ThePoint Exam 3 HA

Which of the following people need to be vaccinated for hepatitis A and B

food-service workers

An adult client has been diagnosed with carpal tunnel syndrome. What type of working conditions may have contributed to this diagnosis?

frequent repetitive movements

A new mother calls the clinic because she is concerned about her infant who is having a stool after each feeding. The nurse explains that this is common occurrence because of what reflex?

gastrocolic

When the client performs straight leg flexion, the client complains of pain that radiates down his leg. The nurse understands that this may indicate what?

herniated disc

When auscultating a client's heart, the nurse hears both S3 and S4. What is this known as?

summation gallop

After assessing the client for posture and body alignment, how would the nurse document head position in relation to the spine if alignment is normal with noticeable defect?

the head is midline and aligned with the spine

Where are the heart and great vessels located in the body?

the mediastinum, between the lungs above the diaphragm

The nurse assessing the client's skin identifies an ulcer. What would indicate to the nurse it is a venous ulcer?

the ulcer is superficial and pale

Which vessels return the lymph fluid to circulation?

thoracic ducts

A nurse is assessing the genitalia of a male client. The nurse finds that the client has a piercing in his penis. Why is it important to investigate details of the piercing?

to assess for health risks relating to how it was performed

In the female client, the tube of muscular tissue that extends from the vaginal introitus to the uterus is called what?

vagina

During the assessment, the nurse identifies warm thick skin that is reddish-blue. The nurse also notes a painful ulcer at the ankle. The nurse suspects the client may have what?

venous insufficiency

Ejaculation occurs with the emission of semen from which of the following? Select all that apply.

-epididymides -vas deferens -prostate -seminal vesicles

How many vertebrae make up the spinal column

33 7 cervical 12 thoracic 5 lumbar 5 sacral 4 coccyx

Of the estimated 15 million new cases of sexually transmitted infections that are reported every year, how many occur in adolescents?

4 million

The exact cause of benign prostatic hypertrophy (BPH) is unknown, but the condition is believed to be associated with what factors?

age-related hormonal changes

Temporary heart pain, resolving in less than 20 minutes, aggravated by physical activity and stress is known as what?

angina

The nurse manager on a cardiac unit should immediately intervene when observing which staff nurse's assessment technique?

palpating carotid pulses simultaneously

The nurse is present during a pelvic examination of an adolescent female client. Which action should the nurse prepare for first?

pap smear specimen collection

The six Ps of peripheral arterial occlusion include which of the following?

paresthesia

The client complains of pain and numbness in his left lower leg. The nurse identifies on assessment that the left leg is cool and gray in color. The nurse suspects what?

arterial occlusion

A male client suffers from urinary retention. Which instructions are best to teach the client?

"Try voiding, then resting a few minutes, before going again"

A 16 year old client asks the nurse if her vaginal examination is going to hurt. What is the nurse's best response?

"you may feel some mild pressure"

When performing an assessment, the nurse presses the tissue on the legs and there is increased pitting with a 4-mm depression. How would the nurse document this?

+2 pitting -2-mm (+1) -4-mm (+2) -6-mm (+3) -8-mm (+4)

The anterior pituitary secretes which of the following hormones? Select all that apply.

-FSH -LH

The nurse is discussing risk factors of an aneurysm. What should be included? select all that apply.

-Hypertension -smoking -family history

Peripheral artery disease, the most prevalent vascular disease, has been found highest in what genders and ethnicities? Select all that apply.

-african american women -mexican american women -african american men

The nurse is providing community education regarding osteoporosis. What risk factors for osteoporosis need to be included in the teaching? Select all that apply.

-alcohol consumption -hormones -smoking

Which of the following are types of connective tissue? Select all that apply.

-bone -ligaments -tendons

A client with hypertension is at increased risk of what medical conditions? Select all that apply.

-cerebrovascular disease -lower-extremity peripheral artery disease -abdominal aneurysms

The wet mount prepared after a female client's pelvic examination reveals motile organisms greater than 10 WBC's per high powered microscopy. The nurse should gather supplies for which diagnostic follow-up? Select all that apply.

-chlamydia culture -gonorrhea culture -HIV testing -syphillis serology

Which assessment questions are appropriate for people of Native American descent? Select all that apply.

-do you drink alcohol? If so, how much and how often? -Have you ever had yellow skin or yellow eyes? -Have you had liver disease, gallbladder disease, or pancreatitis?\ -do you have diabetes?

A nurse receives a client from the cardiac catheterization laboratory. The client is on bed rest and has a weight on the puncture site of the right groin. What must the nurse assess for frequently? Select all that apply.

-hematoma at the puncture site -bleeding at the puncture site -increased blood pressure, which could cause excess bleeding or hematoma

A male client is assessed for suspected benign prostatic hypertrophy. The nurse expects the client to suffer from which symptoms? Select all that apply.

-inability to empty the bladder -weak urinary stream -dribbling after urination -frequent urination during the night

A client is being discharged home from the hospital. This client has a history of falling at home. A caregiver is not able to stay with the client all the time. What can be done to decrease the risk for falling at the client's home? Select all that apply.

-install grab bars in the bathroom -correct environmental hazards in the home -make sure house hallways are well lit

A nurse is assessing the risk factors of the male reproductive system in a client. Of the following questions, which are pertinent in assessing the risk factors? Select all that apply.

-is there infertility in siblings? -do you have any current or chronic illnesses such as diabetes or hypertension? -is there a history of penile cancer in your family? -is there a history of hernia in your family?

Some changes that appear on the skin of the abdomen as a result of pregnancy are what? Select all that apply.

-linea nigra -everted umblicus -striae

A female client has a history of multiple sexual partners, which puts her in the high-risk group for developing HPV and cervical cancer. What should the nurse recommend to this patient to help prevent these problems? Select all that apply.

-monogamy -abstinence -consistent use of condoms

Symptoms of complete arterial occlusion include which of the following? Select all that apply.

-numbness -color change -pain

When educating a client about healthy habits relating to cardiovascular health, it is important to include which of the following? Select all that apply.

-quit or do not start smoking -exercise regularly -undergo regular cholesterol screening -undergo regular screening for diabetes

Prostate enlargement is common in older men. The nurse should be aware of what signs and symptoms when interviewing an older male client? Select all that apply.

-sensation of residual urine -straining to urinate -dribbling

What creates the pressure gradient that regulates blood flow in the venous system? Select all that apply.

-skeletal muscle contraction -respiration -intraluminal valves

Goals, although not specific for peripheral vascular disease, focus on areas of risk. What are these areas of modifiable risk? Select all that apply.

-smoking -overweight -lack of exercise

What teaching should be included to a client diagnosed with peripheral arterial disease? Select all that apply.

-stop smoking -low fat diet -increased activity -weight management

A mother is worried about her teenage child's weight. The teenager weighs 80 kg (176 lbs). What can the nurse teach the mother about her child's eating habits? Select all that apply.

-supply only healthy foods in the house -supply nutritional information to the child -educate the family about the poor nutritional value of fast food

Some client outcomes related to cardiovascular problems include which of the following? Select all that apply.

-the client demonstrates adequate circulation status with strong peripheral pulses -the client maintains normal blood pressure -the client maintains normal urinary output

A college-aged male client is being seen in the college health clinic by the nurse practitioner. During the assessment, the nurse practitioner asks the client if he is aware of the importance of testicular self examination. The nurse would include the following information when sharing with the client. Select all that apply.

-the exam should be performed after the client takes a warm shower -the exam should be performed monthly -it is not uncommon for one testicle to be larger than the other

The nurse is assessing an adult client with severe abdominal pain and asks the client if they have had any prior surgeries. The client states that she had a hysterectomy 20 years ago. Why is this information relevant? Select all that apply.

-the information shows increased risk for adhesions -the information shows increased risk for obstructions -the information shows increased risk for malabsorption

The nurse is collecting a stool specimen for guaiac testing. Place the steps in the correct order that the nurse should follow to test the specimen.

1. open the flap of the carboard guaiac slide. 2. dab the stool on the paper in the boxes of the slide 3. close the flap and remove gloves 4. with clean gloves on, reverse the slide and open the flap 5. apply two drops of developing solution to each box of guaiac paper. 6. wait 30-60 seconds and note the color of the paper.

A mother brings her 13 year old daughter to the clinic to be vaccinated against HPV. Once the girl receives the first dose, the nurse tells the mother to bring her back when?

2 months

By what percent can clients reduce their risk of cardiac events the first year after quitting smoking?

50%

An African American woman brings her 10-year-old daughter to the clinic for evaluation. The mother is concerned because her daughter has started puberty already. The nurse advises the family that African American girls may begin their puberty before what age?

8

Moving a part of the body away from the midline is called?

Abduction

A female client with a history of endometriosis tests positive with a urine pregnancy test. She complains of right lower quadrant pain and nausea. During an ultrasound, an empty gestational sac is seen. What is the nurse's priority action?

Advise client to seek treatment right away.

The nurse is preparing an instructional session for male clients about preventing penile cancer. Which non-modifiable risk factor should the nurse include in the teaching?

Age 60 years or older

The physician is preparing to insert a radial arterial line. What test must be performed prior to insertion?

Allen test (for patency of collateral circulation)

The factor that has the most impact in preventing sexually transmitted infections is which of the following?

Being in a monogamous sexual relationship

During assessment, the nurse notes the client has a decreased pain sensation in his low extremities. The nurse should ask the client about a history of what disease?

Diabetes

The nurse is examining an older adult client. During the physical assessment, the client appears to be getting fatigued. What can nurse do to help the client finish the assessment?

Divide the assessment into portions

Which additional health history question related to the abdominal system is appropriate for people of African American decent?

Do you or your parents have sickle cell disease or trait?

An adolescent male client is diagnosed with testicular torsion. The nurse should prepare the client for which treatment?

Emergency surgery

A mother brings her adolescent daughter to the clinic. The mother is worried that her daughter is sexually active. When assessing the adolescent, it is vital for the nurse to do what?

Establish a trusting and confidential relationship with the client

When collecting subjective data, the nurse knows that assessment of the female client can be very invasive. Starting with questions relating to health history allows the nurse to do what?

Gain the client's confidence

How does the nurse differentiate a pleural friction rub from a pericardial friction rub?

Have the client hold his/her breath; if the rub persists, it is pericardial

Assessment of the musculoskeletal system usually proceeds from general to specific and from?

Head to toe

The nurse is assessing an elderly client and finds and exaggerated thoracic curve. THis would be documented as what?

Kyphosis

A teenage male client comes to the ED with severe left testicular pain and vomiting. Elevation of his left testicle does not lessen the pain. What could these symptoms indicate for this patient?

Left testicular torsion

Increased lumbar curvature, which compensates for the enlarging uterus in pregnant women, is called what?

Lordosis

Aortic aneurysms are seen with which congenital disorder?

Marfan's syndrome

loss of bone density that occurs with greatest frequency in post menopausal women is called?

osteoporosis

A nurse has just performed the test for Allis' sign on a newborn; the result is positive. What did the nurse observe while performing this test?

One knee is lower than the other

A client complains of difficulty sleeping, stating he has to sit up with the help of several pillows and cannot breathe when lying flat. This client has a condition known as what?

Orthopnea

The nurse is testing a client for carpal tunnel syndrome. The client flexes the wrists at an angle of 90 degrees and holds the backs of the hands to each other for 60 seconds. The client tells the nurse that he is experiencing a burning pain as a result. Which test is the nurse preforming on this patient?

Phalen's

The client with an acute appendicitis has been ordered a barium enema. What should the nurse do firts?

Question the order as a barium enema is contraindicated in an acute appendicitis

The client tells the nurse that he has joint stiffness that is worse in the morning but improves as the day progresses. The nurse should assess the client for what musculoskeletal disorder?

Rheumatoid arthritis

The client received in the ICU was shot in the lower abdomen, suffered bladder trauma, and now has a urinary catheter. With these risk factors, what would be an appropriate nursing diagnosis for this client?

Risk for infection

A young homosexual client who is currently HIV negative tells the nurse that he is worried about contracting AIDS someday. What teaching would be appropriate for this client?

Safe-sex practices and proper use of condoms

The nurse is preparing to palpate the client's spleen. What should the nurse instruct the client to do?

Take a deep breath and exhale

The nurse is assessing an older adult with new onset dementia. The nurse is using the Morse Fall Scale; the client's score is 63. What does this tell the nurse?

That the client is at high risk for falling

An older adult client comes to the ED bleeding from the rectum. The client has a history of atrial fibrillation and has had two small strokes. The client is currently taking blood pressure medication and anticoagulation therapy at home. Why might this client need to be hospitalized?

The client is on anticoagulation medication

An uncircumcised male client has just come to the recovery room following a 4-hour back surgery. Before surgery a urinary catheter was placed. During the postoperative assessment, the recovery nurse discovers that the client has developed paraphimosis. What might have happened to the client to cause this?

The foreskin was not pulled back over the head of the penis after catheter placement

A female client presents to the clinic with chills and fever for 3 days. She also complains of sores in her genital region. The nurse should prepare to give which instructions to this client?

abstinence should be practiced while sores are weeping

The nurse is caring for a client exhibiting jugular vein distention and dyspnea. The nurse auscultates an new S3 heart sound. What is the nurse's best action?

administer prescribed diuretic

A new mother brings her newborn to the clinic. She states that the baby has been having black tarry stools. Which of the following could be the cause?

Vitamin K deficiency

An adult female client is being evaluated by the nurse. When obtaining an obstetrical history from this woman, which of the following questions may the nurse omit?

When was your first period?

When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what?

abdominal aortic aneurysm

Which of the following acute abdominal symptoms could be life threatening?

abdominal pain

During range of motion assessment, the nurse moves the limbs away from the median plane of the body. This is known as what?

abduction

The nurse is assessing a male client complaining of testicular pain. Which symptom helps the nurse determine that the client does not need immediate surgical intervention?

absence of nausea and vomiting

Upon assessing the client's jaw, the nurse finds decreased range of motion and notes crepitus. what would the nurse suspect?

arthritis

A client presents to the emergency department complaining of chest pain. The nurse conducts a pain assessment and discovers the client's chest pain has lasted more than 20 minutes and is accompanied by nausea and diaphoresis. The nurse should prepare for which treatment?

balloon angioplasty

A client is experiencing decreased cardiac output. Which vital sign is priority for the nurse to monitor frequently?

blood pressure

The nurse is auscultating the abdomen and notes a swishing sound in the abdominal area. The nurse would document this sound as what?

bruit

The nurse hears high-pitched swooshing sounds over the carotid artery on the right side. What is this sound indicative of?

bruits

Older adults tend to get arteriosclerosis. What is the cause of this disease process?

calcification of the arteries

The client has been diagnosed with peripheral arterial disease. What information should the nurse include when teaching?

check feet daily for cuts or pressure areas

The nurse positions the client for auscultation of heart sounds. What does the nurse do first?

clean the stethoscope

What part of the penis fills with blood when the penis becomes erect?

corpora cavernosa

Why is the appearance of urine important to evaluate during an abdominal examination?

dark urine may be from dehydration

The nurse is present during a pelvic examination of a female client. The healthcare provider states that the multiparous client has several small nodules at the cervix that look like yellow pustules. The nurse should prepare for which action?

document the findings

The nurse is performing percussion on a client's abdomen. What would the nurse expect to hear over the liver of the right upper quadrant?

dullness

A client with dehydration or volume depletion has barely visible neck veins, even when lying flat. These are described as what?

flat neck veins

A client has rheumatoid arthritis most prominent in the hands, where the client has decreased range of motion, pain, and tenderness. What is an appropriate nursing diagnosis for this client?

impaired physical mobility related to reduced strength and ROM

The nurse is assessing an older adult. The client states that she feels a constant, sharp pain only when walking. The nurse suspects the client is experiencing what?

intermittent claudication

The nurse is assessing an older adult client for severe malnutrition. Which of the following factors increases this client's risk for malnutrition?

limited access to a grocery store

The nurse is palpating in the right upper abdominal quadrant and feels an enlarged area. The nurse recognizes that she is most likely feeling what organ?

liver

The nurse assigns a nursing diagnosis of fluid volume deficit to an older adult client diagnosed with severe dehydration. Her vital signs are P 120, BP 84/52, respirations 24, and temp 37.4 C. Which of the following interventions is appropriate for this client?

monitor pulse and blood pressure every 15 mins until stable

The nurse is assessing an adult client with lower quadrant abdominal pain. The client has no history of prior surgeries, has no allergies, and is physically fit. Which of the following should the nurse do during the abdominal examination?

observe the client's face for signs of discomfort

A client has a history of multiple abdominal surgeries from a gunshot wound 3 years ago. The client is currently reporting severe abdominal pain. Auscultation reveals high-pitched, rushing sounds. These sounds could be a sign of what condition?

partial bowel obstruction

During a comprehensive assessment, a female client complains of intense external genital itching. The nurse should carefully assess for which condition that commonly presents with this symptom?

pediculosis pubis

What is the most important sign of acute pericarditis?

pericardial friction rub

A 44 year old woman comes to the clinic. She thinks she is menopausal. Her symptoms are irregular periods, hot flashes, mood swings, and decreased sexual drive. Menopause is the absence of menstrual periods for at least 12 months, so the nurse suspects that this condition is what?

perimenopause

The nurse is assessing a client diagnoses with mitral stenosis. Which technique should the nurse listen to this condition?

place the bell of the stethoscope over the apex with the client on left side

What is the most important lifestyle changes a client can make to improve cardiovascular health?

quitting smoking

Which finding in a female client's history would alert the nurse to assess for signs of diabetes mellitus?

recurrent candidiasis infections

When auscultating a client diagnosed with aortic stenosis, the nurse should place the stethoscope at what location on the client's chest?

right sternal border, 2nd ICS

The nurse is assessing a client with diabetes for peripheral artery disease. How does diabetes affect this client's risk of peripheral artery disease?

significant affect

A 41-year-old woman is considering the use of hormonal contraceptives. What is contraindicated in this client?

smoking

Which organ that resides in the abdominal cavity stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes?

spleen