recognize is responsible for this sensation? a. Cochlea b. CN VIII c. Labyrinth d. Organ of Corti

ANS: C If the labyrinth of the ear becomes inflamed, it feeds the wrong information to the brain, creating a staggering gait and a strong, spinning, whirling sensation called vertigo. The cochlea, which contains the central hearing apparatus, and cranial nerve VIII, the vestibulocochlear nerve, which conducts nerve impulses from the organ of Corti to the brain, are all involved with hearing. The spinning sensation that this patient is experiencing is from the labyrinth of the ear.

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. What does the nurse suspect? a. Another MI b. Increased cardiac output c. Inflammation of the precordium d. Ventricular hypertrophy resulting from muscle damage

ANS: C Inflammation of the precordium gives rise to a friction rub. The sound is high pitched and scratchy, similar to sandpaper being rubbed. A friction rub is best heard with the diaphragm of the stethoscope, with the person sitting up and leaning forward, and with the breath held in expiration. A friction rub can be heard any place on the precordium. Usually, however, the sound is best heard at the apex and left lower sternal border, which are places where the pericardium comes in close contact with the chest wall.

A patient comes to the clinic and tells the nurse that he has been confined to his recliner chair for approximately 3 days with his feet down and he asks the nurse to evaluate his feet. What should the nurse expect to find during the assessment? a. Pallor b. Coolness c. Distended veins d. Prolonged capillary filling time

ANS: C Keeping the feet in a dependent position causes venous pooling, resulting in redness, warmth, and distended veins. Prolonged elevation would cause pallor and coolness. Immobilization or prolonged inactivity would cause prolonged capillary filling time.

A 70-year-old woman who loves to garden has small, flat, brown macules over her arms and hands. She asks, "What causes these liver spots?" Which is the best response by the nurse? a. "They are signs of decreased hematocrit r/t anemia." b. "Those are due to the destruction of melanin in your skin from exposure to the sun." c. "They are clusters of melanocytes that appear after extensive exposure to sunlight." d. "Those are areas of hyperpigmentation r/t decreased perfusion and vasoconstriction."

ANS: C Liver spots, or senile lentigines, are clusters of melanocytes that appear on the forearms and dorsa of the hands after extensive sun exposure. The other responses are not correct. People with anemia will normally present with pallor. Melanin gives brown tones to the skin and hair so a decrease in melanin would produce a lightening of the skin. Decreased perfusion and vasoconstriction do not cause hyperpigmentation. The small, flat, brown macules over this patient's arms and hands are liver spots, or senile lentigines.

A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. What does the nurse suspect? a. Eczema b. Rubeola c. Lyme disease d. Medication allergy

ANS: C Lyme disease occurs in people who spend time outdoors in May through September. The first disease state exhibits the distinctive bull's eye and a red macular or papular rash that radiates from the site of the tick bite with some central clearing. The rash spreads 5 cm or larger, and is usually in the axilla, midriff, inguinal, or behind the knee, with regional lymphadenopathy. Rubeola presents as a red-purple maculopapular blotchy rash that first appears behind the ears and then spreads over the face followed by the neck, trunk, arms and legs. Eczema, or atopic dermatitis, is a chronic inflammatory skin lesion that presents as erythematous papules and vesicles with weeping, oozing, flaking, fissures, crusts, and severe pruritis. An allergic drug allergy often presents with a generalized erythematous and symmetric rash.

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 outer aspect of the right ankle. What do these findings suggest? a. Pain r/t lymphatic abnormalities b. Problems r/t venous insufficiency c. Problems r/t arterial insufficiency d. Pain r/t musculoskeletal abnormalities

ANS: C Night leg pain is common in aging adults and may indicate the ischemic rest pain of peripheral arterial disease (PAD). Alterations in arterial circulation cause pain that becomes worse with leg elevation and is eased when the extremity is dangled. In addition, ulcers associated with PAD, or arterial ulcers, often occur on the lateral ankle (as in this patient), toes, metatarsal heads, and heels.

During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus? a. Presence of tears along the inner canthus b. Blocked nasolacrimal duct in a newborn infant c. Absence of drainage from the puncta when pressing against the inner orbital rim d. Slight swelling over the upper lid and along the bony orbit if the individual has a cold

ANS: C No swelling, redness, or drainage from the puncta should be observed when it is pressed. Regurgitation of fluid from the puncta, when pressed, indicates duct blockage. The lacrimal glands are not functional at birth.

The nurse is performing an assessment on an adult. The adult's vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next? a. Ask the patient about a history of frostbite. b. Suspect that the patient has venous insufficiency. c. Consider this a delayed capillary refill time, and investigate further. d. Consider this a normal capillary refill time that requires no further assessment.

ANS: C Normal capillary refill time is less than 1 to 2 seconds. A capillary refill time of 5 is a decrease in capillary refill which indicates vasoconstriction or decreased cardiac output. The nurse should investigate further. Decreased capillary refill is not a characteristic of previous frostbite or venous insufficiency and some conditions can skew the findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia.

A patient contacts the office and tells the nurse that she is worried about her 10-year-old daughter having breast cancer. She describes a unilateral enlargement of the right breast with associated tenderness. She is worried because the left breast is not enlarged. Which response by the nurse to the mother is best? a. "Breast development is usually fairly symmetric your daughter should be examined right away." b. "You should bring in your daughter right away because breast cancer is fairly common in preadolescent girls." c. "Although an examination of your daughter would rule out a problem, her breast development is most likely normal." d. "It is unusual for breasts that are first developing to feel tender because they haven't developed much fibrous tissue."

ANS: C Occasionally, one breast may grow faster than the other, producing a temporary asymmetry, which may cause some distress; reassurance is necessary. Tenderness is also common.

A black patient is in the intensive care unit because of impending shock after an accident. The nurse expects to find what characteristics in this patient's skin? a. Ruddy blue b. Generalized pallor c. Ashen, gray, or dull d. Patchy areas of pallor

ANS: C Pallor attributable to shock, with decreased perfusion and vasoconstriction, in black-skinned people will cause the skin to appear ashen, gray, or dull

The nurse is performing a well-child checkup on a 5-year-old boy. The child 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? a. Enlarged, warm, and tender nodes b. Lymphadenopathy of the cervical nodes c. Palpable firm, small, shotty, mobile, and nontender lymph nodes d. Firm, rubbery, and large nodes, somewhat fixed to the underlying tissue

ANS: C Palpable lymph nodes are often normal in children and infants and are small, firm, shotty (firm), mobile, and nontender. Vaccinations can produce lymphadenopathy and enlarged, warm, and tender nodes would indicate an infection both of which would not be considered a normal finding.

When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. What should the nurse do next? a. Check for the presence of claudication. b. Refer the individual for further evaluation. c. Consider this finding normal, and proceed with the peripheral vascular evaluation. d. Ask the patient if he or she has experienced any unusual cramping or tingling in the arm.

ANS: C Palpating the ulnar pulses is not usually necessary and they are not often palpable in the normal person. There is no need to check for claudication, refer for further evaluation, or ask about cramping and tingling in the arm.

During the precordial assessment of a patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. What does this finding indicate? a. Right ventricular hypertrophy b. Increased blood flow through the internal mammary artery c. Displacement of the heart from elevation of the diaphragm d. Increased volume and size of the heart as a result of pregnancy

ANS: C Palpation of the apical impulse is higher and more lateral, compared with the normal position, because the enlarging uterus elevates the diaphragm and displaces the heart up and to the left and rotates it on its long axis. This finding does not indicate right ventricular hypertrophy, increased blood flow through the internal mammary artery, or increased volume and size of the 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. "I'll be sleeping great, and then I wake up and feel like I can't get my breath." Which is the best response by the nurse? a. "When was your last electrocardiogram?" b. "It's probably because it's been so hot at night." c. "Do you have any history of problems with your heart?" d. "Have you had a recent sinus infection or upper respiratory infection?"

ANS: C Paroxysmal nocturnal dyspnea (shortness of breath generally occurring at night) occurs with heart failure. Lying down increases the volume of intrathoracic blood, and the weakened heart cannot accommodate the increased load. Classically, the person awakens after 2 hours of sleep, arises, and flings open a window with the perception of needing fresh air. Although the symptom the patient is describing is likely r/t heart failure, asking when his last electrocardiogram was is not as important as finding out about a history of heart problems. These symptoms are not associated with a sinus or upper respiratory infection.

The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. What should the nurse do next? a. Check for the presence of exophthalmos. b. Suspect that the patient has hyperthyroidism. c. Ask the patient if he or she has a history of heart failure. d. Assess for blepharitis, which is often associated with periorbital edema.

ANS: C Periorbital edema occurs with local infections, crying, and systemic conditions such as heart failure, renal failure, allergy, and hypothyroidism. Periorbital edema is not associated with blepharitis. Exophthalmos is associated with hyperthyroidism or thyrotoxicosis and hyperthyroidism is not associated with periorbital edema (although hypothyroidism is). Periorbital edema is not associated with blepharitis, either. Thus, the nurse should ask about these conditions.

During an assessment of an older adult, the nurse should expect to which finding as a normal physiologic change associated with the aging process? a. Hormonal changes causing vasodilation and a resulting drop in blood pressure b. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency c. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure d. Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities

ANS: C Peripheral blood vessels become more rigid with age, resulting in a rise in systolic blood pressure. Aging produces progressive enlargement of the intramuscular calf veins, not atrophy. The other options are not correct. Although older age does increase the risk for varicose veins, it is due to the thinning of elastic lamina of veins and degeneration of vascular smooth muscle, not narrowing of the inferior vena cava.

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says "I can't always tell where the sound is coming from" and that the words often sound "mixed up." What might the nurse suspect as the cause for this change? a. Atrophy of the apocrine glands b. Cilia becoming coarse and stiff c. Nerve degeneration in the inner ear d. Scar tissue in the tympanic membrane

ANS: C Presbycusis is a type of hearing loss that occurs in 60% of those older than 65 years of age, even in those living in a quiet environment. This sensorineural loss is gradual and caused by nerve degeneration in the inner ear. Words sound garbled, and the ability to localize sound is also impaired. This communication dysfunction is accentuated when background noise is present. Atrophy of the apocrine glands causes cerumen to be more dry and cilia becoming coarse and stiff may cause cerumen to accumulate and oxidize and reduce hearing but they do cause this patient's symptoms of not being able to locate the source of sounds or sounds being mixed up. Scarring of the tympanic eardrum are sequelae of repeated ear infections but do not necessarily affect hearing.

A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this? a. Perform the confrontation test. b. Assess the individual's near vision. c. Observe the distance between the palpebral fissures. d. Perform the corneal light test, and look for symmetry of the light reflex.

ANS: C Ptosis is a drooping of the upper eyelid that would be apparent by observing the distance between the upper and lower eyelids. The confrontation test measures peripheral vision, not ptosis. Measuring near vision or the corneal light test does not check for ptosis.

A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. What is the best response by the nurse? a. "Blue dilation of blood vessels in a star-shaped linear pattern on the legs." b. "Fiery red, star-shaped marking on the cheek that has a solid circular center." c. "Confluent and extensive patch of petechiae and ecchymoses on the feet." d. "Tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color."

ANS: C Purpura is a confluent and extensive patch of petechiae and ecchymoses and a flat macular hemorrhage observed in generalized disorders such as thrombocytopenia and scurvy. The blue dilation of blood vessels in a star-shaped linear pattern on the legs describes a venous lake. The fiery red, star-shaped marking on the cheek that has a solid circular center describes a spider or star angioma. The tiny areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color describe petechiae.

A patient has been identified as having a sensorineural hearing loss. What would be important for the nurse to do during the assessment of this patient? a. Speak loudly so the patient can hear the questions. b. Assess for middle ear infection as a possible cause. c. Ask the patient what medications he is currently taking. d. Look for the source of the obstruction in the external ear.

ANS: C Sensorineural hearing loss may be caused by presbycusis, which is a gradual nerve degeneration that occurs with aging and by ototoxic drugs, which affect the hair cells in the cochlea. So the nurse should ask the patients about the medications they have been taking. A simple increase in amplitude may not enable the person to understand spoken words. The middle ear and obstruction of the external ear are not associated with sensorineural hearing loss so the nurse should not assess for a middle ear infection or external ear obstruction.

The nurse is reviewing an assessment of a patient's peripheral pulses and notices that the documentation states that the radial pulses are "2+." The nurse recognizes that this reading indicates what type of pulse? a. Weak b. Absent c. Normal d. Bounding

ANS: C When documenting the force, or amplitude, of pulses, 3+ indicates an increased, full, or bounding pulse, 2+ indicates a normal pulse, 1+ indicates a weak pulse, and 0 indicates an absent pulse.

During an oral assessment of a 30-year-old black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding? a. Check the patient's Hb for anemia. b. Assess for other signs of insufficient oxygen supply. c. Proceed with the assessment, this appearance is a normal finding. d. Ask if he has been exposed to an excessive amount of carbon monoxide.

ANS: C Some blacks may have bluish lips and a dark line on the gingival margin; this appearance is a normal finding so the nurse should proceed with the assessment. Some blacks may have bluish lips and a dark line on the gingival margin, so this is a normal finding and there is no need to check the Hb for anemia, assess for other signs of insufficient oxygen supply, or ask if he has been exposed to an excessive amount of carbon monoxide. Instead, the nurse should continue with the assessment.

Which of these findings would the nurse expect to notice during a cardiac assessment on a 4-year-old child? a. S3 when sitting up b. Persistent tachycardia above 150 beats per minute c. Murmur at the second left intercostal space when supine d. Palpable apical impulse in the fifth left intercostal space lateral to midclavicular line

ANS: C Some murmurs are common in healthy children or adolescents and are termed innocent or functional. The innocent murmur is heard at the second or third left intercostal space and disappears with sitting, and the young person has no associated signs of cardiac dysfunction.

What component of the conduction system is referred to as the pacemaker of the heart? a. Bundle of His b. Bundle branches c. Sinoatrial (SA) node d. Atrioventricular (AV) node

ANS: C Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. Because the SA node has an intrinsic rhythm, it is called the pacemaker of the heart. After the electrical impulse is initiated, it travels across the atria to the AV node where it is delayed slightly so the atria have time to contract before the ventricles are stimulated. Then the impulse travels to the bundle of His, the right and left bundle branches, and then through the ventricles.

The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed? a. Perform the confrontation test. b. Ask the patient to read the print on a handheld Jaeger card. c. Use the Snellen chart positioned 20 feet away from the patient. d. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches.

ANS: C The Snellen alphabet chart is the most commonly used and most accurate measure of visual acuity. The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are used to test near vision

The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique? a. The best time to perform BSE is in the middle of the menstrual cycle. b. A woman should perform BSEs 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 after her baby is born

ANS: C The best time to conduct a BSE is right after the menstrual period, or the fourth through seventh day of the menstrual cycle, when the breasts are the smallest and least congested. The pregnant or menopausal woman who is not having menstrual periods should be advised to select a familiar date to examine her breasts each month—for example, her birth date or the day the rent is due. Women do not need to be advised to perform BSEs bimonthly.

In performing an assessment of a woman's axillary lymph system, the nurse should assess which of these nodes? a. Central, axillary, lateral, and sternal b. Pectoral, lateral, anterior, and sternal c. Central, lateral, pectoral, and subscapular d. Lateral, pectoral, axillary, and suprascapular

ANS: C The breast has extensive lymphatic drainage, but there are no sternal or suprascapular lymph nodes. The four groups of axillary nodes are the (1) central, (2) pectoral (anterior), (3) subscapular (posterior), and (4) lateral.

When the nurse is auscultating the carotid artery for bruits, which of these statements reflects the correct technique? a. While listening with the bell of the stethoscope, the patient is asked to take a deep breath and hold it. b. While auscultating one side with the bell of the stethoscope, the carotid artery is palpated on the other side to check pulsations. c. While lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it. d. While firmly placing the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold it.

ANS: C The correct technique for auscultating the carotid artery for bruits involves the nurse lightly applying the bell of the stethoscope over the carotid artery at three levels. While listening, the nurse asks the patient take a breath, exhale, and briefly hold it. Holding the breath on inhalation will also tense the levator scapulae muscles, which makes it hard to hear the carotid arteries. Examining only one carotid artery at a time will avoid compromising arterial blood flow to the brain. Pressure over the carotid sinus, which may lead to decreased heart rate, decreased blood pressure, and cerebral ischemia with syncope, should be avoided.

The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct? a. Wet, honey-colored cerumen is a sign of infection. b. The presence of cerumen is indicative of poor hygiene. c. The purpose of cerumen is to protect and lubricate the ear. d. Cerumen is necessary for transmitting sound through the auditory canal.

ANS: C The ear is lined with glands that secrete cerumen. Cerumen is genetically determined, with two distinct types. Wet, honey-brown occurs in Caucasians and African Americans, and a dry, flaky white is found in East Asians and American Indians. Cerumen is supposed to be present-to lubricate, waterproof, and clean the external auditory canal. It also is antibacterial, and traps foreign bodies. Wet, honey-colored cerumen is not a sign of infection. Cerumen is not a sign of poor hygiene. It is supposed to be present-to lubricate, waterproof, and clean the external auditory canal. It also is antibacterial, and traps foreign bodies. It is not necessary for transmitting sound through the auditory canal and too much cerumen can impair hearing.

A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had "a runny nose for a week." When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. What should the nurse do next? a. Ask the mother if the infant has had trouble with feedings. b. Assure the mother that these signs are normal symptoms of a cold. c. Recognize that these are serious signs, and contact the physician. d. Perform a complete cardiac assessment because these signs are probably indicative of early heart failure.

ANS: C The infant is an obligatory nose breather until the age of 3 months. Normally no flaring of the nostrils and no sternal or intercostal retraction occurs.

During 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 trying to find the cause of the rash, which question would be important for the nurse to ask? a. "Is the rash raised and red?" b. "Does it appear to be cyclic?" c. "Where did the rash first appear—on the nipple, the areola, or the surrounding skin?" d. "What was she doing when she first noticed the rash, and do her actions make it worse?"

ANS: C The location where the rash first appeared is important for the nurse to determine. Paget disease starts with a small crust on the nipple apex and then spreads to the areola. Eczema or other dermatitis rarely starts at the nipple unless it is a result of breastfeeding. It usually starts on the areola or surrounding skin and then spreads to the nipple.

The nurse is reviewing the blood supply to the arm. What major artery supplies blood to the arm? a. Ulnar b. Radial c. Brachial d. Deep palmar

ANS: C The major artery supplying blood to the arm is the brachial artery. The brachial artery bifurcates into the ulnar and radial arteries immediately below the elbow. In the hand, the ulnar and radial arteries form two arches known as the superficial and deep palmar arches.

A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. Which nerve does the nurse suspect is damaged and how should the nurse proceed with the examination? a. XII; assess for a positive Romberg sign. b. XI; palpate the anterior and posterior triangles. c. XI; have patient shrug their shoulders against resistance. d. XII; percuss the sternomastoid and submandibular neck muscles.

ANS: C The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. The innervated muscles assist with head rotation and head flexion, movement of the shoulders, and extension and turning of the head. To assess the function of cranial nerve XI the nurse should have the patient shrug their shoulders against resistance. Cranial nerve XII is the hypoglossal nerve which innervates the muscles of the tongue involved with speech and swallowing and is not involved in head movement. Identifying the anterior and posterior triangles are helpful guidelines when describing findings in the neck but palpating them does not assess any cranial nerves.

The nurse is testing a patient's visual accommodation. How is accommodation assessed? a. Pupillary dilation when looking at a distant object b. Involuntary blinking in the presence of bright light c. Pupillary constriction when looking at a near object d. Changes in peripheral vision in response to bright light

ANS: C The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction. The other responses are not correct.

What is the primary purpose of the ciliated mucous membrane in the nose? a. To warm the inhaled air b. To filter out dust and bacteria c. To filter coarse particles from inhaled air d. To facilitate the movement of air through the nares

ANS: C The nasal hairs, or cilia, filter the coarsest matter from inhaled air, whereas the mucous blanket filters out dust and bacteria. The rich blood supply of the nasal mucosa warms the inhaled air. The rich blood supply of the nasal mucosa warms the inhaled air, not the ciliated mucous membrane. The mucous blanket, not the cilia, filters out dust and bacteria. The cilia in the nose do not facilitate the movement of air through the nares. Instead, the nasal hairs, or cilia, filter the coarsest matter from inhaled air.

The nurse is reviewing the function of the cranial nerves (CNs). Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti? a. I b. III c. VIII d. XI

ANS: C The nerve impulses are conducted by the auditory portion of CN VIII to the brain. Cranial nerve I, the olfactory nerve, is responsible for the sense of smell. Cranial nerve III, the oculomotor, innervates the superior, inferior, and medial rectus and the inferior oblique muscles of the eye. Cranial nerve XI, the accessory nerve, controls the muscles of the neck. The nerve that conducts nerve impulses from the organ of Corti to the brain is CN VIII, the vestibulocochlear nerve.

A newborn infant is in the clinic for a well-baby checkup. The nurse observes the infant for the possibility of fluid loss because of which of these factors? a. Subcutaneous fat deposits are high in the newborn. b. Sebaceous glands are overproductive in the newborn. c. The newborn's skin is more permeable than that of the adult. d. The amount of vernix caseosa dramatically rises in the newborn.

ANS: C The newborn's skin is thin, smooth, and elastic and is relatively more permeable than that of the adult; consequently, the infant is at greater risk for fluid loss. The subcutaneous layer in the infant is inefficient, not thick, and the sebaceous glands are present but decrease in size and production. Vernix caseosa is not produced after birth. The subcutaneous layer in the infant is inefficient, not thick, and the sebaceous glands are present but decrease in size and production. Infants are at greater risk for fluid loss because the newborn's skin is thin, smooth, and elastic and is relatively more permeable than that of the adult.

The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. What should the nurse look for during an inspection of this child's mouth? a. Swollen, red tonsils b. Ulcerations on the hard palate c. Bruising on the buccal mucosa or gums d. Small yellow papules along the hard palate

ANS: C The nurse should notice any bruising or laceration on the buccal mucosa or gums of an infant or young child. Trauma may indicate child abuse from a forced feeding of a bottle or spoon.

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct? a. Tilt the person's head forward during the examination. b. Once the speculum is in the ear, releasing the traction. c. Pulling the pinna up and back before inserting the speculum. d. Using the smallest speculum to decrease the amount of discomfort.

ANS: C The pinna is pulled up and back on an adult or older child, which helps straighten the S-shape of the canal. Traction should not be released on the ear until the examination is completed and the otoscope is removed. The nurse should tilt the patient's head slightly away from them and toward the opposite shoulder, not forward. The traction on the pinna of the ear should not be released until the examination is finished and the otoscope has been removed. The largest speculum that fits comfortably in the ear, not the smallest, should be used. The correct action is to pull the pinna up and back on an adult or older child (down and back on an infant or child under the age of 3), which helps straighten the S-shape of the canal.

What is the nurse assessing for when he or she directs a light across the iris of a patient's eye from the temporal side? a. Drainage from dacryocystitis b. Presence of conjunctivitis over the iris c. Presence of shadows, which may indicate glaucoma d. Scattered light reflex, which may be indicative of cataracts

ANS: C The presence of shadows in the anterior chamber may be a sign of acute angle-closure glaucoma. The normal iris is flat and creates no shadows. This technique (directing a light across the iris of a patient's eye from the temporal side) is not the technique to assess for dacryocystitis, conjunctivitis, or cataracts.

What are the projections in the nasal cavity that increase the surface area are called? a. Meatus b. Septum c. Turbinates d. Kiesselbach plexus

ANS: C The projections in the nasal cavity that increases the surface area are called turbinates. The lateral walls of each nasal cavity contain three parallel bony projections: the superior, middle, and inferior turbinates. These increase the surface area, making more blood vessels and mucous membrane available to warm, humidify, and filter the inhaled air. A meatus is the passageway or canal underlying each turbinate that collects drainage. The septum is what divides the nasal cavity into two slitlike air passages. The Kiesselbach plexus is a rich vascular network in the anterior part of the septum.

In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the patient's pupils. Based on this finding, what should the nurse do? a. Suspect that an opacity is present in the lens or cornea. b. Check the light source of the ophthalmoscope to verify that it is functioning. c. Consider the red glow a normal reflection of the ophthalmoscope light off the inner retina. d. Continue with the ophthalmoscopic examination, and refer the patient for further evaluation.

ANS: C The red glow filling the person's pupil is the red reflex and is a normal finding caused by the reflection of the ophthalmoscope light off the inner retina, so there is no need to check the light source of the ophthalmoscope or referral of the patient, and the interruption or absence, not the presence, of the red reflex would indicate an opacity. The other responses are not correct.

When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. What should the nurse recognize about this finding? a. Observed in patients with kyphosis. b. Indicative of pectus excavatum. c. A normal finding in a healthy adult. d. An expected finding in a patient with a barrel chest.

ANS: C The right and left costal margins form an angle where they meet at the xiphoid process. Usually, this angle is 90 degrees or less. The angle increases when the rib cage is chronically overinflated (barrel chest), as in emphysema.This is a normal finding and is not associated with kyphosis or indicative of pectus excavatum.

The nurse needs to palpate the temporomandibular joint for crepitation. Where is this joint located? a. Just below the hyoid bone and posterior to the tragus b. Just below the vagus nerve and posterior to the mandible c. Just below the temporal artery and anterior to the tragus d. Just below the temporal artery and anterior to the mandible

ANS: C The temporomandibular joint is just below the temporal artery and anterior to the tragus.

During an examination of a patient in her third trimester of pregnancy, the nurse notices that the patient's thyroid gland is slightly enlarged. No enlargement had been previously noticed. What does the nurse suspect? a. An iodine deficiency b. Early signs of goiter c. A normal enlargement of the thyroid gland during pregnancy d. Possible thyroid cancer and the need for further evaluation

ANS: C The thyroid gland enlarges slightly during pregnancy because of hyperplasia of the tissue and increased vascularity.

The physician reports that a patient with a neck tumor has a tracheal shift. The nurse should understand that what is occurring to the patient's trachea? a. Pushed downward b. Pulled to the affected side c. Pushed to the unaffected side d. Pulled downward in a rhythmic pattern

ANS: C The trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, or a pneumothorax. The trachea is pulled to the affected side with large atelectasis, pleural adhesions, or fibrosis. Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm. The trachea is pulled to the affected side with large atelectasis, pleural adhesions, or fibrosis. Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm. The trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, or a pneumothorax.

While performing a well-child assessment on a 5 year old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 cm in size, round, mobile, and nontender. What do these findings lead the nurse to conclude? a. The child has chronic allergies. b. The child likely has an infection. c. These are normal findings for a well child of this age. d. These findings indicate a need for additional evaluation.

ANS: C These are not signs of chronic allergies or an infection and do not require additional evaluation. Palpable lymph nodes are normal in children until puberty when the lymphoid tissue begins to atrophy. Lymph nodes may be up to 1 cm in size in the cervical and inguinal areas but are discrete, movable, and nontender.

While examining a 75-year-old woman, the nurse notices that the skin over her right breast is thickened and the hair follicles are exaggerated. What is this condition called? a. Dimpling b. Retraction c. Peau d'orange d. Benign breast disease

ANS: C This condition is known as peau d'orange. Lymphatic obstruction produces edema, which thickens the skin and exaggerates the hair follicles. The skin has a pig-skin or orange-peel appearance. This condition suggests cancer. Dimpling, or a pucker, indicates skin retraction. Retraction signs are caused by fibrosis in the breast tissue, usually caused by growing neoplasms. The fibrosis shortens with time, causing contrasting signs with the normally loose breast tissue. Benign breast disease is multiple tender masses that occur with numerous symptoms and physical findings such as swelling and tenderness, nodularity, dominant lumps, nipple discharge, and infections or inflammation. The symptoms this patient has indicate peau d'orange. In peau d'orange, lymphatic obstruction produces edema, which thickens the skin and exaggerates the hair follicles. The skin has a pig-skin or orange-peel appearance. This condition suggests cancer.

During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" What does this indicate? a. Vertigo b. Pruritus c. Tinnitus d. Cholesteatoma

ANS: C Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders. Vertigo is a strong spinning, whirling sensation; pruritus is itching; and cholesteatoma is an overgrowth of epidermal tissue in the middle ear or temporal bone that has a pearly white, cheesy appearance. The buzzing sound this patient is hearing is tinnitus.

In assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history? a. Family history, hypertension, stress, and age b. Personality type, high cholesterol, diabetes, and smoking c. Smoking, hypertension, obesity, diabetes, and high cholesterol d. Alcohol consumption, obesity, diabetes, stress, and high cholesterol

ANS: C To assess for major risk factors of coronary artery disease, the nurse should collect data regarding elevated serum cholesterol, elevated blood pressure, blood glucose levels above 100 mg/dL or known diabetes mellitus, obesity, cigarette smoking, low activity level, and length of any hormone replacement therapy for postmenopausal women. Although heredity, or inherited DNA variation, and lifestyle factors each contribute independently to the development of coronary artery disease (CAD), a favorable lifestyle is associated with a 46% lower risk for CAD events than is an unfavorable lifestyle.

When assessing the pupillary light reflex, the nurse should use which technique? a. Shine a penlight from directly in front of the patient, and inspect for pupillary constriction. b. Ask the patient to follow the penlight in eight directions, and observe for bilateral pupil constriction. c. Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. d. Ask the patient to focus on a distant object. Then ask the patient to follow the penlight to approximately 7 cm from the nose.

ANS: C To test the pupillary light reflex, the nurse should advance a light in from the side and note the direct and consensual pupillary constriction.

In a patient who has anisocoria, what would the nurse expect to observe? a. Dilated pupils b. Excessive tearing c. Pupils of unequal size d. Uneven curvature of the lens

ANS: C Unequal pupil size is termed anisocoria. It normally exists in 5% of the population but may also be indicative of central nervous system disease. Dilated pupils, excessive tearing, and uneven curvature of the lens are not associated with anisocoria. Anisocoria is the term for unequal pupil size. It exists in about 5% of the population but may also be indicative of central nervous system disease.

When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. How should the nurse interpret these findings? a. Normal sounds auscultated over the trachea. b. Bronchial breath sounds that are normal in that location. c. Vesicular breath sounds that are normal in that location. d. Bronchovesicular breath sounds that are normal in that location.

ANS: C Vesicular breath sounds are low-pitched, soft sounds with inspiration being longer than expiration. These breath sounds are expected over the peripheral lung fields where airflows through smaller bronchioles and alveoli.

A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. What should the nurse include in the teaching of vitiligo? a. It is associated with an excess of melanin pigment. b. It is a result of excess apocrine glands in her feet. c. It is caused by the complete absence of melanin pigment in an area. d. It is r/t impetigo and can be treated with a prescription ointment.

ANS: C Vitiligo is the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices—otherwise, the depigmented skin is normal.

The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? a. The infant shows no obvious response to the noise. b. The infant shows a startle and acoustic blink reflex. c. The infant turns his or her head to localize the sound. d. The infant stops any movement, and appears to listen for the sound.

ANS: C With a loud sudden noise, the nurse should notice the infant turning his or her head to localize the sound and to respond to his or her own name. A startle reflex and acoustic blink reflex is expected in newborns; at age 3 to 4 months, the infant stops any movement and appears to listen. A 7-month-old infant should respond to noise. With a loud sudden noise, the nurse should notice the infant turning his or her head (not stopping any movement) to localize the sound and to respond to his or her own name.

The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient? a. "Have you had any symptoms of a cold?" b. "Do you have an elevated temperature?" c. "Are you aware of having any allergies?" d. "Have you been having frequent nosebleeds?"

ANS: C With chronic allergies, the mucosa looks swollen, boggy, pale, and gray. Elevated body temperature, colds, and nosebleeds do not cause these mucosal changes. Elevated body temperature, colds, and nosebleeds do not cause the nasal mucosa to appear pale, gray, and swollen. Chronic allergies do cause the mucosa to look swollen, boggy, pale, and gray.

During an examination, the nurse notices that the patient stumbles a little while walking, and, when she sits down, she holds on to the sides of the chair. The patient states, "It feels like the room is spinning!" What do this signs and symptoms indicate? a. Tinnitus b. Dizziness c. Objective vertigo d. Subjective vertigo

ANS: C With objective vertigo, the patient feels like the room spins; with subjective vertigo, the person feels like he or she is spinning. Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders. Dizziness is not the same as true vertigo; the person who is dizzy may feel unsteady and light-headed. With subjective vertigo, the person feels like he or she is spinning. The symptom this patient has, that the room is spinning, is objective vertigo.

The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? (Select all that apply.) a. Test for fluid wave b. Test for the Murphy sign c. Test for the Blumberg sign d. Test for shifting dullness e. Perform the iliopsoas muscle test

ANS: C, E Testing for the Blumberg sign (rebound tenderness) and performing the iliopsoas muscle test should be used when assessing for appendicitis. The Murphy sign is used when assessing for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is performed when assessing for ascites.

The nurse is performing a digital examination of a patient's prostate gland and notices that a normal prostate gland includes which of the following characteristics? (Select all that apply.) a. Fixed mobility b. Boggy with a soft consistency c. 1 cm protrusion into the rectum d. Flat shape with no palpable groove e. Heart-shaped with a palpable central groove f. Smooth surface, elastic, and rubbery consistency

ANS: C, E, F The size of a normal prostate gland should be 2.5 cm long by 4 cm wide and should not protrude more than 1 cm into the rectum. The prostate should be heart-shaped, with a palpable central groove, a smooth surface, and elastic with a rubbery consistency. Abnormal findings include a flat shape with no palpable groove, boggy with a soft consistency, and fixed mobility.

A patient's abdomen is bulging and stretched in appearance. How should the nurse document this finding? a. Obese b. Scaphoid c. Herniated d. Protuberant

ANS: D A bulging and stretched abdomen is described as protuberant. A protuberant abdomen is rounded, bulging, and stretched. A scaphoid abdomen caves inward. An obese abdomen appears uniformly rounded with a sunken umbilicus. A hernia is a protrusion of the abdominal viscera through an abnormal opening in the abdominal muscle wall.

What is a common assessment finding in a boy younger than 2 years old? a. Inflamed and tender spermatic cord b. Presence of a hernia in the scrotum c. Penis that looks large in relation to the scrotum d. Presence of a hydrocele, or fluid in the scrotum

ANS: D A common scrotal finding in boys younger than 2 years of age is a hydrocele, or fluid in the scrotum. The other options are not correct.

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. What does the nurse suspect? a. Joint effusion b. Tear of rotator cuff c. Adhesive capsulitis d. Dislocated shoulder

ANS: D A dislocated shoulder occurs with trauma involving abduction, extension, and external rotation (e.g., falling on an outstretched arm or diving into a pool). Joint effusion is swelling from excess fluid in the joint capsule. Tear of rotator cuff typically presents in a "hunched" position and limited abduction of arm. Adhesive capsulitis (frozen shoulder) presents with stiffness; progressive limitation of motion in abduction and external rotation, and unable to reach overhead; and pain caused by the formation of fibrous tissues in the joint capsule. Joint effusion is swelling from excess fluid in the joint capsule. Tear of rotator cuff typically presents in a "hunched" position and limited abduction of arm. Adhesive capsulitis (frozen shoulder) presents with stiffness; progressive limitation of motion in abduction and external rotation, and unable to reach overhead; and pain caused by the formation of fibrous tissues in the joint capsule. This patient appears to have a dislocated shoulder.

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. Which response by the nurse is best? a. "Don't worry, most men your age develop hernias." b. "A hernia is often the result of a prenatal growth abnormality." c. "You should talk to your physician since he or she made the initial diagnosis." d. "A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles."

ANS: D A hernia is a loop of bowel protruding through a weak spot in the musculature of the abdominal wall. It is not a result of a prenatal growth abnormality. Although the patient may need to talk to the physician who diagnosed the hernia, the nurse should still answer his question and should not tell him not to worry, but acknowledge his concerns. A hernia is not a result of a prenatal growth abnormality. The nurse should explain to him that a hernia is a loop of bowel protruding through a weak spot in the musculature of the abdominal wall.

During an assessment of a 20-year-old man, the nurse finds a small palpable lesion with a tuft of hair located directly over the coccyx. What does this finding indicate? a. Carcinoma b. Rectal polyp c. Pruritus ani d. Pilonidal cyst

ANS: D A pilonidal cyst or sinus is a hair-containing cyst or sinus located in the midline over the coccyx or lower sacrum. It often opens as a dimple with a visible tuft of hair and, possibly, an erythematous halo. Carcinoma, or a malignant neoplasm, in the colon or rectum is typically asymptomatic. Rectal polyps are protruding growths from the rectal mucous membrane and are fairly common. They are difficult to palpate and found on examination with a scope. Pruritus ani is intense itching and burning in the perineum and has several causes such as soaps, fecal soiling or hemorrhoids, sexually transmitted infections, and pinworm manifestations in children.

The nurse has completed the musculoskeletal examination of a patient's knee and has found a positive bulge sign. How does the nurse interpret this finding? a. Irregular bony margins b. Soft-tissue swelling in the joint c. Swelling from fluid in the epicondyle d. Swelling from fluid in the suprapatellar pouch

ANS: D A positive bulge sign confirms the presence of swelling caused by fluid in the suprapatellar pouch. The other options are not correct.

A nurse notices that a patient has abdominal ascites. What does this finding indicate? a. Flatus b. Fibroid tumors c. Presence of feces d. Presence of fluid

ANS: D Ascites is free fluid in the peritoneal cavity and occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.

Which of these statements is true regarding the penis? a. The urethral meatus is located on the ventral side of the penis. b. The prepuce is the fold of foreskin covering the shaft of the penis. c. The penis is made up of two cylindric columns of erectile tissue. d. The corpus spongiosum expands into a cone of erectile tissue called the glans.

ANS: D At the distal end of the shaft, the corpus spongiosum expands into a cone of erectile tissue, the glans. The penis is made up of three (not two) cylindric columns of erectile tissue. The prepuce is the skin that covers the glans (not the shaft) of the penis. The urethral meatus forms at the tip of the glans (not on the ventral side).

The nurse should use which test to check for large amounts of fluid around the patella? a. Tinel sign b. Phalen test c. McMurray test d. Ballottement

ANS: D Ballottement of the patella is reliable when large amounts of fluid are present. The Tinel sign and the Phalen test are used to check for carpal tunnel syndrome. The McMurray test is used to test the knee for a torn meniscus.

A patient who is visiting the clinic reports having "stomach pains for 2 weeks" and describes his stools as being "soft and black" for approximately the last 10 days. He denies taking any medications. What do these symptoms suggest? a. Excessive fat caused by malabsorption b. Absent bile pigment from liver problems c. Increased iron intake, resulting from a change in diet d. Occult blood, resulting from gastrointestinal bleeding

ANS: D Black stools may be tarry as a result of occult blood (melena) from gastrointestinal bleeding or nontarry from ingestion of iron medications (not diet). Excessive fat causes the stool to become frothy. The absence of bile pigment causes clay-colored stools.

A 35-year-old woman is at the clinic for a gynecologic examination. During the examination, she asks the nurse, "How often do I need to have this Pap test done?" Which reply by the nurse is correct? a. "It depends. Do you smoke?" b. "A Pap test needs to be performed annually until you are 65 years of age." c. "If you have two consecutive normal Pap tests, then you can wait 5 years between tests." d. "After age 30 years, if you have three consecutive normal Pap tests, then you may be screened every 2 to 3 years."

ANS: D Cervical cancer screening with the Pap test continues annually until age 30 years. After age 21, regardless of sexual history or activity, women should be screened every 3 years until age 30, then every 5 years until age 65.

The nurse notices that a woman in an exercise class is unable to do one-person jump rope. What does the nurse know that the shoulder must be able to do in order for one to be able to do one-person jump rope? a. Inversion b. Supination c. Protraction d. Circumduction

ANS: D Circumduction is defined as moving the arm in a circle around the shoulder. This movement is necessary to perform one-person jump rope. Inversion is the moving of the sole of the foot inward at the ankle. Supination is turning the forearm so the palm is down. Protraction is moving a body part forward and parallel to the ground.

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? a. 2 b. 3 c. 4 d. 5

ANS: D Complete range of motion against gravity is normal muscle strength and is recorded as grade 5 muscle strength. The other options are not correct

The nurse is describing a scaphoid abdomen. When assessing the contour of the abdomen from the rib margin to the pubic bone, what would the contour look like? a. Flat b. Convex c. Bulging d. Concave

ANS: D Contour describes the profile of the abdomen from the rib margin to the pubic bone; a scaphoid contour is one that is concave from a horizontal plane. The contour describes the nutritional state and normally ranges from flat to round.

A patient is having difficulty swallowing medications and food. How should the nurse document this? a. Aphasia b. Anorexia c. Dysphasia d. Dysphagia

ANS: D Dysphagia is a condition that occurs with disorders of the throat or esophagus and results in difficulty swallowing. Aphasia and dysphasia are speech disorders. Anorexia is a loss of appetite.

The nurse is performing a genital examination on a male patient and notices urethral drainage. What should the nurse do when collecting urethral discharge for microscopic examination and culture? a. Ask the patient to urinate into a sterile cup. b. Ask the patient to obtain a specimen of semen. c. Insert a cotton-tipped applicator into the urethra. d. Compress the glans between the examiner's thumb and forefinger, and collect any discharge.

ANS: D If urethral discharge is noticed, then the examiner should collect a smear for microscopic examination and culture by compressing the glans anteroposteriorly between the thumb and forefinger. The other options are not correct actions.

What are the fibrous bands that run directly from one bone to another, strengthen the joint, and help prevent movement in undesirable directions called? a. Bursa b. Tendons c. Cartilage d. Ligaments

ANS: D Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called ligaments. The other options are not correct.

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. What finding would support this suspicion? a. Negative Allis test b. Positive Ortolani sign c. Limited range of motion during Lasègue test d. Limited range of motion during the Moro reflex

ANS: D For a fractured clavicle, the nurse should observe for limited arm range of motion and unilateral response to the Moro reflex. The Allis test and Ortolani sign are performed to assess for hip dislocations, not fractured clavicle. The Lasègue test is performed to assess for sciatica or herniated nucleus pulposus. For a fractured clavicle, the nurse should observe for limited arm range of motion and unilateral response to the Moro reflex. The other tests are not appropriate for this type of fracture.

The nurse is aware that what change may occur in the gastrointestinal system with aging? a. Increased salivation b. Increased liver size c. Increased esophageal emptying d. Decreased gastric acid secretion

ANS: D Gastric acid secretion decreases with aging. As one ages, salivation decreases, esophageal emptying is delayed, and liver size decreases.

A 22-year-old woman is being seen at the clinic for problems with vulvar pain, dysuria, and fever. On physical examination, the nurse notices clusters of small, shallow vesicles with surrounding erythema on the labia. Inguinal lymphadenopathy is also present. What do these findings indicate? a. HPV b. Pediculosis pubis c. Contact dermatitis d. Herpes simplex virus type 2

ANS: D Herpes simplex virus type 2 exhibits clusters of small, shallow vesicles with surrounding erythema that erupt on the genital areas. Inguinal lymphadenopathy is also present. The woman reports local pain, dysuria, and fever. HPV presents with pink or flesh-colored, soft, points, moist, painless warty papules on the external genitalia. Pediculosis pubis presents with severe perineal itching and excoriations and erythematous areas on the external genitalia. May see little dark spots (lice are small), nits (eggs), or lice adherent to pubic hair near roots. Contact dermatitis presents as red, swollen vesicles with severe itching that may be a result from contact with an allergenic substance. There may be weeping lesions, crusts, scales, thickening of ski, and excoriations from scratching.

During a health history, a patient tells the nurse that he has trouble in starting his urine stream. How should the nurse document this finding? a. Urgency b. Dribbling c. Frequency d. Hesitancy

ANS: D Hesitancy is trouble in starting the urine stream. Urgency is the feeling that one cannot wait to urinate. Dribbling is the last of the urine before or after the main act of urination. Frequency is urinating more often than usual.

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 true regarding assessment of the spleen in this situation? a. The spleen can be enlarged as a result of trauma. b. The spleen is normally felt on routine palpation. c. If an enlarged spleen is noted, then the nurse should thoroughly palpate to determine its size. d. An enlarged spleen should not be palpated because it can easily rupture.

ANS: D If an enlarged spleen is felt, then the nurse should not continue to palpate it but refer the patient to a physician. An enlarged spleen is friable and can easily rupture with overpalpation.

Which statement concerning the anal canal is true? a. Slants backward toward the sacrum b. Contains hair and sebaceous glands c. Approximately 2 cm long in the adult d. The outlet for the gastrointestinal tract

ANS: D The anal canal is the outlet for the gastrointestinal tract and is approximately 3.8 cm long in the adult. It is lined with a modified skin that does not contain hair or sebaceous glands, and it slants forward toward the umbilicus.

A nurse is assessing a patient's risk for contracting a sexually transmitted infection (STI). What is an appropriate question to ask this patient? a. "Do you have a sexually transmitted infection?" b. "You are aware of the dangers of unprotected sex, aren't you?" c. "You know that it's important to use condoms for protection, right?" d. "Do you use a condom with each episode of sexual intercourse?"

ANS: D In reviewing a patient's risk for STIs, the nurse should ask in a nonconfrontational manner whether condoms are being used during each episode of sexual intercourse. Asking a person whether he or she has an infection does not address the risk.

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? a. Her cervical mucosa will be red and dry looking. b. She will not need to have a Pap smear performed. c. The nurse can expect to find that her uterus will be somewhat enlarged and her ovaries small and hard. d. The nurse should plan to lubricate the instruments and the examining hand adequately to avoid a painful examination.

ANS: D In the aging adult woman, natural lubrication is decreased; therefore, to avoid a painful examination, the nurse should take care to lubricate the instruments and the examining hand adequately. Menopause, with the resulting decrease in estrogen production, shows numerous physical changes. The cervix shrinks and looks pale and glistening. With the bimanual examination, the uterus feels smaller and firmer and the ovaries are not normally palpable. Women should continue cervical cancer screening up to age 65 years if they have an intact cervix and are in good health. Women who have had a total hysterectomy do not need cervical cancer screening if they have 3 consecutive negative Pap tests or 2 or more consecutive negative HIV and Pap tests within the last 10 years.

The nurse is explaining to a patient that there are shock absorbers in his back to cushion the spine and to help it move. What is the nurse referring to as shock absorbers? a. Vertebral column b. Nucleus pulposus c. Vertebral foramen d. Intervertebral disks

ANS: D Intervertebral disks are elastic fibrocartilaginous plates that cushion the spine similar to shock absorbers and help it move. The vertebral column is the spinal column itself. The nucleus pulposus is located in the center of each disk. The vertebral foramen is the channel, or opening, for the spinal cord in the vertebrae.

The nurse is aware that which statement is true regarding the incidence of testicular cancer? a. The cure rate for testicular cancer is low. b. Testicular cancer is the most common cancer in men aged 30 to 50 years. c. The early symptoms of testicular cancer are pain and induration. d. Men with a history of cryptorchidism are at the greatest risk for the development of testicular cancer.

ANS: D Men with undescended testicles (cryptorchidism) are at the greatest risk for the development of testicular cancer. The overall incidence of testicular cancer is rare. Although testicular cancer has no early symptoms, when detected early and treated before metastasizing, the cure rate is almost 100%.

The nurse is reviewing information on lactose intolerance and learned that in some racial groups lactase activity (ability to digest and absorb lactose) is high at birth but declines to low levels by adulthood. Which ethnic group has the highest potential for lactose-intolerance symptoms in adulthood? a. Asians b. African Americans c. White Americans d. American Indians

ANS: D Millions of American adults have the potential for lactose-intolerance symptoms; while 70-80% of White Americans produce lactase adequately into adulthood, only 30% of Mexican Americans, 20% of African Americans, and no American Indians will maintain adequate ability to digest lactose without adverse symptoms.

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. How should the nurse interpret these findings? a. These findings are all within normal limits. b. Pain may occur during palpation of the cervix. c. Cervical consistency should be soft and velvety—not firm. d. The cervix should move when palpated; an immobile cervix may indicate malignancy.

ANS: D Normally the cervix feels smooth and firm, similar to the consistency of the tip of the nose. It softens and feels velvety at 5 to 6 weeks of pregnancy (Goodell sign). The cervix should be evenly rounded. With a finger on either side, the examiner should be able to move the cervix gently from side to side, and doing so should produce no pain for the patient. Hardness of the cervix may occur with malignancy. Immobility may occur with malignancy, and pain may occur with inflammation or ectopic pregnancy.

The nurse is auscultating the lungs of a patient who had been sleeping and notices short, popping, crackling sounds that stop after a few breaths. What does this finding indicate? a. Fine wheezes b. Vesicular breath sounds c. Fine crackles and may be a sign of pneumonia d. Atelectatic crackles that do not have a pathologic cause

ANS: D One type of adventitious sound, atelectatic crackles, does not have a pathologic cause. They are short, popping, crackling sounds that sound similar to fine crackles but do not last beyond a few breaths. When sections of alveoli are not fully aerated (as in people who are asleep or in older adults), they deflate slightly and accumulate secretions. Crackles are heard when these sections are expanded by a few deep breaths. Atelectatic crackles are heard only in the periphery, usually in dependent portions of the lungs, and disappear after the first few breaths or after a cough. Although crackles can be a sign of pneumonia, this patient's crackles resolved after a few deep breaths which would not happen if there was pneumonia.

A 22-year-old woman has been considering using oral contraceptives. As a part of her health history, what should the nurse ask? a. "Do you have a history of heart murmurs?" b. "Will you be in a monogamous relationship?" c. "Have you carefully thought this choice through?" d. "If you smoke, how many cigarettes do you smoke per day?"

ANS: D Oral contraceptives, together with cigarette smoking, increase the risk for cardiovascular side effects. If cigarettes are used, then the nurse should assess the patient's smoking history. The other questions are not appropriate.

While performing an assessment of the perianal area of a patient, the nurse notices that the pigmentation of the anus is darker than the surrounding skin, the anal opening is closed, and a skin sac that is shiny and blue is noted. The patient mentioned that he has had pain with bowel movements and has occasionally noted some spots of blood. What does this assessment and history most likely indicate? a. Anal fistula b. Pilonidal cyst c. Rectal prolapse d. Thrombosed hemorrhoid

ANS: D The anus normally looks moist and hairless, with coarse folded skin that is more pigmented than the perianal skin, and the anal opening is tightly closed. The shiny blue skin sac indicates a thrombosed hemorrhoid.

The nurse is assessing a patient for possible peptic ulcer disease. Which condition or history often causes this disorder? a. Hypertension b. Streptococcal infections c. Recurrent constipation with frequent laxative use d. Frequent use of nonsteroidal antiinflammatory drugs

ANS: D Peptic ulcers occur when acid in the digestive tract eats away at the inner surface of the stomach or small intestine. The acid can create a painful open sore that may bleed. Peptic ulcers often occur with the frequent use of nonsteroidal antiinflammatory drugs, alcohol use, smoking, and Helicobacter pylori infections all of which can cause inflammation and irritation to the stomach lining or mucosa.

The nurse is providing patient teaching about an erectile dysfunction drug. One of the drug's potential side effects is prolonged, painful erection of the penis without sexual stimulation. What is the medical term for this condition? a. Orchitis b. Phimosis c. Stricture d. Priapism

ANS: D Priapism is prolonged, painful erection of the penis without sexual desire. Orchitis is inflammation of the testes. Stricture is a narrowing of the opening of the urethral meatus. Phimosis is the inability to retract the foreskin.

A patient is reporting sharp pain along the costovertebral angles. What does this symptom most often indicate? a. Ovarian infection b. Liver enlargement c. Spleen enlargement d. Kidney inflammation

ANS: D Sharp pain along the costovertebral angles occurs with inflammation of the kidney or paranephric area. The other options are not correct. Ovarian infection and liver or spleen enlargement do not cause pain along the costovertebral angles.

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. Based on these findings, what two signs is the patient exhibiting? a. Tanner and Hegar b. Hegar and Goodell c. Chadwick and Hegar d. Goodell and Chadwick

ANS: D Shortly after the first missed menstrual period, the female genitalia show signs of the growing fetus. The cervix softens (Goodell sign) at 4 to 6 weeks, and the vaginal mucosa and cervix look cyanotic (Chadwick sign) at 8 to 12 weeks. These changes occur because of increased vascularity and edema of the cervix and hypertrophy and hyperplasia of the cervical glands. Hegar sign occurs when the isthmus of the uterus softens at 6 to 8 weeks. Tanner sign is not a correct response

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. What does this finding suggest? a. Dysuria b. Hematuria c. Urge incontinence d. Stress incontinence

ANS: D Stress incontinence is involuntary urine loss with physical strain, sneezing, or coughing. Dysuria is pain or burning with urination. Hematuria is bleeding with urination. Urge incontinence is involuntary urine loss that occurs as a result of an overactive detrusor muscle in the bladder that contracts and causes an urgent need to void.

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. What is the appropriate term for these nodules? a. Epicondylitis b. Gouty arthritis c. Olecranon bursitis d. Subcutaneous nodules.

ANS: D Subcutaneous nodules are raised, firm, and nontender and occur with rheumatoid arthritis in the olecranon bursa and along the extensor surface of the ulna. Epicondylitis (Tennis elbow) is pain at the lateral epicondyle of the humerus. Gout is a painful inflammatory arthritis characterized by excess uric acid in the blood and deposits of urate crystals in the joint space. Symptoms include redness, swelling, heat and extreme pain. Olecranon bursitis is a large, soft knob or "goose egg" and redness from swelling and inflammation of olecranon bursa.

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. What do these findings indicate? a. Genital warts b. Herpes infection c. Carcinoma lesion d. Syphilitic chancre

ANS: D Syphilitic chancres begin as a small, solitary, silvery papule within 2 to 4 weeks of infection which then erodes to a red, round or oval, superficial ulcer with a yellowish serous discharge. The lesions of genital warts are soft, pointed, moist, fleshy, painless papules that may be single or multiple in a cauliflower-like patch. They occur on the shaft of the penis, behind the corona, or around the anus, where they may grow into large grapelike clusters. Genital herpes (HSV-2 infection) appears as clusters of small vesicles with surrounding erythema which are often painful and erupt on the glans, foreskin, or anus. Genital carcinoma begins as red, raised, warty growth or as an ulcer with watery discharge which almost always occur on the glans or inner lip of foreskin. The symptoms this patient is experiencing are those of syphilitic chancre.

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 I'd like them to go away!" What is the nurse's best response? a. "The HPV vaccine is for girls and women ages 9 to 26 years, so we can start that today." b. "This vaccine is only for girls who have not yet started to become sexually active." c. "Let's check with the physician to see if you are a candidate for this vaccine." d. "The vaccine cannot protect you if you already have an HPV infection."

ANS: D The HPV vaccine is appropriate for girls and women age 9 to 26 years and is administered to prevent cervical cancer by preventing HPV infections before girls become sexually active. However, it cannot protect the woman if an HPV infection is already present.

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? a. Percuss and palpate in the lumbar region b. Inspect and palpate in the epigastric region c. Auscultate and percuss in the inguinal region d. Percuss and palpate the midline area above the suprapubic bone

ANS: D The bladder is located in the suprapubic area (above the pubic bone) and if distended would elicit a dull sound when percussed and feel firm to palpation. However, this technique has been found to be unreliable and bedside bladder scanning with ultrasound is commonly used to estimate bladder volume.

During an internal examination, the nurse notices that the cervix bulges outside the introitus when the patient is asked to strain. How should the nurse document this finding? a. A normal finding b. Uterine prolapse, graded first degree c. Uterine prolapse, graded third degree d. Uterine prolapse, graded second degree

ANS: D The cervix should not be found to bulge into the vagina. Uterine prolapse is graded as follows: first degree—the cervix appears at the introitus with straining; second degree—the cervix bulges outside the introitus with straining; and third degree—the whole uterus protrudes, even without straining (essentially, the uterus is inside out).

A professional tennis player comes into the clinic complaining of a sore elbow. Where should the nurse assess for tenderness? a. Olecranon bursa b. Annular ligament c. Base of the radius d. Medial and lateral epicondyle

ANS: D The epicondyles, the head of the radius, and the tendons are common sites of inflammation and local tenderness, commonly referred to as tennis elbow. The other locations are not affected.

During the assessment of an 18-month-old infant, the mother expresses concern to the nurse about the infant's inability to toilet train. What would be the best response by the nurse? a. "Some children are just more difficult to train, so I wouldn't worry about it yet." b. "Have you considered reading any of the books on toilet training? They can be very helpful." c. "This could mean that there is a problem with your baby's development. We'll watch her closely for the next few months." d. "The nerves that allow your baby to have control over the passing of stools are not developed until at least 18 to 24 months of age."

ANS: D The infant passes stools by reflex. Voluntary control of the external anal sphincter cannot occur until the nerves supplying the area have become fully myelinated, usually around 11 2 to 2 years of age. Toilet training usually starts after the age of 2 years.

When the nurse is conducting a sexual history from a male adolescent, which statement would be most appropriate to use at the beginning of the interview? a. "Do you use condoms?" b. "You don't masturbate, do you?" c. "Have you had sex in the last 6 months?" d. "Often adolescents your age have questions about sexual activity."

ANS: D The interview should begin with a permission statement, which conveys that it is normal and acceptable to think or feel a certain way. Sounding judgmental, such as saying "You don't masturbate, do you?" should be avoided.

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. What is the name of this patient's affected joint? a. Tibiotalar b. Interphalangeal c. Tarsometatarsal d. Metacarpophalangeal

ANS: D The joint located just above the ring on the finger is the metacarpophalangeal joint. The interphalangeal joint is located distal to the metacarpophalangeal joint. The tarsometatarsal and tibiotalar joints are found in the foot and ankle.

When reviewing the musculoskeletal system, the nurse should recall that hematopoiesis takes place where? a. Liver b. Spleen c. Kidneys d. Bone marrow

ANS: D The musculoskeletal system functions to encase and protect the inner vital organs, to support the body, to produce red blood cells (hematopoiesis) in the bone marrow, and to store minerals. The other options are not correct. The liver has many functions such as detoxifying the blood, production of bile, and synthesis of proteins needed for blood to clot, but hematopoiesis is not one of its functions. The spleen has many functions such as filtering the blood as part of the immune system, recycling old red blood cells, and storing platelets and white bloods cells but it is not the location of hematopoiesis. The kidney also has many functions such as maintaining fluid balance, filtering minerals, and production of hormones that help stimulate red blood cells production; however, it is not the location of hematopoiesis.

Which statement would be most appropriate when the nurse is introducing the topic of sexual relationships during a health interview? a. "Now, it is time to talk about your sexual history. When did you first have intercourse?" b. "Most women your age have had more than one sexual partner. How many would you say you have had?" c. "Women often feel dissatisfied with their sexual relationships. Would it be okay to discuss this now?" d. "Women often have questions about their sexual relationship and how it affects their health. Do you have any questions?"

ANS: D The nurse should begin with an open-ended question to assess individual needs. The nurse should include appropriate questions as a routine part of the health history, because doing so communicates that the nurse accepts the individual's sexual activity and believes it is important. The nurse's comfort with the discussion prompts the patient's interest and, possibly, relief that the topic has been introduced. The initial discussion establishes a database for comparison with any future sexual activities and provides an opportunity to screen sexual problems.

A 13-year-old girl is visiting the clinic for a sports physical examination. The nurse should remember to include which of these tests in the examination? a. Valsalva maneuver b. Testing for occult blood c. Internal palpation of the anus d. Inspection of the perianal area

ANS: D The perianal region of the school-aged child and adolescent should be inspected during the examination of the genitalia. Internal palpation is not routinely performed at this age. Testing for occult blood and performing the Valsalva maneuver are also not necessary.

A 60-year-old man has just been told that he has benign prostatic hypertrophy (BPH). He has a friend who just died from cancer of the prostate and is concerned this will happen to him. How should the nurse respond? a. "The swelling in your prostate is only temporary and will go away." b. "We will treat you with chemotherapy so we can control the cancer." c. "It would be very unusual for a man your age to have cancer of the prostate." d. "The enlargement of your prostate is caused by hormonal changes, and not cancer."

ANS: D The prostate gland commonly starts to enlarge during the middle adult years. BPH is present in 1 in 10 men at the age of 40 years and increases with age. It is believed that the hypertrophy is caused by hormonal imbalance that leads to the proliferation of benign adenomas. The other responses are not appropriate.

Which structure is located in the left lower quadrant of the abdomen? a. Liver b. Duodenum c. Gallbladder d. Sigmoid colon

ANS: D The sigmoid colon is located in the left lower quadrant of the abdomen. The duodenum, or first part of the small intestine, and the gallbladder are located in the right upper abdominal quadrant. The sigmoid colon then is the structure that is located in the left lower abdominal quadrant.

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. What do these findings suggest? a. Endometriosis b. Uterine fibroids c. Ectopic pregnancy d. Pelvic inflammatory disease

ANS: D These signs and symptoms are suggestive of acute pelvic inflammatory disease, also known as acute salpingitis. Endometriosis may have masses (in various locations in the pelvic area) that are small, firm, nodular, and tender to palpation, with enlarged ovaries. Uterine fibroids often are asymptomatic. Symptoms that may occur included vague discomfort, bloating, heaviness, pelvic pressure, dyspareunia, urinary frequency backache or excessive uterine bleeding. The uterus may be irregularly enlarged, firm, mobile and nodular with hard, painless nodules in the uterine wall. An ectopic pregnancy presents with sharp, stabbing abdominal or pelvic pain, vaginal spotting or new-onset bleeding, and positive pregnancy test. There will likely be a softening of the cervix and fundus; movement of cervix and uterus causes pain; and palpable tender, round mobile swelling, lateral to uterus.

As the nurse is taking the health history, the patient states, "It really hurts back there, and sometimes it itches, too. I have even seen blood on the tissue when I have a bowel movement. Is there something there?" The nurse should expect to see which of these upon examination of the anus? a. Rectal prolapse b. Internal hemorrhoid c. External hemorrhoid that has resolved d. External hemorrhoid that is thrombosed

ANS: D These symptoms are consistent with an external hemorrhoid. An external hemorrhoid, when thrombosed, contains clotted blood and becomes a painful, swollen, shiny blue mass that itches and bleeds with defecation. When the external hemorrhoid resolves, it leaves a flabby, painless skin sac around the anal orifice. An internal hemorrhoid is not palpable but may appear as a red mucosal

The nurse is examining a 3-month-old infant. While the nurse holds his or her thumbs on the infant's inner mid thighs and the fingers on the outside of the infant's hips, touching the greater trochanter, the nurse adducts the legs until the his or her thumbs touch and then abducts the legs until the infant's knees touch the table. The nurse does not notice any "clunking" sounds. How should the nurse document this finding? a. Positive Allis test b. Negative Allis test c. Positive Ortolani sign d. Negative Ortolani sign

ANS: D This maneuver is the Ortolani sign. Normally this maneuver feels smooth and has no sound (negative Ortolani sign). However, with a positive Ortolani sign the nurse will feel and hear a "clunk," as the head of the femur pops back into place. A positive Ortolani sign also reflects hip instability. The Allis test also tests for hip dislocation but is performed by comparing leg lengths. The Allis test is a test that assesses for hip dislocation but comparing leg lengths. The maneuver described in this question is the Ortolani sign. Normally this maneuver feels smooth and has no sound (negative Ortolani sign). However, with a positive Ortolani sign the nurse will feel and hear a "clunk," as the head of the femur pops back into place. A positive Ortolani sign also reflects hip instability.

Which statement concerning the testes is true? a. The vas deferens is located along the inferior portion of each testis. b. The lymphatic vessels of the testes drain into the abdominal lymph nodes. c. The right testis is lower than the left because the right spermatic cord is longer. d. The cremaster muscle contracts in response to cold and draws the testicles closer to the body.

ANS: D When it is cold, the cremaster muscle contracts, which raises the scrotal sac and brings the testes closer to the body to absorb heat necessary for sperm viability. The lymphatic vessels of the testes drain into the inguinal lymph nodes. The vas deferens is located along the upper portion of each testis. The left testis is lower than the right because the left spermatic cord is longer.

When the nurse is performing a genital examination on a male patient, which action is correct? a. Auscultating for the presence of a bruit over the scrotum b. Palpating the inguinal canal only if a bulge is present in the inguinal region during inspection c. Palpating for the vertical chain of lymph nodes along the groin, inferior to the inguinal ligament d. Having the patient shift his weight onto the left (unexamined) leg when palpating for a hernia on the right side

ANS: D When palpating for the presence of a hernia on the right side, the male patient is asked to shift his weight onto the left (unexamined) leg. Auscultating for a bruit over the scrotum is not appropriate. When palpating for lymph nodes, the horizontal chain is palpated. The inguinal canal should be palpated whether a bulge is present or not.

When the nurse is performing a genital examination on a male patient, the patient has an erection. How should the nurse respond? a. Ask the patient if he would like someone else to examine him. b. Continue with the examination as though nothing has happened. c. Stop the examination, leave the room while stating that the examination will resume at a later time. d. Reassure the patient that this is a normal response and continue with the examination.

ANS: D When the male patient has an erection, the nurse should reassure the patient that this is a normal physiologic response to touch and proceed with the rest of the examination. The other responses are not correct and may be perceived as judgmental.

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 reports pain when straining. What do these findings indicate? a. Femoral hernia b. Incisional hernia c. Direct inguinal hernia d. Indirect inguinal hernia

ANS: D With indirect inguinal hernias, pain occurs with straining and a soft swelling increases with increased intra-abdominal pressure, which may decrease when the patient lies down. A femoral hernia usually presents with pain that is constant and may be severe and become strangulated. An incisional, or ventral, hernia occurs at the site of a previous surgical incision in either the groin or abdominal area. A direct hernia is usually painless and is easily reduced when supine. The symptoms this patient is experiencing are those of an indirect hernia.

A 46-year-old woman is in the clinic for her annual gynecologic examination. She voices concern about ovarian cancer because her mother and sister died of it. Which statement does the nurse know to be correct regarding ovarian cancer? a. Ovarian cancer rarely has any symptoms. b. The Pap smear detects the presence of ovarian cancer. c. Women over age 40 years should have a thorough pelvic examination every 3 years. d. Women at high risk for ovarian cancer should have annual transvaginal ultrasonography for screening.

ANS: D With ovarian cancer, the patient may have abdominal pain, pelvic pain, increased abdominal size, bloating, and nonspecific gastrointestinal symptoms; or she may be asymptomatic. The Pap smear does not detect the presence of ovarian cancer. Annual transvaginal ultrasonography may detect ovarian cancer at an earlier stage in women who are at high risk for developing it.

A semiconscious woman is brought to the emergency department after she was found on the floor in her kitchen. Her face, nail beds, lips, and oral mucosa are a bright cherry-red color. What should the nurse suspect is the likely cause of these findings? a. Uremia b. Carotenemia c. Polycythemia d. Carbon monoxide poisoning

ANS: D A bright cherry-red coloring in the face, upper torso, nail beds, lips, and oral mucosa appears in cases of carbon monoxide poisoning. Uremia presents as an orange-green or gray pallor, not bright red. Carotenemia presents as a yellow-orange color in the forehead, palms and soles, nasolabial folds but no yellowing in the sclera or mucous membranes. Polycythemia presents as ruddy blue in the face, oral mucosa, conjunctiva, hands, and feet.

A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe? a. Unilateral cool foot b. Thin, shiny, atrophic skin c. Pallor of the toes and cyanosis of the nail beds d. Brownish discoloration to the skin of the lower leg

ANS: D A brown discoloration occurs with chronic venous stasis as a result of hemosiderin deposits (a by-product of red blood cell degradation). Pallor, cyanosis, atrophic skin, and unilateral coolness are all signs associated with arterial problems.

When auscultating over a patient's femoral arteries, the nurse notices the presence of a bruit on the left side. Which statement about bruits is accurate? a. Often associated with venous disease b. Occur in the presence of lymphadenopathy c. Femoral artery bruits are caused by hypermetabolic states d. Occur with turbulent blood flow, indicating partial occlusion

ANS: D A bruit occurs with turbulent blood flow and indicates partial occlusion of the artery. The other responses are not correct.

During an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and the ear canal wall. What does this finding suggest? a. Malignancy b. Viral infection c. Blood in the middle ear d. Yeast or fungal infection

ANS: D A colony of black or white dots on the drum or canal wall suggests a yeast or fungal infection (otomycosis). A colony of black and white dots on the eardrum is not a manifestation of malignancy, a viral infection, of blood in the middle year. Blood in the middle year would cause a blue or dark red appearance of the eardrum.

A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion? a. Smooth and clear corneas b. Opacity of the lens behind the cornea c. Bleeding from the areas across the cornea d. Shattered look to the light rays reflecting off the cornea

ANS: D A corneal abrasion causes irregular ridges in reflected light, which produce a shattered appearance to light rays. No opacities should be observed in the cornea. The other responses are not correct.

During percussion, the nurse hears a dull percussion note elicited over a lung lobe. What is the most likely cause of this finding? a. Shallow breathing b. Normal lung tissue c. Decreased adipose tissue d. Increased density of lung tissue

ANS: D A dull percussion note indicates an abnormal density in the lungs, as with pneumonia, pleural effusion, atelectasis, or a tumor. Resonance is the expected finding in normal lung tissue.

While performing a rectal examination, the nurse notices a firm, irregularly shaped mass. What should the nurse do next? a. Continue with the examination, and document the finding in the chart. b. Instruct the patient to return for a repeat assessment in 1 month. c. Tell the patient that a mass was felt, but it is nothing to worry about. d. Report the finding, and refer the patient to a specialist for further examination.

ANS: D A firm or hard mass with an irregular shape or rolled edges may signify carcinoma. Any mass that is discovered should be promptly reported for further examination. The other responses are not correct.

A mother brings her 4-month-old infant to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notices a 0.5-cm, fleshy, elevated area in the middle of the upper lip. No evidence of inflammation or drainage is observed. What would the nurse tell this mother? a. "This area of irritation is caused from teething and is nothing to worry about." b. "This finding is abnormal and should be evaluated by another health care provider." c. "This area of irritation is the result of chronic drooling and should resolve within the next month or two." d. "This elevated area is a sucking tubercle caused from the friction of breastfeeding or bottle-feeding and is normal."

ANS: D A normal finding in infants is the sucking tubercle, a small pad in the middle of the upper lip from the friction of breastfeeding or bottle-feeding. This condition is not caused by irritation, teething, or excessive drooling, and evaluation by another health care provider is not warranted.

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. How should the nurse document this finding? a. A bulla b. A wheal c. A nodule d. A papule

ANS: D A papule is something one can feel, is solid, elevated, circumscribed, less than 1 cm in diameter, and is due to superficial thickening in the epidermis. A bulla is larger than 1 cm, superficial, and thin walled. A wheal is superficial, raised, transient, erythematous, and irregular in shape attributable to edema. A nodule is solid, elevated, hard or soft, and larger than 1 cm. The solid, elevated, circumscribed lesion less than 1 cm in diameter that this patient has is a papule.

A patient with pleuritis has been admitted to the hospital and reports pain with breathing. What other key assessment finding would the nurse expect to find upon auscultation? a. Stridor b. Crackles c. Wheezing d. Friction rub

ANS: D A patient with pleuritis will exhibit a pleural friction rub upon auscultation. This sound is made when the pleurae become inflamed and rub together during respiration. The sound is superficial, coarse, and low-pitched, as if two pieces of leather are being rubbed together. Stridor is associated with croup, acute epiglottitis in children, and foreign body inhalation. Crackles are associated with pneumonia, heart failure, chronic bronchitis, and other diseases. Wheezes are associated with diffuse airway obstruction caused by acute asthma or chronic emphysema.

A 70-year-old patient is being seen in the clinic for severe exacerbation of his heart failure. Which of these findings is the nurse most likely to observe in this patient? a. Fever, dry nonproductive cough, and diminished breath sounds b. Rasping cough, thick mucoid sputum, wheezing, and bronchitis c. Productive cough, dyspnea, weight loss, anorexia, and tuberculosis d. Shortness of breath, orthopnea, paroxysmal nocturnal dyspnea, and ankle edema

ANS: D A person with heart failure often exhibits increased respiratory rate, shortness of breath on exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, ankle edema, and pallor in light-skinned individuals. A patient with rasping cough, thick mucoid sputum, and wheezing may have bronchitis. Productive cough, dyspnea, weight loss, and dyspnea indicate tuberculosis; fever, dry nonproductive cough, and diminished breath sounds may indicate Pneumocystis jiroveci (P. carinii) pneumonia.

A 14-year-old girl is anxious about not having reached menarche. When taking the health history, the nurse should ascertain which of the following? a. The age her mother developed breasts b. The age she began to develop pubic hair c. The age she began developing axillary hair d. The age the girl began to develop breasts

ANS: D According to Tanner's five stages of breast development, full development from stage 2 to stage 5 takes an average of 3 years, although the range is 11 2 to 6 years. Pubic hair develops during this time, and axillary hair appears 2 years after the onset of pubic hair. The beginning of breast development precedes menarche by approximately 2 years. Menarche occurs in breast development stage 3 or 4, usually just after the peak of the adolescent growth spurt, which occurs around age 12 years.

During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly. What additional finding would the nurse assess for to confirm this suspicion? a. Exophthalmos b. Bowed long bones c. Acorn-shaped cranium d. Coarse facial features

ANS: D Acromegaly is the excessive secretion of growth hormone that creates an enlarged skull and thickened cranial bones. Patients will have elongated heads, massive faces, prominent noses and lower jaws, heavy eyebrow ridges, and coarse facial features. Exophthalmos is associated with hyperthyroidism. Bowed long bones and an acorn-shaped cranium result from Paget disease.

A 9-year-old girl is in the clinic for a sport physical examination. After some initial shyness she finally asks, "Am I normal? I don't seem to need a bra yet, but I have some friends who do. What if I never get breasts?" Which response by the nurse is best? a. "Don't worry, you still have plenty of time to develop." b. "I know just how you feel, I was a late bloomer myself. Just be patient, and they will grow." c. "You will probably get your periods before you notice any significant growth in your breasts." d. "I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age."

ANS: D Adolescent breast development usually begins between 8 and 10 years of age. The nurse should not belittle the girl's feelings by using statements like "don't worry" or by sharing personal experiences. The beginning of breast development precedes menarche by approximately 2 years.

A 65-year-old patient remarks that she just cannot believe that her breasts "sag so much." She states it must be from a lack of exercise. What explanation should the nurse offer her? a. After menopause, only women with large breasts experience sagging. b. After menopause, sagging is usually due to decreased muscle mass within the breast. c. After menopause, a diet that is high in protein will help maintain muscle mass, which keeps the breasts from sagging. d. After menopause, the glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag.

ANS: D After menopause, the glandular tissue atrophies and is replaced with connective tissue. The fat envelope also atrophies, beginning in the middle years and becoming significant in the eighth and ninth decades of life. These changes decrease breast size and elasticity; consequently, the breasts droop and sag, looking flattened and flabby. There is no or little muscle mass in the breast, so sagging is not due to decreased muscle mass and a diet high in protein will not help minimize sagging.

The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct? a. "Your breast milk is immediately present after the delivery of your baby." b. "Breast milk is rich in protein and sugars (lactose) but has very little fat." c. "The colostrum, which is present right after birth, does not contain the same nutrients as breast milk." d. "You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy."

ANS: D After the fourth month, colostrum may be expressed. This thick yellow fluid is the precursor of milk, and it contains the same amount of protein and lactose but practically no fat. The breasts produce colostrum for the first few days after delivery. It is rich with antibodies that protect the newborn against infection; therefore, breastfeeding is important.

A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started to bleed. What would be an appropriate response by the nurse? a. "Your condition is probably due to a vitamin C deficiency." b. "I'm not sure what causes swollen and bleeding gums, but let me know if it's not better in a few weeks." c. "You need to make an appointment with your dentist as soon as possible to have this checked." d. "Swollen and bleeding gums can be caused by a change in hormonal balance during pregnancy."

ANS: D Although with gingivitis (which can be caused by a vitamin C deficiency) gum margins are red and swollen and easily bleed, a changing hormonal balance during puberty or pregnancy may also cause these symptoms. Since this patient is pregnant, a change in hormonal balance is likely the cause.

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be r/t which factor in the older adult? a. Increased vascularity of the skin b. Increased numbers of sweat and sebaceous glands c. An increase in elastin and a decrease in subcutaneous fat d. An increased loss of elastin and a decrease in subcutaneous fat

ANS: D An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, a decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging, an increasingly sedentary lifestyle, and the chance of immobility. With aging there is a decrease in the vascularity, number of sweat and sebaceous glands, and elastin not an increase.

A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these? a. Unequal chest expansion b. Increased tactile fremitus c. Atrophied neck and trapezius muscles d. Anteroposterior-to-transverse diameter ratio of 1:1

ANS: D An anteroposterior-to-transverse diameter ratio of 1:1 or barrel chest is observed in individuals with COPD because of hyperinflation of the lungs. The ribs are more horizontal, and the chest appears as if held in continuous inspiration. Neck muscles are hypertrophied from aiding in forced respiration. Chest expansion may be decreased but symmetric.

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?" How should the nurse reply? a. "Venous insufficiency is a common problem after this type of surgery." b. "Oh, you have lots of veins—you won't even notice that it has been removed." c. "You will probably experience decreased circulation after the vein is removed." d. "This vein can be removed without harming your circulation because the deeper veins in your leg are in good condition."

ANS: D As long as the femoral and popliteal veins remain intact, the superficial veins can be excised without harming circulation. The other responses are not correct. Venous insufficiency or decreased circulation is not a common problem with this procedure. The nurse should not just say "you won't even notice" but should provide more factual information.

The nurse is preparing to auscultate for heart sounds. Which technique is correct? a. Listening for all possible sounds at a time at each specified area. b. Listening to the sounds at the aortic, tricuspid, pulmonic, and mitral areas. c. Listening to the sounds only at the site where the apical pulse is felt to be the strongest. d. Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex.

ANS: D Auscultation of breath sounds should not be limited to only four locations. Sounds produced by the valves may be heard all over the precordium. The stethoscope should be inched in a rough Z pattern from the base of the heart across and down, then over to the apex; or, starting at the apex, it should be slowly worked up. Listening selectively to one sound at a time is best.

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. What does this finding indicate? a. Decreased fluid volume b. Increased cardiac output c. Narrowing of jugular veins d. Elevated pressure r/t heart failure

ANS: D Because no cardiac valve exists to separate the superior vena cava from the right atrium, the jugular veins give information about the activity on the right side of the heart. They reflect filling pressures and volume changes. Normal jugular venous pulsation is 2 cm or less above the sternal angle. Elevated pressure is more than 3 cm above the sternal angle at 45 degrees and occurs with heart failure.

The nurse is assessing color vision of a male child. Which statement is correct? a. Color vision should be checked annually until the age of 18 years. b. Color vision screening should begin at the child's 2-year checkup. c. The nurse should ask the child to identify the color of his or her clothing. d. Testing for color vision should be done once between the ages of 4 and 8 years.

ANS: D Boys should be tested only once for color vision between the ages of 4 and 8 years. Color vision is not tested in girls because it is rare in girls. Testing is performed with the Ishihara test, which is a series of polychromatic cards.

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which finding? a. Anasarca b. Scleroderma c. Pedal erythema d. Clubbing of the nails

ANS: D Clubbing of the nails occurs with congenital cyanotic heart disease and neoplastic and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases. Anasarca is bilateral or generalized edema all over the body and is not associated with pulmonary diseases. Scleroderma is tight, "hard" skin that causes problems with mobility and is not associated with pulmonary diseases. Pedal erythema is redness of the feet and is not associated with pulmonary diseases.

A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is erythema. What is the likely cause? a. Decreased amounts of bilirubin in the blood b. Excess blood in the underlying blood vessels c. Decreased perfusion to the surrounding tissues d. Excess blood in the dilated superficial capillaries

ANS: D Erythema is an intense redness of the skin caused by excess blood (hyperemia) in the dilated superficial capillaries.

Which of these statements describes the closure of the valves in a normal cardiac cycle? a. The pulmonic valve closes slightly before the aortic valve. b. The aortic valve closes slightly before the tricuspid valve. c. Both the tricuspid and pulmonic valves close at the same time. d. The tricuspid valve closes slightly later than the mitral valve.

ANS: D Events occur just slightly later in the right side of the heart because of the route of myocardial depolarization. As a result, two distinct components to each of the heart sounds exist, and sometimes they can be heard separately. In the first heart sound, the mitral component (M1) closes just before the tricuspid component (T1).

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. "Breastfed babies eat more often than infants on formula." c. "Breastfeeding is second nature, and every woman can do it." d. "Breastfeeding provides the perfect food and antibodies for your baby."

ANS: D Exclusively breastfeeding for 6 months provides the perfect food and antibodies for the baby, decreases the risk for ear infections, promotes bonding, and provides relaxation. The other statements are not accurate.

The nurse is conducting a child safety class for new mothers. Which factor places young children at risk for ear infections? a. Family history b. Air conditioning c. Excessive cerumen d. Passive cigarette smoke

ANS: D Exposure to passive and gestational smoke is a risk factor for ear infections in infants and children. A family history of ear infections, air conditioning, or excessive cerumen are at not risk factors for ear infections.

A 52-year-old patient describes the presence of occasional floaters or spots moving in front of his eyes. How should the nurse proceed? a. Examine the retina to determine the number of floaters. b. Presume the patient has glaucoma and refer him for further testing. c. Consider these to be abnormal findings, and refer him to an ophthalmologist. d. Understand that floaters are usually insignificant and are caused by condensed vitreous fibers.

ANS: D Floaters are a common sensation with myopia or after middle age and are attributable to condensed vitreous fibers. Floaters or spots are not usually significant, but the acute onset of floaters may occur with retinal detachment. The floaters or spots would not be visible for the nurse to see or count. A decrease in peripheral vision is a symptom of glaucoma, not floaters.

A 32-year-old woman is at the clinic for "little white bumps in my mouth." During the assessment, the nurse notes that she has a 0.5-cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient? a. "These spots indicate an infection such as strep throat." b. "These bumps could be indicative of a serious lesion, so I will refer you to a specialist." c. "This condition is called leukoplakia and can be caused by chronic irritation such as with smoking." d. "These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition."

ANS: D Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and are not significant. Chalky white, thick, raised patches would indicate leukoplakia. In strep throat, the examiner would see tonsils that are bright red, swollen, and may have exudates or white spots. In strep throat, the examiner would see tonsils that are bright red, swollen, and may have exudates or white spots and leukoplakia would appear as chalky white, thick, raised patches. These findings are not indicative of a serious lesion but are fordyce granules. Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and are not significant.

Which of these clinical situations would the nurse consider to be outside normal limits? a. A patient has had one pregnancy and states that she believes she may be entering menopause. Her breast examination reveals breasts that are soft and slightly sagging. b. A patient has never been pregnant. Her breast examination reveals large pendulous breasts that have a firm, transverse ridge along the lower quadrant in both breasts. c. A patient has never been pregnant and reports that she should begin her period tomorrow. Her breast examination reveals breast tissue that is nodular and somewhat engorged. She states that the examination was slightly painful. d. A patient has had two pregnancies, and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipples.

ANS: D If any discharge appears, the nurse should note its color and consistency. Except in pregnancy and lactation, any discharge is abnormal. In nulliparous women, normal breast tissue feels firm, smooth, and elastic; after pregnancy, the tissue feels soft and loose. Premenstrual engorgement is normal, and consists of a slight enlargement, tenderness to palpation, and a generalized nodularity. A firm, transverse ridge of compressed tissue in the lower quadrants, known as the inframammary ridge, is especially noticeable in large breasts.

A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next? a. Refer the patient to an ophthalmologist or optometrist for further evaluation. b. Assess whether the patient can count the nurse's fingers when they are placed in front of his or her eyes. c. Ask the patient to put on his or her reading glasses and attempt to read the Snellen chart again. d. Shorten the distance between the patient and the chart until the letters are seen, and record that distance.

ANS: D If the person is unable to see even the largest letters when standing 20 feet from the chart, then the nurse should shorten the distance to the chart until the letters are seen, and record that distance (e.g., "10/200"). If visual acuity is even lower, then the nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight. If vision is poorer than 20/30, then a referral to an ophthalmologist or optometrist is necessary, but the nurse must first assess the visual acuity. The nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight only if unable to see the letters on the Snellen chart when the distance is shortened. Applying reading glasses will not help with reading the Snellen chart as that is assessing far vision, not near vision.

How should the nurse perform an examination of a 2-year-old child with a suspected ear infection? a. Pull the ear up and back before inserting the speculum. b. Omit the otoscopic examination if the child has a fever. c. Ask the mother to leave the room while examining the child. d. Perform the otoscopic examination at the end of the assessment.

ANS: D In addition to its place in the complete examination, eardrum assessment is mandatory for any infant or child requiring care for an illness or fever. For the infant or young child, the timing of the otoscopic examination is best toward the end of the complete examination because many young children protest vigorously during this procedure and it is difficult to re-establish cooperation afterward. When performing an ear examination on a 2-year-old child, with or without a suspected ear infection, the pinna should be pulled down (not up) and back. In addition to its place in the complete examination, eardrum assessment is mandatory for any infant or child requiring care for an illness or fever, so should not be omitted. Rather than asking the parent to leave the room, the nurse should enlist the parent's help in holding the child to protect the eardrum from injury.

When assessing a patient's pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. What do these findings indicate? a. Pulsus alternans b. Pulsus bisferiens c. Pulsus bigeminus d. Pulsus paradoxus

ANS: D In pulsus paradoxus, beats have weaker amplitude with inspiration and stronger amplitude with expiration and is best determined during blood pressure measurement; reading decreases (>10 mm Hg) during inspiration and increases with expiration. In pulsus alternans, the rhythm is regular, but force varies, with alternating beats of large and small amplitude. In pulsus bisferiens, each pulse has two strong systolic peaks with a dip in between and is best assessed at the carotid artery. In pulsus bigeminus, the beats are coupled, every other beat comes early, or normal beat is followed by a premature beat. The force of the premature beat is decreased because of shortened cardiac filling time. This patient's weaker amplitude during inspiration and stronger during expiration is pulsus paradoxus.

The nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory system of the older adult? a. Decrease in small airway closure occurs, leading to problems with atelectasis. b. Severe dyspnea is experienced on exertion, resulting from changes in the lungs. c. Respiratory muscle strength increases to compensate for a decreased vital capacity. d. Lungs are less elastic and distensible, which decreases their ability to collapse and recoil.

ANS: D In the aging adult, the lungs are less elastic and distensible, which decreases their ability to collapse and recoil. Vital capacity is decreased, and a loss of intra-alveolar septa occurs, causing less surface area for gas exchange. The lung bases become less ventilated, and the older person is at risk for dyspnea with exertion beyond his or her usual workload.

During the aging process, the hair can look gray or white and begin to feel thin and fine. What should the nurse understand causes this? a. Increased adipose tissue b. Increase in the vascularity of the scalp c. Decrease in the number of functioning phagocytes d. Decrease in the number of functioning melanocytes

ANS: D In the aging hair matrix, the number of functioning melanocytes decreases; as a result, the hair looks gray or white and feels thin and fine. The other options are not correct. Adipose tissue does not affect the color or texture of the hair and does not increase with aging, but decreases. Vascularity of the skin, including the scalp, decreases with aging, not increases. Phagocytes are cells that help protect the body from foreign microorganisms. What does cause the hair to look gray or white and feel thin and fine in the aging hair matrix is a decrease in the number of functioning melanocytes in the hair matrix that occurs with aging.

The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, "I think she is getting her first tooth because she has started drooling a lot." What is the best response by the nurse? a. "You're right, drooling is usually a sign of the first tooth." b. "It would be unusual for a 3-month-old to be getting her first tooth." c. "This could be the sign of a problem with the salivary glands." d. "She is just starting to salivate and hasn't learned to swallow the saliva."

ANS: D In the infant, salivation starts at 3 months. The baby will drool for a few months before learning to swallow the saliva. This drooling does not herald the eruption of the first tooth, although many parents think it does. Although many parents think the start of drooling signals the eruption of the first tooth, it does not. Although teeth usually erupt between 6 and 24 months, the nurse should not just say it would be unusual for a 3-month-old to be getting her first tooth as that does not address the issue of the drooling. It is also not a sign of a problem.

When inspecting the anterior chest of an adult, the nurse should include which assessment? a. Diaphragmatic excursion b. Symmetric chest expansion c. Presence of breath sounds d. Shape and configuration of the chest wall

ANS: D Inspection of the anterior chest includes shape and configuration of the chest wall; assessment of the patient's level of consciousness and the patient's skin color and condition; quality of respirations; presence or absence of retraction and bulging of the intercostal spaces; and use of accessory muscles. Symmetric chest expansion is assessed by palpation. Diaphragmatic excursion is assessed by percussion of the posterior chest. Breath sounds are assessed by auscultation.

The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure? a. Thickness or bulging of the lens b. Posterior chamber as it accommodates increased fluid c. Contraction of the ciliary body in response to the aqueous within the eye d. Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber

ANS: D Intraocular pressure is determined by a balance between the amount of aqueous produced and the resistance to its outflow at the angle of the anterior chamber. The other responses are incorrect.

The nurse is assessing the skin of a patient who has acquired immunodeficiency syndrome (AIDS) and notices multiple patchlike lesions on the temple and beard area that are faint pink in color. What does the nurse suspect? a. Angiomas b. Herpes zoster c. Measles (rubeola) d. Kaposi's sarcoma

ANS: D Kaposi's sarcoma is a vascular tumor that, in the early stages, appears as multiple, patchlike, faint pink lesions over the patient's temple and beard areas. Cherry (senile) angiomas are small (1 to 5 mm), smooth, slightly raised bright red dots that commonly appear on the trunk in all adults over 30 years old. Herpes zoster causes vesicles up to 1 cm in size that are elevated with a cavity containing clear fluid. Measles is characterized by a red-purple maculopapular blotchy rash that appears on the third or fourth day of illness. The rash is first observed behind the ears, spreads over the face, and then spreads over the neck, trunk, arms, and legs. The faint pink patchlike lesions on this patient's temple and beard appear to be Kaposi's sarcoma.

A patient has had a "terrible itch" for several months that he has been continuously scratching. What might the nurse expect to find upon physical examination? a. A keloid b. A fissure c. Keratosis d. Lichenification

ANS: D Lichenification results from prolonged, intense scratching that eventually thickens the skin and produces tightly packed sets of papules. A keloid is a hypertrophic scar. Keratoses are lesions that are raised, thickened areas of pigmentation that appear crusted, scaly, and warty. A fissure is a linear crack with abrupt edges, which extends into the dermis; it can be dry or moist. A patient with itches often develops lichenification.

A mother brings her 2-month-old daughter in for an examination and says, "My daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong?" How should the nurse respond? a. "Perhaps that could be a result of your dietary intake during pregnancy." b. "Your baby may have craniosynostosis, a disease of the sutures of the skull." c. "That 'soft spot' may be an indication of cretinism or congenital hypothyroidism." d. "That 'soft spot' is normal, and actually allows for growth of the brain during the first year of your baby's life."

ANS: D Membrane-covered "soft spots" allow for growth of the brain during the first year of life. They gradually ossify; the triangular-shaped posterior fontanel is closed by 1 to 2 months, and the diamond-shaped anterior fontanel closes between 9 months and 2 years.

A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which complication may occur? a. Rubella b. Leukoplakia c. Scarlet fever d. Rheumatic fever

ANS: D Untreated strep throat may lead to rheumatic fever. When performing a health history, the patient should be asked whether his or her sore throat has been documented as streptococcal

A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. What should the nurse suspect? a. Hypertension b. Cluster headaches c. Tension headaches d. Migraine headaches

ANS: D Migraine headaches tend to be supraorbital, retro-orbital, or frontotemporal with a throbbing quality. They are severe in quality and are relieved by lying down. Migraines are associated with a family history of migraine headaches. Although hypertension may cause headaches, the blood pressure needs to be severely elevated and would likely not be relieved with lying down. Cluster headaches produce pain around the eye, temple, forehead, and cheek and are unilateral and always on the same side of the head. They are excruciating and occur once or twice per day and last 1 2 to 2 hours each. Tension headaches are occipital, frontal, or with bandlike tightness.

A father brings in his 2-month-old infant to the clinic because the infant has had diarrhea for the last 24 hours. He says his baby has not been able to keep any formula down and that the diarrhea has been at least every 2 hours. The nurse suspects dehydration. Where should the nurse test for skin mobility and turgor? a. Over the sternum b. On the forehead c. On the forearms d. Over the abdomen

ANS: D Mobility and turgor are tested over the abdomen in an infant. Poor turgor, or tenting, indicates dehydration or malnutrition. The other sites are not appropriate for checking skin turgor in an infant.

A woman who is in the second trimester of pregnancy mentions that she has had "more nosebleeds than ever" since she became pregnant. What is the likely reason for this? a. Inappropriate use of nasal sprays b. A problem with the patient's coagulation system c. Increased susceptibility to colds and nasal irritation d. Increased vascularity in the upper respiratory tract as a result of the pregnancy

ANS: D Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract. Inappropriate use of nasal sprays often causes rebound congestion or swelling, but not usually nosebleeds. Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract so this patient's nose bleeds are more likely to be due to the increased vascularity in the upper respiratory tract than to a problem with the coagulation system or an increased susceptibility to colds and nasal irritation

The nurse is explaining to a student nurse the four areas in the body where lymph nodes are accessible. Which areas should the nurse include in her explanation to the student? a. Head, breasts, groin, and abdomen b. Arms, breasts, inguinal area, and legs c. Head and neck, arms, breasts, and axillae d. Head and neck, arms, inguinal area, and axillae

ANS: D Nodes are located throughout the body, but they are accessible to examination only in four areas: head and neck, arms, inguinal region, and axillae.

The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true? a. Percussion is easier in patients who are obese. b. Percussion is a useful tool for outlining the heart's borders. c. Only expert health care providers should attempt percussion of the heart. d. Studies show that percussed cardiac borders do not correlate well with the true cardiac border.

ANS: D Numerous comparison studies have shown that the percussed cardiac border correlates only moderately with the true cardiac border. Percussion is of limited usefulness with the female breast tissue, in a person who is obese, or in a person with a muscular chest wall. Chest x-ray images or echocardiographic examinations are significantly more accurate in detecting heart enlargement.

The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant? a. Sphenoid sinuses are full size at birth. b. Maxillary sinuses reach full size after puberty. c. Frontal sinuses are fairly well developed at birth. d. Maxillary and ethmoid sinuses are the only sinuses present at birth.

ANS: D Only the maxillary and ethmoid sinuses are present at birth. The sphenoid sinuses are minute at birth and develop after puberty. The frontal sinuses are absent at birth, are fairly well developed at age 7 to 8 years, and reach full size after puberty. The sphenoid sinuses are minute at birth and develop after puberty. The frontal sinuses are absent at birth, are fairly well developed at age 7 to 8 years, and reach full size after puberty. Only the maxillary and ethmoid sinuses are present at birth but the maxillary sinus does not reach full size until all permanent teeth have erupted (not after puberty).

An ophthalmic examination reveals papilledema. What does this finding indicate? a. Retinal detachment b. Diabetic retinopathy c. Acute-angle glaucoma d. Increased intracranial pressure

ANS: D Papilledema, or choked disk, is a serious sign of increased intracranial pressure, which is caused by a space-occupying mass such as a brain tumor or hematoma. This pressure causes venous stasis in the globe, showing redness, congestion, and elevation of the optic disc, blurred margins, hemorrhages, and absent venous pulsations. Papilledema is not associated with the conditions in the other responses. Papilledema is not associated with retinal detachment, diabetic retinopathy, or acute-angle glaucoma.

During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition? a. Asthma b. Emphysema c. Airway obstruction d. Pulmonary consolidation

ANS: D Pathologic conditions that increase lung density, such as pulmonary consolidation, will enhance the transmission of voice sounds, such as bronchophony. Asthma, emphysema, and airway obstruction do not increase lung density and thus, do not enhance the transmission of voices sounds.

A newborn infant has Down syndrome. During the skin assessment, the nurse notices a transient mottling in the trunk and extremities in response to the cool temperature in the examination room. The infant's mother also notices the mottling and asks what it is. What should the nurse tell the mother that this mottling is called? a. Carotenemia b. Acrocyanosis c. Café au lait d. Cutis marmorata

ANS: D Persistent or pronounced cutis marmorata occurs with infants born with Down syndrome or those born prematurely and is a transient mottling in the trunk and extremities in response to cool room temperatures. Carotenemia produces a yellow-orange color in light-skinned persons. Acrocyanosis is a bluish color around the lips, hands and fingernails, and feet and toenails. A café au lait spot is a large round or oval patch of light-brown pigmentation.

The mother of a 2-year-old toddler is concerned about the upcoming placement of tympanostomy tubes in her son's ears. The nurse would include which of these statements in the teaching plan? a. The tubes are placed in the inner ear. b. The tubes are used in children with sensorineural loss. c. The tubes are permanently inserted during a surgical procedure. d. The purpose of the tubes is to decrease the pressure and allow for drainage.

ANS: D Polyethylene tubes are surgically inserted into the eardrum (not the inner ear) to relieve middle ear pressure and to promote drainage of chronic or recurrent middle ear infections (not for sensorineural hearing loss). The tube is not permanent but spontaneously extrudes in 6 months to 1 year.

While obtaining a health history from the mother of a 1-year-old child, the nurse notices that the baby has had a bottle in his mouth the entire time. The mother states, "It makes a great pacifier." What is the best response by the nurse? a. "You're right. Bottles make very good pacifiers." b. "Using a bottle as a pacifier is better for the teeth than thumb-sucking." c. "It's okay to use a bottle as long as it contains milk and not juice." d. "Prolonged use of a bottle can increase the risk for tooth decay and ear infections."

ANS: D Prolonged bottle use during the day or when going to sleep places the infant at risk for tooth decay and middle ear infections.

A 31-year-old patient tells the nurse that he has noticed pain in his left ear when people speak loudly to him. What does this finding indicate? a. A cerumen impaction b. Normal for people of his age c. Possible middle ear infection d. A characteristic of recruitment

ANS: D Recruitment is significant hearing loss occurring when speech is at low intensity, but sound actually becomes painful when the speaker repeats at a louder volume. The other responses are not correct. A cerumen impaction and ear infection do not cause these symptoms and these are not normal findings. Instead, this patient's symptoms are a characteristic of recruitment.

An assessment of a 23-year-old patient reveals the following: an auricle that is tender and reddish-blue in color with small vesicles. The nurse would need to know additional information that includes which of these? a. Any change in ability to hear b. Any recent drainage from the ear c. Recent history of trauma to the ear d. Any prolonged exposure to extreme cold

ANS: D Reddish-blue discoloration and swelling of the auricle are manifestations of frostbite so the nurse should ask about any prolonged exposure to extreme cold rather than changes in ability to hear or drainage or recent trauma to the ear. Frostbite causes reddish-blue discoloration and swelling of the auricle after exposure to extreme cold. Vesicles or bullae may develop, and the person feels pain and tenderness.

When examining the nares of a 45-year-old patient who is experiencing rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause? a. Nasal polyps b. Acute rhinitis c. Acute sinusitis d. Allergic rhinitis

ANS: D Rhinorrhea, itching of the nose and eyes, and sneezing are manifestations of allergic rhinitis. On physical examination, serous edema is noted, and the turbinates usually appear pale with a smooth, glistening surface. Nasal polyps appear as smooth, pale gray nodules which are overgrowths of mucosa most commonly caused by chronic allergic rhinitis and often cause absence of sense of smell and a sensation of a "valve that moves" in the nose when breathing. Acute rhinitis initially presents with clear, watery discharge (rhinorrhea) which later become purulent, with sneezing nasal itching, stimulation of cough reflex, and inflamed mucosa with dark red and swollen turbinates which cause nasal obstruction. With sinusitis, there is usually mucopurulent drainage, nasal obstruction, facial pain or pressure, and may have fever, chills, and malaise. This patient's symptoms of rhinorrhea, itching of the nose and eyes, and sneezing are manifestations of allergic rhinitis. On physical examination, serous edema is noted, and the turbinates usually appear pale with a smooth, glistening surface.

A patient comes into the clinic complaining of facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. What do these findings indicate? a. Nasal polyps b. Frontal sinusitis c. Posterior epistaxis d. Maxillary sinusitis

ANS: D Signs of maxillary sinusitis include facial pain after upper respiratory infection, red swollen nasal mucosa, swollen turbinates, and purulent discharge. The person also has fever, chills, and malaise. With maxillary sinusitis, dull throbbing pain occurs in the cheeks and teeth on the same side, and pain with palpation is present. With frontal sinusitis, pain is above the supraorbital ridge. Nasal polyps appear as smooth, pale gray nodules which are overgrowths of mucosa most commonly caused by chronic allergic rhinitis and often cause absence of sense of smell and a sensation of a "valve that moves" in the nose when breathing. Epistaxis is a nosebleed and the most common site of bleeding is the Kiesselbach plexus in the anterior septum. With frontal sinusitis, pain is above the supraorbital ridge. This patient's signs and symptoms are indicative of maxillary sinusitis. Signs of maxillary sinusitis include facial pain after upper respiratory infection, red swollen nasal mucosa, swollen turbinates, and purulent discharge. The person also has fever, chills, and malaise. With maxillary sinusitis, dull throbbing pain occurs in the cheeks and teeth on the same side, and pain with palpation is present.

Which sequence does the electrical stimulus of the cardiac cycle follow? a. AV node → SA node → bundle of His b. Bundle of His → AV node → SA node c. SA node → AV node → bundle of His → bundle branches d. AV node → SA node → bundle of His → bundle branches

ANS: D Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. The current flows in an orderly sequence, first across the atria to the AV node low in the atrial septum. There it is delayed slightly, allowing the atria the time to contract before the ventricles are stimulated. Then the impulse travels to the bundle of His, the right and left bundle branches, and then through the ventricles.

During a morning assessment, the nurse notices that the patient's sputum is frothy and pink. Which condition could this finding indicate? a. Croup b. Tuberculosis c. Viral infection d. Pulmonary edema

ANS: D Sputum, alone, is not diagnostic, but some conditions have characteristic sputum production. Pink, frothy sputum indicates pulmonary edema or it may be a side effect of sympathomimetic medications. Croup is associated with a barking cough, not sputum production. Tuberculosis may produce rust-colored sputum. Viral infections may produce white or clear mucoid sputum.

When examining a patient's eyes, what should the nurse be aware that stimulation of the sympathetic branch of the autonomic nervous system causes? a. Pupillary constriction b. Adjusts the eye for near vision c. Causes contraction of the ciliary body d. Elevates the eyelid and dilates the pupil

ANS: D Stimulation of the sympathetic branch of the autonomic nervous system dilates the pupil and elevates the eyelid. Parasympathetic nervous system stimulation causes the pupil to constrict. The muscle fibers of the iris contract the pupil in bright light to accommodate for near vision. The ciliary body controls the thickness of the lens. Parasympathetic nervous system stimulation, not sympathetic nervous system, causes the pupil to constrict. The muscle fibers of the iris contract the pupil in bright light to accommodate for near vision, not sympathetic nervous system stimulation.

The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has a "lazy eye". What should the nurse do next? a. Examine the external structures of the eye. b. Assess visual acuity with the Snellen eye chart. c. Assess the child's visual fields with the confrontation test. d. Test for strabismus by performing the corneal light reflex test.

ANS: D Testing for strabismus is done by performing the corneal light reflex test and the cover test. The Snellen eye chart and confrontation test are not used to test for strabismus. Examining the external structures of the eye, assessing visual acuity with the Snellen eye chart, and assessing for confrontation are not used to test for strabismus.

In assessing for an S4 heart sound, what part of the stethoscope should the nurse use and in what location? a. Bell of the stethoscope at the base with the patient leaning forward b. Diaphragm of the stethoscope in the aortic area with the patient sitting c. Diaphragm of the stethoscope in the pulmonic area with the patient supine d. Bell of the stethoscope at the apex with the patient in the left lateral position

ANS: D The S4 is a ventricular filling sound that occurs when the atria contract late in diastole and is heard immediately before the S1. The S4 is a very soft sound with a very low pitch. The nurse needs a good bell and must listen for this sound. An S4 is heard best at the apex, with the person in the left lateral position.

The nurse is assessing a patient's eyes for the accommodation response and would expect to see which normal finding? a. Dilation of the pupils b. Consensual light reflex c. Disconjugate movement of the eyes d. Convergence of the axes of the eyes

ANS: D The accommodation reaction includes pupillary constriction and convergence of the axes of the eyes. The other responses are not correct. Dilation of the pupil occurs with dimming the lights and having the person look in the distance, not when assessing for accommodation. Consensual light reflex is simultaneous constriction of the pupil opposite the pupil that light is being shined on. Conjugate, not disconjugate, movement of the eye (the axes of both eyes remains parallel while moving) is a normal finding.

A 19-year-old college student is brought to the emergency department with a severe headache he describes as, "Like nothing I've ever had before." His temperature is 40° C, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem? a. Head injury b. Cluster headache c. Migraine headache d. Meningeal inflammation

ANS: D The acute onset of neck stiffness and pain along with headache and fever occurs with meningeal inflammation. A severe headache in an adult or child who has never had it before is a red flag. Head injury and cluster or migraine headaches are not associated with a fever or stiff neck.

During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? a. Third left intercostal space at the midclavicular line b. Fourth left intercostal space at the sternal border c. Fourth left intercostal space at the anterior axillary line d. Fifth left intercostal space at the midclavicular line

ANS: D The apical impulse should occupy only one intercostal space, the fourth or fifth, and it should be at or medial to the midclavicular line.

The nurse educator is preparing an education module on skin, hair, and nails for the nursing staff. Which of these statements about the dermal layer of the skin should be included in the module? a. Contains mostly fat cells b. Consists mostly of keratin c. Is replaced every 4 weeks d. Contains sensory receptors

ANS: D The dermis consists mostly of collagen, has resilient elastic tissue that allows the skin to stretch, and contains nerves, sensory receptors, blood vessels, and lymphatic vessels. It is not replaced every 4 weeks. The dermal layer consists mostly of collagen, not fat or keratin cells and is not replaced every 4 weeks. The dermis has resilient elastic tissue that allows the skin to stretch, and contains nerves, sensory receptors, blood vessels, and lymphatic vessels.

The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation? a. Behind the knee b. Over the lateral malleolus c. In the groove behind the medial malleolus d. Lateral to the extensor tendon of the great toe

ANS: D The dorsalis pedis artery is located on the dorsum of the foot. The nurse should palpate just lateral to and parallel with the extensor tendon of the big toe. The popliteal artery is palpated behind the knee. The posterior tibial pulse is palpated in the groove between the malleolus and the Achilles tendon. No pulse is palpated at the lateral malleolus.

The nurse educator is preparing an education module on skin, hair, and nails for the nursing staff. Which of these statements about the epidermal layer of the skin should be included in the module? a. Highly vascular b. Thick and tough c. Thin and nonstratified d. Replaced every 4 weeks

ANS: D The epidermis is thin yet tough, replaced every 4 weeks, avascular, and stratified into several zones. The epidermis is avascular, not highly vascular; thin and tough, not thick; and stratified into several zones, not nonstratified. The epidermis is also replaced every 4 weeks.

When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next? a. Assess the patient's abdomen, and notice any tenderness. b. Carefully assess the cervical lymph nodes, and check for any enlargement. c. Ask additional health history questions regarding any recent ear infections or sore throats. d. Examine the patient's lower arm and hand, and check for the presence of infection or lesions

ANS: D The epitrochlear nodes are located in the antecubital fossa and drain the hand and lower arm. The nurse should examine the patient's lower arm and hand, and check for the presence of infection or lesions. The other actions are not correct for this assessment finding. The epitrochlear nodes are located in the antecubital fossa and drain the hand and lower arm, thus, there is no need to assess the patient's abdomen, cervical lymph nodes, or ask about recent ear infections or sore throats based on an enlarged epitrochlear lymph node. Instead, the nurse should examine the patient's lower arm and hand, and check for the presence of infection or lesions.

What is the tissue that connects the tongue to the floor of the mouth called? a. Uvula b. Palate c. Papillae d. Frenulum

ANS: D The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth. The uvula is the free projection hanging down from the middle of the soft palate. The palate is the arching roof of the mouth. Papillae are the rough, bumpy elevations on the tongue's dorsal surface. The uvula is the free projection hanging down from the middle of the soft palate. The palate is the arching roof of the mouth. Papillae are the rough, bumpy elevations on the tongue's dorsal surface. The frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth

The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse? a. "It is unusual for a small child to have frequent ear infections unless something else is wrong." b. "We need to check the immune system of your son to determine why he is having so many ear infections." c. "Ear infections are not uncommon in infants and toddlers because they tend to have more cerumen in the external ear." d. "Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily."

ANS: D The infant's eustachian tube is relatively shorter and wider than the adult's eustachian tube, and its position is more horizontal; consequently, pathogens from the nasopharynx can more easily migrate through to the middle ear. The other responses are not appropriate. It is not unusual for a small child to have frequent ear infections, thus, it is not necessary to check the immune system. The reason that ear infections in infants and toddlers is not uncommon is not due to more cerumen but because the infant's eustachian tubes are relatively shorter and wider than the adult's eustachian tube, and its position is more horizontal; consequently, pathogens from the nasopharynx can more easily migrate through to the middle ear.

In an individual with otitis externa, which of these signs would the nurse expect to find on assessment? a. Rhinorrhea b. Periorbital edema c. Pain over the maxillary sinuses d. Enlarged superficial cervical nodes

ANS: D The lymphatic drainage of the external ear flows to the parotid, mastoid, and superficial cervical nodes. The signs are severe swelling of the canal, inflammation, and tenderness. Rhinorrhea, periorbital edema, and pain over the maxillary sinuses do not occur with otitis externa.

During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she first started using it. Which is the best response by the nurse? a. "You should never use over-the-counter nasal sprays because of the risk for addiction." b. "You should try switching to another brand of medication to prevent this problem." c. "Continuing to use this spray is important to keep your allergies under control." d. "Frequent use of these nasal medications irritates the lining of the nose and may cause rebound swelling."

ANS: D The misuse of over-the-counter nasal medications irritates the mucosa and causes the blood vessels to become swollen, rebound swelling, which is a common problem.

The nurse is assessing for clubbing of the fingernails. Which is the best description of clubbing? a. Nail bases that are firm and slightly tender b. Curved nails with a convex profile and ridges across the nails c. Nail bases that feel spongy with an angle of the nail base of 150 degrees d. Nail bases with an angle of 180 degrees or greater and nail bases that feel spongy

ANS: D The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy.

Which vein(s) is(are) responsible for most of the venous return in the arm? a. Deep b. Ulnar c. Subclavian d. Superficial

ANS: D The superficial veins of the arms are in the subcutaneous tissue and are responsible for most of the venous return.

During a health history interview, a female patient states that she has noticed a few drops of clear discharge from her right nipple. What should the nurse do next? a. Ask her if she is possibly pregnant. b. Immediately contact the physician to report the discharge. c. Immediately obtain a sample for culture and sensitivity testing. d. Ask the patient some additional questions about the medications she is taking.

ANS: D The use of some medications, such as oral contraceptives, phenothiazines, diuretics, digitalis, steroids, methyldopa, and calcium channel blockers, may cause clear nipple discharge. Bloody or blood-tinged discharge from the nipple, not clear, is significant, especially if a lump is also present. In the pregnant female, colostrum may be expressed after the fourth month of pregnancy, but colostrum would be a thick, yellowish liquid, not clear. In the pregnant female, colostrum would be a thick, yellowish liquid, and it would be normally expressed after the fourth month of pregnancy.

The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place them at a higher risk for breast cancer? a. 37-year-old who is slightly overweight b. 42-year-old who has had ovarian cancer c. 45-year-old who has never been pregnant d. 66-year-old whose mother had breast cancer

ANS: D The woman at highest risk is the 66-year-old woman whose mother had breast cancer. This woman has two risk factors for breast cancer with >4.0 relative risk, which are her age (≥65) and a first-degree relative (her mother) with breast cancer. The 37-year-old woman who is slightly overweight does not have any risk factors for breast cancer. The 42-year-old woman who has had ovarian cancer has one risk factor for breast cancer with a relative risk for 1.1 to 2.0 and that is her personal history of ovarian cancer. The 45-year-old woman who has never been pregnant has one risk factor for breast cancer with a relative risk for 1.1 to 2.0 and that is having no full-term pregnancies.

The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? a. Have the patient bend over and touch her toes. b. Have the patient lie down on her left side and observe for any retraction. c. Have the patient shift from a supine position to a standing position, and note any lag or retraction. d. Have the patient slowly lift her arms above her head, and note any retraction or lag in movement

ANS: D The woman should be directed to change position while checking the breasts for signs of skin retraction. Initially, she should be asked to lift her arms slowly over her head. Both breasts should move up symmetrically. Retraction signs are due to fibrosis in the breast tissue, usually caused by growing neoplasms. The nurse should notice whether movement of one breast is lagging.

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. What do these findings most likely indicate? a. Heart failure b. Aortic stenosis c. Pulmonary edema d. Mitral regurgitation

ANS: D These findings are consistent with mitral regurgitation. Its subjective findings include fatigue, palpitation, and orthopnea, and its objective findings are (1) a thrill in systole at the apex; (2) a lift at the apex; (3) the apical impulse displaced down and to the left; (4) the S1 is diminished, the S2 is accentuated, and the S3 at the apex is often present; and (5) a pansystolic murmur that is often loud, blowing, best heard at the apex, and radiating well to the left axilla.

The nurse is assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of what disease or disorder? a. Measles b. Leukemia c. A carcinoma d. Acquired immunodeficiency syndrome (AIDS)

ANS: D This dark red confluent macule on the hard palate is an oral Kaposi's sarcoma. An oral Kaposi's sarcoma is a bruiselike, dark red or violet, confluent macule that usually occurs on the hard palate but may also appear on the soft palate or gingival margin. Oral lesions such as a Kaposi's sarcoma are among the earliest lesions to develop with AIDS.

During an inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. What does this finding most likely indicate? a. Systolic murmur b. Diastolic murmur c. Enlargement of the left ventricle d. Enlargement of the right ventricle

ANS: D This movement along the sternal border is an apical impulse. Normally the examiner may or may not see an apical impulse, but when visible, it occupies the fourth or fifth intercostal space at or inside the midclavicular line. A heave or lift is a sustained forceful thrusting of the ventricle during systole. It occurs with ventricular hypertrophy as a result of increased workload. A right ventricular heave is seen at the sternal border, as in this patient; a left ventricular heave is seen at the apex.

The mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short-time hungry again. What other information would the nurse want to have? a. Infant's sleeping position b. Sibling history of eating disorders c. Amount of background noise when eating d. Presence of dyspnea or diaphoresis when sucking

ANS: D To screen for heart disease in an infant, the focus should be on feeding. Fatigue during feeding should be noted. An infant with heart failure takes fewer ounces each feeding, becomes dyspneic with sucking, may be diaphoretic, and then falls into exhausted sleep and awakens after a short -time hungry again. The infant's sleeping position, sibling history of eating disorders, and amount of background noise with eating are not r/t the symptoms this infant is experiencing. These symptoms are characteristic of heart disease.

The nurse is reviewing the anatomy and physiologic functioning of the heart. Which statement best describes what is meant by atrial kick? a. The atria contract during systole and attempt to push against closed valves. b. Contraction of the atria at the beginning of diastole can be felt as a palpitation. c. Atrial kick is the pressure exerted against the atria as the ventricles contract during systole. d. The atria contract toward the end of diastole and push the remaining blood into the ventricles.

ANS: D Toward the end of diastole, the atria contract and push the last amount of blood (approximately 25% of stroke volume) into the ventricles. This active filling phase is called presystole, or atrial systole, or sometimes the atrial kick.

A mother brings her 10-year-old daughter into the clinic for an examination of the scalp and hair. She states that the child has developed irregularly shaped patches with broken-off, stublike hair in some places; she is worried that this condition could be some form of premature baldness. What is the best response by the nurse? a. "This looks like folliculitis which can be treated with an antibiotic." b. "This sounds like traumatic alopecia which can be treated with antifungal medications." c. "This appears to be tinea capitis which is highly contagious and needs immediate attention." d. "This appears to be trichotillomania. Does your daughter have a habit of absentmindedly twirling her hair?"

ANS: D Trichotillomania, self-induced hair loss, is usually due to habit. It forms irregularly shaped patches with broken-off, stublike hairs of varying lengths. A person is never completely bald. It occurs as a child absentmindedly rubs or twirls the area while falling asleep, reading, or watching television. Folliculitis is inflammation of hair follicles which causes a pustule with a hair visible in the center. Traumatic alopecia is not a real term. Traction alopecia is hair loss along the hairline, part in the hair or scattered that is caused by trauma such as tight braids, ponytails, barretts, cornrows, and hair weaves. Tinea capitis is rounded patchy hair loss on the scalp, leaving broken-off hairs, pustules, and scales on the skin, and is caused by a fungal infection. Tinea capitis is highly contagious.

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? a. "Do you ever notice ringing or crackling in your ears?" b. "When was the last time you had your hearing checked?" c. "Have you ever been told that you have any type of hearing loss?" d. "Is there any relationship between the ear pain and the discharge you mentioned?"

ANS: D Typically with perforation, ear pain occurs first and resolves after a popping sensation, then drainage occurs.

The nurse is performing an assessment. Which of these findings would cause the greatest concern? a. A painful vesicle inside the cheek for 2 days b. The presence of moist, nontender Stensen's ducts c. Stippled gingival margins that snugly adhere to the teeth d. An ulceration on the side of the tongue with rolled edges

ANS: D Ulceration on the side or base of the tongue or under the tongue raises the suspicion of cancer and must be investigated. The risk for early metastasis is present because of rich lymphatic drainage. The vesicle may be an aphthous ulcer, which is painful but not dangerous. The other responses are normal findings. The presence of moist, nontender Stensen's ducts and stippled gingival margins that snugly adhere to the teeth are normal findings. Although a painful vesicle inside the cheek for 2 days is not that uncommon or concerning, but an ulceration on the side, base, or under the tongue raises the suspicion of cancer and must be investigated. The risk for early metastasis is present because of rich lymphatic drainage. The vesicle may be an aphthous ulcer, which is painful but not dangerous.

The nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about the ABI is true? a. Normal ABI indices are from 0.5 to 1.0. b. Normal ankle pressure is slightly lower than the brachial pressure. c. The ABI is a reliable measurement of peripheral vascular disease in individuals with diabetes. d. An ABI of 0.9 to 0.7 indicates the presence of peripheral vascular disease and mild claudication.

ANS: D Use of the Doppler stethoscope is a noninvasive way to determine the extent of peripheral vascular disease. The normal ankle pressure is slightly greater than or equal to the brachial pressure. An ABI of 0.9 to 0.7 indicates the presence of peripheral vascular disease and mild claudication. The ABI is less reliable in patients with diabetes mellitus because of claudication, which makes the arteries noncompressible and may give a false high-ankle pressure.

The nurse notices that a patient's submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, what should the nurse assess? a. Infraclavicular area b. Supraclavicular area c. Area distal to the enlarged node d. Area proximal to the enlarged node

ANS: D When nodes are abnormal, the nurse should check the area into which they drain for the source of the problem. The area proximal (upstream) to the location of the abnormal node should be explored.

A 72-year-old patient has a history of hypertension and chronic lung disease. Which is an important question for the nurse to include in this patient's health history? a. "Do you use a fluoride supplement?" b. "Have you had tonsillitis in the last year?" c. "At what age did you get your first tooth?" d. "Have you noticed any dryness in your mouth?"

ANS: D With a history of hypertension and chronic lung disease, this patient is likely on medications and a side effect of antihypertensive and bronchodilator medication (and many other drugs such as antidepressants, anticholinergics, antispasmodics, and antipsychotics) is dry mouth, or xerostomia. The nurse should ask the patient if they've noticed dryness in their mouth.

A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot whistle but the nurse notes he can still raise his eyebrows. What does the nurse suspect? a. Bell palsy b. Cushing syndrome c. Parkinson syndrome d. Experienced a cerebrovascular accident (CVA) or stroke

ANS: D With an upper motor neuron lesion, as with a CVA, the patient will have paralysis of lower facial muscles, but the upper half of the face will not be affected owing to the intact nerve from the unaffected hemisphere. The person is still able to wrinkle the forehead and close the eyes. Bell palsy presents as complete paralysis of one side of the face. The person cannot wrinkle forehead, raise eyebrows, close eyelids, whistle, or show teeth on the affected side. With Cushing syndrome the person develops a rounded, "moonlike" face, prominent jowls, red cheeks, hirsutism on the upper lip, lower cheeks, and chin, and acneiform rash on the chest. The facial features characteristic of Parkinson syndrome are a flat and expressionless, "masklike," with elevated eyebrows, staring gaze, oily skin, and drooling. This patient who cannot whistle but can still raise his eyebrows has probably experienced a cerebrovascular accident.

An older adult woman is brought to the emergency department after being found lying on the kitchen floor for 2 days; she is extremely dehydrated. What would the nurse expect to see during the examination? a. Pale mucous membranes b. Smooth mucous membranes and lips c. White patches on the mucous membranes d. Dry mucous membranes and cracked lips

ANS: D With dehydration, mucous membranes appear dry and the lips look parched and cracked. The other responses are not found in dehydration. Pale mucous membranes, smooth mucous membranes and lips, and white patches on the mucous membranes are not signs of dehydration.

The nurse notices that a school-aged child has bluish-white, red-based spots in her mouth that are elevated approximately 1 to 3 mm. What other signs would the nurse expect to find in this patient? a. Pink, papular rash on the face and neck b. Pruritic vesicles over her trunk and neck c. Hyperpigmentation on the chest, abdomen, and back of the arms d. Red-purple, maculopapular, blotchy rash behind the ears and on the face

ANS: D With measles (rubeola), the examiner assesses a red-purple, blotchy rash on the third or fourth day of illness that appears first behind the ears, spreads over the face, and then over the neck, trunk, arms, and legs. The rash appears coppery and does not blanch. The bluish-white, red-based spots in the mouth are known as Koplik spots.

A patient comes to the emergency department after a boxing match, and his O.S. is almost swollen shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his O.S. The physician suspects retinal detachment. What finding would support this suspicion? a. Loss of central vision b. Loss of peripheral vision c. Sudden loss of pupillary constriction and accommodation d. Shadow or diminished vision in one quadrant or one half of the visual field

ANS: D With retinal detachment, the person has shadows or diminished vision in one quadrant or one half of the visual field. The other responses are not signs of retinal detachment. Loss of central or peripheral vision or sudden loss of pupillary constriction and accommodation are not signs of retinal detachment.

During an examination, the nurse finds that a patient's left temporal artery is tortuous and feels hardened and tender, compared with the right temporal artery. The nurse suspects which condition? a. Bell palsy b. Crepitation c. Mastoiditis d. Temporal arteritis

ANS: D With temporal arteritis, the artery appears more tortuous and feels hardened and tender. These assessment findings are not consistent with the other responses. Bell palsy presents as complete paralysis of one side of the face. The person cannot wrinkle forehead, raise eyebrows, close eyelids, whistle, or show teeth on the affected side. Crepitation is a crackling sound. Mastoiditis is an inflammation of the mastoid process which is behind the ears. The signs and symptoms this patient has are consistent with temporal arteritis. With temporal arteritis, the artery appears more tortuous and feels hardened and tender.

During an assessment, the nurse notes that the patient's apical impulse is laterally displaced and is palpable over a wide area. What does this finding indicate? a. Systemic hypertension b. Pulmonic hypertension c. Pressure overload, as in aortic stenosis d. Volume overload, as in heart failure

ANS: D With volume overload, as in heart failure and cardiomyopathy, cardiac enlargement laterally displaces the apical impulse and is palpable over a wider area when left ventricular hypertrophy and dilation are present. A thrill in the second and third right interspaces occurs with systemic hypertension and aortic stenosis and a thrill in the second and third left interspaces occurs with pulmonic hypertension.

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. Urinalysis b. Prostate biopsy c. Transrectal ultrasound d. Digital rectal examination (DRE) e. Blood test for prostate-specific antigen (PSA)

ANS: D, E Prostate cancer is typically detected by testing the blood for PSA or by a DRE. It is recommended that both PSA and DRE be offered to men annually, beginning at age 50 years. If PSA is elevated, then further laboratory work or a transrectal ultrasound (TRUS) and biopsy may be recommended.

A patient has been admitted to a hospital after the staff in the nursing home noticed a pressure ulcer in his sacral area. The nurse examines the pressure ulcer and determines that it is a stage II ulcer. Which of these findings are characteristic of a stage II pressure ulcer? (Select all that apply.) a. Intact skin appears red but is not broken. b. Patches of eschar cover parts of the wound. c. Ulcer extends into the subcutaneous tissue. d. Open blister areas have a red-pink wound bed. e. Localized redness in light skin will blanch with fingertip pressure. f. Partial thickness skin erosion is observed with a loss of epidermis or dermis

ANS: D, F Stage II pressure ulcers have partial thickness skin erosion with a loss of epidermis or also the dermis; open blisters have a red-pink wound bed. Stage I pressure ulcers have intact skin that appears red but is not broken, and localized redness in intact skin will blanche with fingertip pressure. Stage III pressure ulcers are full thickness, extending into the subcutaneous tissue; subcutaneous fat may be seen but not muscle, bone, or tendon. Stage IV pressure ulcers involve all skin layers and extend into supporting tissue, exposing muscle, bone, and tendon. Slough (stringy matter attached to the wound bed) or eschar (black or brown necrotic tissue) may be present. Intact skin that appears red but is not broken and localized redness that blanches with fingertip pressure in light skinned people both describe a Stage I pressure ulcer. Patches of eschar covering parts of the wound describe a Stage IV wound. An ulcer that extends into the subcutaneous tissue is a Stage III pressure ulcer.

The nurse is palpating an ovarian mass during an internal examination of a 63-year-old woman. Which findings of the mass's characteristics would suggest the presence of an ovarian cyst? (Select all that apply.) a. Fixed b. Poorly defined c. Heavy and solid d. Mobile and solid e. Smooth and round f. Mobile and fluctuant

ANS: E, F An ovarian cyst (fluctuant ovarian mass) is usually asymptomatic and would feel like a smooth, round, fluctuant, mobile, nontender mass on the ovary. A mass that is heavy, solid, fixed, and poorly defined suggests malignancy. A benign mass may feel mobile and solid.

BEGINNING OF CHAPTER 16 - EARS ***FOCUS ONLY ON THE AGING ADULT QUESTIONS!!

CHAPTER 16 - EARS

FOR CHAPTERS 13, 14, 15, 16, 17, 18, 19, 20, & 21 - FOCUS ON THE AGING ADULT; SKIP OR DELETE ANY OTHER QUESTIONS NOT RELATED TO THE OLDER ADULT!

SKIP OR DELETE ANY OTHER QUESTIONS NOT RELATED TO THE OLDER ADULT!

The nurse is preparing to perform an examination of the eyes. Which test will the nurse conduct to assess the patient's vision? a. Weber test b. Snellen test c. Confrontation test d. Corneal light reflex

Health Assessment - Test Bank (Exam 4)

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