NF111 Unit 4+5

The nurse is teaching breast self-examination (BSE) to a client who has had a hysterectomy. The appropriate instruction regarding when the BSE should be performed is at which time?

If the client has had a hysterectomy or is no longer menstruating, the BSE should be performed on the same day every month. Options that recommend scheduling related to menses are inappropriate because the client who had a hysterectomy would not be menstruating. It is best not to perform the BSE at ovulation time because of the hormonal changes that occur.

The nurse is instructing a client to perform a testicular self-examination (TSE). The nurse should provide the client with which information about the procedure?

The TSE is recommended monthly after a warm bath or shower when the scrotal skin is relaxed. The client should stand to examine the testicles. Using both hands, with fingers under the scrotum and thumbs on top, the client should gently roll the testicles, feeling for any lumps.

The community health nurse is instructing a group of young female clients about breast self-examination. The nurse should instruct the clients to perform the examination at which time?

The breast self-examination should be performed regularly, 7 days after the onset of the menstrual period. Performing the examination weekly is not recommended. At the onset of menstruation and during ovulation, hormonal changes occur that may alter breast tissue.

The nurse is performing a neurological assessment on a client with a head injury. The nurse should use which technique to assess the plantar reflex?

The plantar reflex is assessed by stroking the outer plantar surface of the foot from the heel to the toe. The anal reflex is assessed by stimulating the perianal area or gently inserting a gloved finger in the rectum. Pupillary response is tested using a flashlight. The pharyngeal (gag) reflex is tested by touching the back of the throat with an object such as a tongue depressor. A positive response to each of these reflexes is considered normal.

The nurse is assessing for changes in skin color in a dark-skinned client. The nurse finds which areas helpful in assessing for pallor or cyanosis? Select all that apply.

Answer: Tongue, nailbeds, mucous membranes

Which action would the nurse take to test cranial nerve XI, the spinal accessory nerve?

Answer: Ask the client to shrug the shoulders against the nurse's resistance. The spinal accessory nerve, cranial nerve XI, controls strength of the neck and shoulder muscles. One method of testing this nerve is to palpate and inspect the trapezius muscle as the client shrugs the shoulders against the nurse's resistance.

The nurse is performing a physical assessment of a client's musculoskeletal system and notes that the client is right-handed. The nurse would document which assessment findings as normal? Select all that apply.

Answers: Muscle strength graded 5/5 Symmetrical movements bilaterally Increased muscle size on the dominant arm A 1-cm hypertrophy of the right upper arm Rationale: Fasciculations are fine muscle twitches that normally are not present. Muscle strength is graded from 0/5 (paralysis) to 5/5 (normal power). Symmetrical muscle movement is a normal finding. Hypertrophy, or increased muscle size, on the client's dominant side of up to 1 cm is considered normal.

The nurse is assessing a client's muscle strength. The nurse asks the client to hold the arms up and supinated, as if holding a tray, and then asks the client to close the eyes. The client's left hand turns and moves downward slightly. The nurse interprets this to mean that the client has which condition?

Pronator drift occurs when a client cannot maintain the hands in a supinated position with the arms extended and the eyes closed. This assessment may be done to detect small changes in muscle strength that might not otherwise be noted. Ataxia is a disturbance in gait. Nystagmus is characterized by fine, involuntary eye movements. Hyperreflexia is an excessive reflex action.

The community health nurse who is conducting a teaching session about the risks of testicular cancer has reviewed a list of instructions regarding testicular self-examination (TSE) with the clients attending the session. Which statement by a client indicates a need for further instruction?

TSE is performed once a month and should be done on the same day of each month, as an aid to help the client remember to perform the exam. The scrotum is held in 1 hand and the testicle is rolled between the thumb and forefinger of the other hand. It is best to perform the exam during or after (not before) a warm shower or bath when the scrotum is most relaxed.

A nursing student is asked about the procedure used to elicit Homans' sign. Which response by the student indicates an understanding of this assessment technique?

Answer: "I will ask the client to extend the legs flat on the bed, and I will gently dorsiflex the foot forward." To elicit Homans' sign, the nurse asks the client to extend the legs flat on the bed. The nurse then grasps the foot and dorsiflexes it forward. If this causes any discomfort or resistance, the nurse should notify the primary health care provider that Homans' sign may be present. The statements in the remaining options are incorrect descriptions of this assessment technique.

The nurse is conducting a neurological assessment, including a health history, on a client with a neurological disorder. The nurse observes that the client is having difficulty answering the questions and should perform which action?

Answer: Ask the client to give permission for a family member to stay during the interview. The health history and physical assessment for a client with a neurological problem are very similar to those for any other client, with perhaps a more intense neurological examination. If the client is confused or agitated or has difficulty hearing or speaking, the nurse should ask the client to give permission for a family member or significant other to stay with him or her during the history taking to ensure accurate data. Deferring the health history and/or neurological examination will not obtain the assessment data. Having a second nurse present is of no benefit.

The nurse is performing a neurological assessment on a client who had a stroke (brain attack). The nurse checks for proprioception using which assessment technique?

Answer: Holding the sides of the client's great toe and, while moving it, asking what position it is in A method of testing for proprioception is to hold the sides of the client's great toe and, while moving it, asking the client what position it is in. Tapping the Achilles tendon with a reflex hammer describes gastrocnemius muscle contraction. Pricking the skin on the dorsum of the foot in 2 different places describes 2-point discrimination. The plantar reflex is tested when the sole of the foot is stroked with a blunt instrument.

The nurse is testing a client for graphesthesia and asks the client to close his eyes. The nurse should next ask the client to take which action?

Answer: Identify 3 numbers or letters traced in the client's palm. Graphesthesia is the ability to recognize the form of written symbols. The nurse can assess for this by tracing symbols, such as numbers, in the client's palm.

The nurse is testing a client for astereognosis. The nurse should ask the client to close the eyes and perform which action?

Answer: Identify an object placed in the client's hand. Astereognosis is the inability to discern the form or configuration of common objects using the sense of touch. Graphesthesia is the inability to recognize the form of written symbols. The remaining options test for extinction phenomena and 2-point stimulation, respectively.

The nurse is monitoring a wound in a dark-skinned client for signs of erythema. How should the nurse best determine the presence of erythema?

Answer: Palpate for increased skin temperature around the wound edges. Erythema is a form of macula characterized by diffuse redness of the skin. In a dark-skinned client, erythema is best determined by palpating for increased skin temperature. Redness around the wound edges may be difficult to note in the dark-skinned client. Swelling and drainage from the wound are not specific indicators of erythema.

The school nurse has conducted a class on testicular self-examination (TSE) at the local high school. The nurse determines that the information was correctly interpreted if 1 of the students states that which action should be performed?

Answer: Roll the testicle between the thumb and forefinger. TSE is an excellent self-screening examination for testicular cancer, which predominantly affects men in their late teens and 20s. The examination is performed once a month, as is breast self-examination. As an aid to remember to do it, the examination should be done on the same day each month. The scrotum is held in one hand, and the testicle is rolled between the thumb and forefinger of the other hand. The examination should not be painful. It is easiest to do either during or after a warm shower (or bath), when the scrotum is relaxed.

The nurse in the health care clinic is performing a neurological assessment and is testing the motor function of cranial nerve V (trigeminal nerve). Which technique should the nurse implement to test the motor function of this nerve?

Answer: Separate the client's jaw by pushing down on the chin. The motor function (muscles of mastication) of cranial nerve V (trigeminal nerve) is assessed by palpating the temporal and masseter muscles as the person clenches the teeth. The muscles should feel equally strong on both sides. The nurse should try to separate the client's jaws by pushing down on the chin; normally, the jaws cannot be separated. Asking the client to puff out the cheeks tests the facial nerve. Placing an object on the client's tongue tests sense of taste and the sensory function of the facial nerve. Checking for equal strength by asking the person to rotate the head forcibly against resistance applied to the side of the client's chin assesses cranial nerve XI, the spinal accessory nerve.

The clinic nurse is preparing to perform a Romberg test on a client being seen in the clinic. The nurse would perform this test for the purpose of determining which status?

Answer: The functional status of the vestibular apparatus in the inner ear The Romberg test assesses the ability of the vestibular apparatus in the inner ear to help maintain standing balance. The Romberg test also assesses intactness of the cerebellum and proprioception.

The nurse is assessing a client suspected of having meningitis for meningeal irritation and elicits a positive Brudzinski's sign. Which finding did the nurse observe?

Brudzinski's sign is tested with the client in the supine position. The nurse flexes the client's head (gently moves the head to the chest), and there should be no reports of pain or resistance to the neck flexion. A positive Brudzinski's sign is observed if the client passively flexes the hip and knee in response to neck flexion and reports pain in the vertebral column. Kernig's sign also tests for meningeal irritation and is positive when the client flexes the legs at the hip and knee and complains of pain along the vertebral column when the leg is extended. Decorticate posturing is abnormal flexion and is noted when the client's upper arms are flexed and held tightly to the sides of the body and the legs are extended and internally rotated. Decerebrate posturing is abnormal extension and occurs when the arms are fully extended, forearms pronated, wrists and fingers flexed, jaws clenched, neck extended, and feet plantar-flexed.