Exam 5- Module 10,11,12

a nurse is reviewing breast self-examination techniques with a client. which of the following client statements indicates an understanding of the techniques? a. I will use circular motions to feel the texture of my breast tissue b. I will use the palmar surface of my hands to perform breast palpations c. I will lie down and put one hand behind my head to examine the breast on the opposite side of my body d. I will examine my breast after bathing and drying thoroughly

a. I will use circular motions to feel the texture of my breast tissue - client should use small circular motions to palpate the breast and underlying tissues. therefore, the nurse should identify this statement as an indication that the client understand self-examinations

a nurse is teaching a group of newly licensed nurses about routine mammography screenings for female clients. which of the following statements by a newly licensed nurse indicates an understanding of teaching? a. a 55 year old client should receive mammography screenings at least every 2 years b. clients can discontinue routine mammography screenings when they are 65 years old c. clients should begin routine mammography screenings when they are 35 years old d. a 45 year old client should receive mammography screenings at least every 5 years.

a. a 55 year old client should receive mammography screenings at least every 2 years -guidelines recommend routine mammography screenings every 1-2 years for female clients between 40-75 years old.

a nurse is discussing breast cancer with a group of male clients. the nurse should include that which of the following findings is a potential indication of breast cancer? a. dilation of the hair follicles b. bilateral tissue enlargement c. nipple retraction d. small bulging nodule lateral to one breast e. palpable Montgomery glands

a. dilation of the hair follicles c. nipple retraction d. small bulging nodule lateral to one breast -nurse should include that dilation of hair follicles of breast, known as peau d'orange, potential indication of possible breast cancer. nipple retraction and nipple discharge is an indication of possible breast cancer. small bulging nodule lateral to one breast is possible breast cancer.

a nurse is preparing to conduct a head to toe assessment on a client in an outpatient setting. at which of the following times should the nurse plan to collect information about the client's general appearance? a. during an interview about the client's health history b. when introducing themselves to the client c. once the focused assessments have been completed d. while collecting the client's vital signs e. during the discussion of planning for follow up care

a. during an interview about the client's health history b. when introducing themselves to the client d. while collecting the client's vital signs -while interviewing, initial introduction, and assessing vital signs the nurse should collect general information about appearance, nutritional state, emotional status, speech, hearing, and mobility

a nurse is preparing to assist the provider with an assessment of a female cleint's genitourinary system. which of the following actions should the nurse plan to take? a. position the client supine with the head of the bed elevated b. avoid conversation while the provider is performing the assessment c. instruct the client to position their knees inward d. position the client's arms above their head

a. position the client supine with the head of the bed elevated - the client should be positioned supine with the head of the bed elevated 45 degrees or with their head on a pillow so that the provider can maintain eye contact throughout the examination

a nurse is evaluation an older adult client for an alteration in orientation. which of the following questions should the nurse ask the client? a. "can you tell me your birthday?" b. "can you tell me what month it is?" c. "can you tell me what you had for lunch yesterday?" d. "can you repeat the four words that I asked you to remember?"

b. "can you tell me what month it is?" -This question assesses the client's orientation to time. disorientation due to delirium or dementia usually presents initially as confusion to time and then progresses to include place

a nurse is preparing to perform a head-to-toe assessment on a client. which of the following tools should the nurse plan to gather? select all that apply a. blood glucose meter b. penlight c. stethoscope d. sphygmomanometer e. sterile gloves

b. penlight c. stethoscope d. sphygmomanometer -penlight proves additional lighting to allow for close inspection. it is additionally used to assess pupillary light reflex - a stethoscope is used auscultate sounds produced by body -measuring a client's vital signs provides baseline data

a nurse is collecting a health history from a client. which of the following client statements requires further investigation? a. I urinate a lot when I get up in the morning b. I have a bowel movement every morning after breakfast c. I have noticed that it burns when I urinate d. I empty my bladder several times a day

c. I have noticed that it burns when I urinate - a burning sensation when voiding can be an indication of a UTI. UTI s/s- urgent sensation to void, changes in appearance of urine- blood, cloudiness, foul odor

a nurse is performing as assessment of client's abdomen. which of the following actions should the nurse take? a. palpate client-identified areas of discomfort first b. begin auscultation of left upper quadrant c. auscultate bowel sounds prior to palpating d. count the number of bowel sounds auscultated over 1 minute

c. auscultate bowel sounds prior to palpating -auscultation is performing prior to palpation of the abdomen because palpation stimulates peristalsis, which can lead to incorrect assessment of baseline bowel motility

A nurse is caring for a male client who reports the presence of yellow discharge from the meatus and buring with urination. which of the following infections should the nurse suspect? a. human paillomavirus (HPV) b. urinary tract infection (UTI) c. syphilis d. gonorrhea

d. gonorrhea -manifestation of yellow discharge from the meatus and dysuria are associated with a gonorrhea infection. the edges of the meatus can also appear inflamed and edematous

a nurse is performing an assessment of a client's lower extremities. which of the following actions should the nurse include in this assessment? a. palpate the strength of the brachial pulses b. observe the client's gait as they walk across a room c. use a sharp pin to assess for sensation on the sole of the client's foot d. inspect the pattern of hair distribution

d. inspect the pattern of hair distribution -an absence of hair on the lower legs can indicate the presence of inadequate circulation to the lower extremities and should be noted

a nurse is preparing to assess the status of a client's upper extremities. which of the following actions should the nurse take? select all that apply a. inspect the condition of each fingernail b. apply a pulse oximeter to a finger c. compare the amplitude of the radial pulses bilaterally d. evaluate blood pressure in an upper extremity e. palpate the shoulder, elbow, wrist, and finger joints

a. inspect the condition of each fingernail c. compare the amplitude of the radial pulses bilaterally e. palpate the shoulder, elbow, wrist, and finger joints -nurse should inspect a client's fingernails for shape, texture, and color. changes to fingernails can occur for different illnesses -palpate the radial pulses simultaneously to note any differences in rate, rhythm, strength of pulse -palpate each joint in upper extremities to note presence of warmth, swelling, or discomfort

a nurse is providing education to a young adult client about the human papillomavirus (HPV) vaccine. which of the following information should the nurse include in the teaching? a. the HPV vaccine is only recommended for female clients b. an HPV infection can lead to the development of cancer c. HPV vaccine should be administered before age 18 to be effective d. immunization to prevent an HPV infection requires a single injection

b. an HPV infection can lead to the development of cancer -HPV infections are associated with the development of genital, rectal, and oropharyngeal cancers

a nurse is assessing a client's posterior and lateral chest. which of the following actions should the nurse take? a. position the client in prone position b. observe for the use of accessory muscle during inspiration c. begin auscultating at the level of C4 d. reposition the stethoscope downward at 4 in (10cm) intervals

b. observe for the use of accessory muscle during inspiration -nurse should observe for the presence of retractions or use of accessory neck muscles during inspiration. presence of these findings is associated with an airway obstruction or a large amount of collapsed alveoli causing increased effort required to inspire

a nurse is performing an assessment on a client who reports ear pain. which of the following actions should the nurse take? a. palpate the temporomandibular joint for pain b. palpate the mastoid area for pain c. inspect the nasal mucosa for redness d. inspect the conjunctival sac for redness

b. palpate the mastoid area for pain -when a client reports ear pain, the nurse should palpate the outer ear and mastoid area to determine if there is any localized area of discomfort. increased pain with palpation of outer ear indicates external ear infections. tenderness in the mastoid area can indicate an infection

a nurse is providing education to a female client who has expressed a desire to use a natural method of contraception. which of the following methods should the nurse recommend? select all that apply a. condoms b. withdrawal c. fertility tracking with periodic abstinence d. spermicidal sponge e. tubal ligation

b. withdrawal c. fertility tracking with periodic abstinence -withdrawing the penis from the vagina prior to ejaculating is considered natural. (pull out method) -fertility tracking involves an understanding of the reproductive cycle and monitoring for subtle clues that are present during fertile times. natural method

a nurse is providing education to a male client about health promotion screenings. which of the following information should the nurse include in the teaching? a digital rectal examinations can detect enlargement of the prostate gland b. the prostate specific antigen test elevates semen for the presence of cancer cells c. testicular self-examination should be performed when the client is sitting in a cool environment d. a client who has an average risk for colorectal cancer should have colonoscopy every 2 years

a. a digital rectal examination can detect enlargement of the prostate gland

a nurse is assessing a client's vital signs. while counting the number of respirations, which of the following information should the nurse collect? a. characteristics of the respirations b. symmetric expansion of the chest wall c. shape and alignment of the rib cage d. intensity of tactile fremitus

a. characteristics of the respirations -while counting in respirations, the nurse should observe the effort the client is using and the depth and regularity of the breaths

a nurse is inspecting the anterior chest of a client. which of the following findings should the nurse report to the provider? a. distended veins in one breast b. costal margins of 85 degrees c. PMI located to the left of the midclavicular line at the 4th intercostal space d. symmetrical chest expansion during the inspiratory phase

a. distended veins in one breast -dilated veins in one breast is unexpected and should be reported to the provider. during pregnancy, it is an expected finding to have increased vasculation in both breast

a nurse is preparing to assess a client's genitalia. which of the following actions should the nurse plan to take? a. ensure the client has a full bladder b. use a firm, deliberate touch when palpating c. apply sterile gloves prior to touching the genitalia d. remove the drape from the lower half of the client's body

b. use a firm, deliberate touch when palpating -the nurse should use a gentle, firm, deliberate touche when palpating a client's genitals

a nurse is caring for a male client who was recently diagnosed with gynecomastia. which of the following should the nurse identify as a potential cause of this condition? a. presence of the BRCA1 gene b. medication adverse effects c. decreased estrogen levels d. decreased thyroid hormone levels

b. medication adverse effects -nurse should identify gynecomastia, or a swelling of the breast tissue in males, can be caused by medication adverse effects. this condition can also be caused by hormonal changes or weight gain.

a nurse is preparing to assess a client for presence of a hernia. which of the following areas should the nurse plan to inspect? select all that apply a. femoral area b. inguinal area c. rectal area d. length of shaft e. circumference of the glans

a. femoral area b. inguinal area -inspect bilateral areas of femoral canal for presence of bulges, swelling, or asymmetry that can indicate a femoral hernia. femoral hernia- loops of bowel descend through femoral canal -inspect bilateral areas below symphysis pubis, on either side of penile shaft, for presence of bulges, swelling, or asymmetry that can indicate an inguinal hernia.

a nurse is performing a breast inspection during a client's routine physical examination. which of the following findings should the nurse report to the provider? a. areolas are oval-shaped b. scaley skin at the border of one areola c. small bumps visible on each areola d. areolas have darker pigment than the surrounding skin

b. scaley skin at the border of one areola -nurse should identify that the presence of scaley skin on the breast is an unexpected finding. should report to provider for evaluation

a nurse is inspecting the genitalia of an older adult female client. for which of the following findings should the nurse notify the provider? a. sparse pubic hair b. atrophy of the mons pubis c. dry vaginal membranes d. labial ulceration

d. labial ulceration -redness, swelling, or ulcerations in the genital area are always unexpected findings and should be reported

a nurse is performing a breast examination on a client and notices that the client's right arm is edematous. which of the following should the nurse identify as a potential cause of this condition? a. adverse effect of beta-blocker medication b. recent onset of menopause c. arterial occlusion on the right side d. recent surgery on the right side

d. recent surgery on the right side -surgery on the client's right side, such as mastectomy, can disrupt the flow of lymphatic drainage, which can cause edema.

A nurse is assessing a client's neck. Which of the following should the nurse ask the client to perform during this assessment? select all that apply a. instruct the client to swallow b. apply downward pressure and ask the client to shrug their shoulders c. tell the client to open their mouth and say "ahh" d. test the client's ability to protrude their tongue e. request the client move their head forward and backward and then side to side

a. instruct the client to swallow b. apply downward pressure and ask the client to shrug their shoulders e. request the client move their head forward and backward and then side to side -a swallowing motion will cause the thyroid gland to move upward. while this gland is not typically visible, inspecting the neck while the client swallows can enable detection of enlarged thyroid gland -having client move shoulders against pressure allows nurse to evaluate neck muscles and function of cranial nerve XI, spinal accessory nerve -having client move their head allows nurse to evaluate range of motion

a nurse is teaching a newly licensed nurse about nipple inspection. which of the following should the nurse include as an example of expected variation of the nipple? a. a client reports recent serosanguinous nipple discharge b. a client reports that one nipple has begun to point in a different direction c. a client's nipple has remained inverted since childhood d. a client's nipple has a small crust present on the tip

c. a client's nipple has remained inverted since childhood. - nipple inversion since puberty as an example of an expected variation in breast appearance. nipples are inverted at birth and usually begin to protrude during puberty

a nurse is inspecting a client's axillae. which of the following should the nurse identify as an expected finding? a. skin is deeply pigmented b. presence of plaques c. fixation of tissue during arm movement d. skin has a uniform consistency

d. skin has a uniform consistency -the nurse should identify that the client's axillae should be smooth and intact

a nurse is caring for a client who reports palpable lymph nodes under one axilla. the nurse can see small nodules under the skin in the area the client describes. which of the following should the nurse identify as a potential cause of the client's lymph node enlargement? a. a supernumerary nipple b. infection c. increased adipose tissue d. psychotropic medication use

b. infection - nurse should recognize that an infection of the hand, breast, or arm can cause lymph nodes in the axillae to enlarge so that they become palpable, and sometimes they can even be visible upon inspection.

a nurse is preparing to review health promotion recommendations for breast health with a client. which of the following actions should the nurse place to take when reviewing health promotion recommendations for breast health? select all that apply a. ask the client to describe the process for breast self-examination at the end of the teaching b. document instructions provided in the client's medical record. c. provide the client with information about the human papilloma virus (HPV) vaccine d. review recommendations for mammography based on risk with the client e. begin the teaching by listing national guidelines for breast screening

a. ask the client to describe the process for breast self-examination at the end of the teaching b. document instructions provided in the client's medical record. d. review recommendations for mammography based on risk with the client - nurse should ask the client to describe the process for breast self-examination at the end of the teaching to validate understanding. nurse should document any education provided or reinforced with client in medical record as accurate documentation. nurse should review recommendations for breast screenings, such as mammography based on risk factors.

a nurse is obtaining a past health history for a client prior to a breast examination. which of the following questions should the nurse ask while obtaining the client's past health history? select all that apply a. have you ever had breast disease? b. have you experienced breast trauma? c. have you had breast surgery? d. do you perform breast self-examinations? e. has anyone in your family had breast cancer?

a. have you ever had breast disease? b. have you experienced breast trauma? c. have you had breast surgery? d. do you perform breast self-examinations? -ask whether the client has ever had breast disease, such as fibrocystic disease or cancer. whether client has ever experienced breast trauma. whether they had breast surgery (can cause atypical hyperplasia of breast tissue increasing breast cancer risk)

a nurse is preparing to care for a group of clients in an acute care setting. which of the following assessments should the nurse plan to perform on every client? select all that apply a. lung sounds b. bowel sounds c. measurements of abdominal girth d. pedal pulses e. mental status

a. lung sounds b. bowel sounds d. pedal pulses e. mental status -nurse should plan to asses every client's pulmonary status. this includes lung sounds, respiratory effort, and skin color -plan to asses every client's bowel function. auscultation is performed prior to palpation of abdomen: palpation stimulates peristalsis -assess every client's cardiovascular status. includes cap refill, pulses, and edema -plan to assess the level of consciousness of every client to determine a baseline

a nurse in an outpatient setting is performing a head to toe assessment on a client. which of the following should the nurse inspect when performing a general survey of the client? select all that apply a. nutritional status b. hygiene c. lung expansion d. posture e. range of motion

a. nutritional status b. hygiene d. posture -during general survey, the nurse should assess the client's nutritional status -observe client to determine if they appear clean and groomed. additionally note the presence of body odor and if their dress is appropriate for weather -during general survey, the nurse can observe the client's upright posture, including the alignment of their hips and shoulders.

a nurse is assessing a client's radial pulse rate. which of the following information should the nurse collect while performing this action? select all that apply a. depth of pedal pitting edema b. regularity of the pulse c. presence of a murmur d. presence of a bruit e. strength of the pulse

b. regularity of the pulse e. strength of the pulse -note the regularity of the pulse. the pulse is irregular, the nurse should count the rate for a full minute for accuracy - the strength of pulse provides information about the amount of blood is being ejected during each contraction of the heart muscle

a nurse is teaching a client about performing a breast examination at home. in which order should the nurse instruct the client to perform the steps of a breast examination. place order of performance a. inspect the breasts for changes in shape, color, or contour b. lie down and prepare to palpate breasts with the pads of the second, third, and fourth fingers c. look at the breasts in front of a mirror with hands placed on hips d. inspect the nipples for a rash or drainage e. palpate each breast from the outer edge, moving from top to bottom across the breast

c. look at the breasts in front of a mirror with hands placed on hips a. inspect the breasts for changes in shape, color, or contour d. inspect the nipples for a rash or drainage b. lie down and prepare to palpate breasts with the pads of the second, third, and fourth fingers e. palpate each breast from the outer edge, moving from top to bottom across the breast

A nurse is teaching a group of female clients about breast self-awareness. which of the following instructions should the nurse include? a. breasts are the least tender during the first 3 days of the menstrual cycle b. females can discontinue breast self-examination after menopause c. menstruating females should examine their breasts about 5 days after their menstrual cycle begins d. benign breast nodules are less prominent during the premenstrual phase

c. menstruating females should examine their breasts about 5 days after their menstrual cycle begins -nurse should instruct the client to perform breast self-examination 4-7 days after the onset of their menstrual cycle. this time is optimal because breasts are at their smallest and least congested. before onset of menstruation, breasts tend to swell and are more nodule from increasing levels of estrogen.

a nurse is preparing to assist with a prostate examination. which of the following actions should the nurse plan to take? a. supply sterile gloves for the provider b. provide the supplies for a specimen culture c. position the client standing, facing the examination table d. darken the lighting in the room

c. position the client standing, facing the examination table -an ambulatory client can be positioned standing with the examination table supporting the upper body. alternately, the provider might prefer the client to be positioned on their left side with the hip and knee flexed to stabilize their position and enable adequate visualization of the area

a nurse is performing a physical assessment of a client. in which of the following positions should the nurse place the client prior to inspecting the client's breasts? a. standing upright with their arms held straight out to their sides b. bending over at the waist with hands reaching towards the toes c. sitting straight up with arms relaxed and close to the body d. lying supine with hands clasped together at the umbilicus

c. sitting straight up with arms relaxed and close to body -the nurse should place the client in a seated position with arms relaxed at their sides. nurse should also drape the client's gown at waist level to allow visualizations

a nurse is performing breast inspection on a client. which of the following findings should the nurse report to the provider? a. striae b. flat, brown nevi c. visible capillaries beneath the skin surface bilaterally d. dimpling

d. dimpling - nurse should identify that dimpling, warmth, or a rash on the client's breast are unexpected findings that should be reported to the provider for evaluation.

a nurse is planning to complete a physical assessment on a client. which of the following actions should the nurse plan to include? a. maintain client modesty by auscultating over the client's clothing b. include the nurse's interpretation when recording objective information c. perform the assessment in the same order d. use quotation marks when documenting client statements

d. use quotation marks when documenting client statements -statements made by the client are considered subjective data. pertinent statements should reflect the client's exact words and always be recorded within quotation marks