final exam 366

A perimenopausal female presents to the clinic with complaints of vaginal dryness and painful intercourse. The woman states, "This has never been a problem before." What is the best response by the nurse?

"As a woman ages, estrogen levels decrease causing vaginal drying and pain during intercourse."

A nurse is assessing a client for abnormalities of gait due to a concern that the client is at increased risk for a fall. Which instruction should the nurse give the client first?

"Walk across the room and back."

The nurse is teaching a group of nursing students about the HPV vaccine. Which individual would be a candidate for the HPV vaccine?

14-year-old Cindy who is a freshman in high school

What should the nurse assess to test the function of the occipital lobe?

Ability to read

A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test CN I. What would the nurse do?

Ask a client to identify scents.

The nurse is assessing the genitalia and rectum of a 71-year-old client. When assessing the client's vagina, the nurse should know that age-related changes increase the client's risk of what abnormal finding?

Atrophic vaginitis

A 72-year-old male presents at a local clinic and states: "I have to urinate all the time, and I never feel like my bladder is emptied. It really bothers me at night." What condition might the nurse suspect related to this chief complaint?

BPH

A client is explaining to the nurse how vaginal dryness has decreased her enjoyment of sexual intercourse. The nurse is aware that which of the following are the glands that produce mucus that lubricates the vagina during intercourse?

Bartholin's glands

"A nurse inspects the cervix of a 28-year-old client during a routine assessment. Which coloration of the cervix may indicate that the client is pregnant?"

Blue

The nurse is caring for a client who suffered a stroke and is able to carry out simple instructions correctly but has trouble writing responses to questions. The nurse plans to review the client's MRI report of the brain and expects to find that which area of the brain has been adversely affected?

Broca area Broca area regulates verbal expression and writing ability.

A nurse cares for a client who suffered a cerebrovascular accident and demonstrates the inability to speak clearly. The nurse recognizes that injury has occurred to what portion of the brain?

Broca's area

Regulates verbal expression and writing ability.

Broca's area

During the Romberg test, a client is unable to stand with the feet together and demonstrates a wide-based, staggering, unsteady gait. The nurse would interpret this finding as suggestive of which of the following?

Cerebellar ataxia

The husband of a 65-year-old female tells the nurse, "My wife is having trouble navigating the steps in our home and needs my help to step down off a curb." What part of the nervous system should the nurse assess for a potential source of the problem?

Cerebellum

The nurse walks into a client's room and finds that the client is disoriented to time and place but is awake and responsive. What term best describes this patient?

Confused

An older client demonstrates mental status changes after being diagnosed with a urinary tract infection. Which finding suggests that this client is experiencing delirium?

Delirium

A son brings his 80-year-old father into the clinic. The son is concerned because he feels as if his father is growing weak, losing interest in things he used to care about, and no longer coming to dinner on Sundays. The nurse would know that the father is at risk for what?

Depression

When documenting assessment of the nervous system, a nurse should keep in mind what important principle?

Describe the response

The school nurse is presenting a class on female reproductive health. While discussing prevention the nurse teaches what about a Pap smear?

Detect cervical cancer.

A client has been to the clinic multiple times in the past year with vaginal infections, the most frequent of which was candidiasis. The nurse would assess the client for symptoms most likely related to which condition?

Diabetes mellitus

A 55-year-old male presents to the health care clinic with reports of difficulty starting the urine stream, dribbling frequently, and getting up several times a night to urinate. He has decreased his fluid intake to try to control the nighttime urination. The nurse assesses a temperature of 101.5°F oral, dry skin and mucous membranes, and suprapubic tenderness. Which nursing diagnosis can the nurse confirm from this data?

Disturbed Sleep Pattern

Some symptoms are common in elderly clients. Which of the following is less likely to be a common problem in old age?

Fever

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

A female client has presented for a Pap smear test, and the nurse is discussing risk factors for cervical cancer. What risk factor should the nurse describe?

Having multiple sexual partners

A nurse is working with an 88-year-old client who has developed stress incontinence. In this case, as in all cases, the nurse should understand that which of the following is the key to recognizing pathology and illness in the very old?

Knowing the person's baseline functional status and recognizing deviations from it

When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence?

Mental status, cranial nerves, motor/cerebellar, sensory, reflexes

Which cranial nerve controls pupillary constriction?

Oculomotor

The nurse suspects that a client is experiencing meningitis. Which assessment finding caused the nurse to make this clinical determination?

Pain and hip flexion when the neck is flexed

What would be most appropriate for the nurse to do when assessing motor function of a client's trigeminal nerve?

Palpate temporal and masseter muscles while client clenches the teeth.

Examination of a client's gait reveals that the client is stooped over when walking and that he slowly shuffles. As well, the client maintains a stiff posture when walking. The nurse should document what type of gait?

Parkinsonian gait

A patient is in the emergency room with what could be a lumbar injury. Which deep tendon reflex would be most appropriate to test?

Patellar

A client has sustained nerve damage as a result of an automobile accident and has lost the ability to sense position, vibration, and fine touch. Which neural pathway should the nurse suspect to be damaged?

Posterior columns

The nurse is reviewing the functions of the ovaries, uterus, clitoris and vagina with a group of high school students. Based on this information, what would be the best response by a high school student about the function of the vagina?

Receives sperm, provides an exit for menstrual flow and serves as the birth canal.

The nurse is reviewing the functions of the ovaries, uterus, clitoris and vagina with a group of nursing students. Based on this information, what would be the best response by a nursing student about the function of the uterus?

Receives the fertilized ovum and provides housing and nourishment for a fetus.

A client's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding?

Right knee +2; Left knee +1

Which finding should a nurse expect to observe when inspecting the external genitalia of an elderly male client?

Smaller penis with lower hanging testicles

When the nurse is assessing the motor function of cranial nerve VII as part of the neurological examination, what should the nurse instruct the client to do?

Smile

In an interview with an elderly female client, the nurse learns that the client often has involuntary loss of urine when coughing, sneezing, or laughing. What type of incontinence should the nurse document in the client's record?

Stress

Scar tissue is visible on the perineum of an adult female client. What would the nurse consequently question the client about?

Tearing during vaginal delivery

The nurse is assessing an older adult client who lives alone and was brought to the clinic by the client's grandson. The client's hair is messy, clothes are very dirty, and the client has very bad body odor. What do these signs most likely indicate to the nurse?

The client has decreased functional ability

The nurse is performing the Romberg test as part of a client's focused neurological assessment. What finding would constitute a positive Romberg test?

The client moves her feet apart to prevent herself from falling.

Which action by a nurse demonstrates the correct technique to use the reflex hammer?

Use rapid wrist movement and strike the tendon

When assessing cranial nerves IX and X, what would the nurse consider as a normal finding?

Uvula and soft palate rising bilaterally

Which area of the brain integrates the understanding of spoken and written words?

Wernicke's area

Which tests are appropriate for a nurse to perform to test the cranial nerve VIII?

Whisper test, Rinne, and Weber

A 43-year-old woman comes to the ob/gyn clinic for her yearly examination. She tells the nurse that she wants to renew the prescription for her birth control pills. During the assessment interview, the patient tells the nurse that she smokes ½ pack a day and drinks several drinks a day. What should the nurse include in patient education?

Women older than 40 years who smoke should not take birth control pills.

The nurse notes a white curd-like discharge when inspecting a female client's labia. What should the nurse suspect this client is experiencing?

candida vaginitis

A client is scheduled for a routine pelvic examination. What should the nurse do to prepare the client for this examination?

drapes the client from the mid-abdomen to the knees

The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the

glossopharyngeal.

What should the nurse assess to test the function of the parietal lobe?

impulses from the ear

What information should a nurse give a client who reports a routine of frequent douching?

predisposes the vagina to yeast infections

What should the nurse assess to test the function of the parietal lobe?

tactile sensation

The diencephalon of the brain consists of the

thalamus and hypothalamus.

When examining the eye, the nurse notices difficulty with downward motion. The nurse understands that which cranial nerve is involved?

trochlear