HA Exam 3 practice questions

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When viewing urine under the microscope what should the nurse expect to see in a patient with a UTI?a. bacteria b. crystals c. casts d. proteins

a. bacteria

A retention cyst in the epididymis filled with milky fluid containing sperm is called: a. a spermatocele. b. a prepuce c. a varicocele. d. Peyronie disease.

ans: a A spermatocele is a retention cyst in the epididymis filled with milky fluid containing sperm. A varicocele is a dilated, tortuous varicose vein in the spermatic cord. Peyronie disease is a result of hard, nontender, subcutaneous plaques on the penis that cause a painful bending of the penis during an erection. Over the glans, the skinfolds in and back on itself forming a hood or flap called the foreskin or prepuce.

The first sign of puberty in boys is: a. enlargement of the testes. b. pubic hair growth extending up the abdomen. c. an increase in penis size. d. the appearance of pubic hair.

ans: a The first sign of puberty in boys is enlargement of the testes. Following the enlargement of the testes, pubic hair appears, then penis size increases. Pubic hair growth extending up the abdomen occurs after puberty.

a side effect of amitriptyline is urine may change what color? a. green b. orange c. red d. blue

d. blue

it is an abnormal finding if there is coarse skin that has an increased pigmentation around the anus, true or false

false

the right testicle should hang lower than the left, true or false

false

a patient asks about treatment for stress urinary incontinence. Which is the nurse's best response? a. perform pelvic floor exercises b.drink cranberry juice c. avoid voiding frequently d. wear an adult diaper

catheters are based on what scale? a. french b. urinary c. kegel d. all of the above

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.

Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? A. Fatigue B. Muscle injury C. Sensory disorientation D. Orthostatic hypotension

Correct Answer: D Explanation/Rationale:A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop in blood pressure) when transferred.

The most common sexually transmitted infection in the United States is: a. trichomoniasis. b. syphilis. c. gonorrhea. d. chlamydia.

ans: d Chlamydia is the most common sexually transmitted infection in the United States.

When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with no resistance. What grade of muscle strength should the nurse record using a 0- to 5-point scale?

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

Continuous seizure activity that lasts longer than 10 minutes is known as _______________.

ANS: status epilepticus Continuous seizure activity

Body balance is achieved when a wide _____________ exists.

base of support Body balance is achieved when a wide base of support exists, the center of gravity falls within the base of support, and a vertical line can be drawn from the center of gravity through the base of support.

The nurse teaches a patient ROM exercises for the shoulder. For abduction, how high is the patient taught to raise the arm? 120 degrees 140 degrees 180 degrees 220 degrees

c Raising the arm above the head achieves 180-degree abduction.

Place in correct order from first to last step in the following steps for climbing stairs with a railing with crutches (partial weight bearing, one leg).1. Hold handrail with one hand (strong leg next to rail).2. Transfer body weight to crutch.3. Stand in tripod position.4. Bring crutch and weak leg up the stairs at the same time.5. Support weight evenly between handrail and crutch. 1, 2, 3, 4, 5 2, 1, 3, 4, 5 1, 3, 4, 5, 2 3, 2, 1, 5, 4

3, 2, 1, 5, 4 Climbing stairs with use of a railing is safest way for patient with crutches to ascend stairs.

A single-lumen catheter that is inserted into the bladder through the urethra only to empty the bladder and then is removed is known as a _______________ catheter.

ANS: straight or intermittent straight intermittent A straight or intermittent catheter is a single-lumen catheter that is inserted into the bladder through the urethra only to empty the bladder, and then is removed. Use this type of catheter on a one-time basis, for example, to determine the amount of residual urine in the bladder, or intermittently, when the patient cannot urinate because of a urinary obstruction or a neurological disorder such as spinal cord injury.

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 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.

During a mental status assessment, which question by the nurse would best assess a person's judgment? a. "Do you feel that you are being watched, followed, or controlled?" b. "Tell me what you plan to do once you are discharged from the hospital." c. "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?" d. "What would you do if you found a stamped, addressed envelope lying on the sidewalk?"

ANS: B A person exercises judgment when he or she can compare and evaluate the alternatives in a situation and reach an appropriate course of action. Rather than testing the person's response to a hypothetical situation (as illustrated in the option with the envelope), the nurse should be more interested in the person's judgment about daily or long-term goals, the likelihood of acting in response to delusions or hallucinations, and the capacity for violent or suicidal behavior.

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.

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.

1. The nurse is assessing a patient whose 24-hour output is 2400 mL. Which finding reflects the nurse's understanding of urine output? a. Increased output b. Decreased output c. Normal output d. Balanced output

ANS: C The average output range for adult urinary output averages between 2200 and 2700 mL in 24 hours.

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.

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 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.

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.

choose close ended questions when asking patient about sexual activity, true or false

false

patients may be taught to insert and remove intermittent catheters themselves True or false?

true

a 24-hour output of less than __ ml is considered oliguria

400

when reviewing laboratory results, the nurse should immediately notify the provider about which finding? a. glomerular filtration rate of 20 ml/min b.pH of 6.4 c. urine output of 80 mL/hr d. protein level of 2 mg/100ml

1. ____________ refers to an ability to move about freely.

ANS: Mobility Mobility refers to an ability to move about freely.

5. _________________ is the volume of urine in the bladder after a normal voiding.

ANS: Residual urine Residual urine, also referred to as postvoid residual (PVR), is the volume of urine in the bladder after a normal voiding.

A noninvasive device that is used to provide accurate determination of a patient's bladder volume by first creating an ultrasound image of the patient's bladder and then calculating the urine volume in the bladder is known as a ______________.

ANS: bladder scanner The bladder scanner is noninvasive, so there is no risk for nosocomial urinary tract infection (UTI) and possible trauma associated with urinary catheterization. It provides accurate determination of a patient's bladder volume by first creating an ultrasound image of the patient's bladder and then calculating the urine volume in the bladder.

1. Antimicrobial catheters coated with silver or antibiotics have been shown to reduce the incidence of ________________.

ANS: catheter-associated urinary tract infection (CAUTI) Silver coated antimicrobial catheters have been effective in reducing incidences of CAUTI in short-term catheter use.

2. A person's inability to move about freely is known as _______________.

ANS: immobility Immobility refers to a person's inability to move about freely.

2. More than ____________ patients are injured in falls in inpatient settings annually in the United States.

ANS: one million 1 million Patient falls are the most common type of inpatient accidents in the United States. The Joint Commission (TJC) recommends that all hospitals develop a fall prevention program and evaluate its effectiveness regularly.

3. A drop in blood pressure that occurs when the patient changes position from a horizontal to a vertical position is known as _________________.

ANS: orthostatic hypotension Orthostatic hypotension is a drop in blood pressure that occurs when the patient changes position from a horizontal to a vertical position.

Awareness of posture and changes in equilibrium is known as _______________.

ANS: proprioceptive function Assess the patient's proprioceptive function (awareness of posture and changes in equilibrium). Determine the stability of the patient's balance for transfer.

In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what response should the nurse make? a. "Does the tremor change when you drink alcohol?" b. "Does your family know you are drinking every day?" c. "We'll do some tests to see what is causing the tremor." d. "You really shouldn't drink so much alcohol; it may be causing your tremor."

ANS: A Although not a recommended treatment, senile tremor is relieved by alcohol. The nurse should assess how alcohol affects the tremor and whether the person is abusing alcohol in an effort to relieve the tremor. Asking whether the family knows he drinks daily does not address the issue of the tremor and it is possible cause. Before ordering tests, a thorough assessment should be performed. Telling the patient he shouldn't drink so much and that drinking may be the cause of his tremor is inappropriate and will likely make the patient defensive.

To assess the head control of a 4-month-old infant, the nurse lifts up the infant in a prone position while supporting his chest. The nurse looks for what normal response? a. Infant raises the head and arches the back. b. Infant extends the arms and drops down the head. c. Infant flexes the knees and elbows with the back straight. d. Infant holds the head at 45 degrees and keeps the back straight.

ANS: A At 3 months of age, the infant raises the head and arches the back as if in a swan dive. This response is the Landau reflex, which persists until 11 2 years of age. The other responses are incorrect.

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.

To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate? a. Have the child hop on one foot. b. Have the child stand on his head. c. Ask the child to touch his finger to his nose. d. Ask the child to make "funny" faces at the nurse.

ANS: A Normally a child can hop on one foot and balance on one foot for approximately 5 seconds by 4 years of age and can balance on one foot for 8 to 10 seconds at 5 years of age. Children enjoy performing these tests. Failure to hop after 5 years of age indicates incoordination of gross motor skills. Asking the child to touch his or her finger to the nose checks fine motor coordination; and asking the child to make "funny" faces tests CN VII. Asking a child to stand on his or her head is not appropriate.

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.

A patient drifts off to sleep when she is not being stimulated. The nurse can easily arouse her by calling her name, but the patient remains drowsy during the conversation. What is the best description of this patient's level of consciousness? a. Lethargic b. Obtunded c. Stuporous d. Semi-coma

ANS: A The term lethargic best describes a patient who drifts off to sleep when not being stimulated, can easily be aroused by calling his or her name, but remains drowsy during conversation. Lethargic (or somnolent) is when the person is not fully alert, drifts off to sleep when not stimulated, and can be aroused when called by name in a normal voice but looks drowsy. He or she appropriately responds to questions or commands, but thinking seems slow and fuzzy. He or she is inattentive and loses the train of thought. Spontaneous movements are decreased. Obtunded is a transitional state between lethargy and stupor. Stuporous and semi-coma have the same meaning which is unconscious and responding only to persistent or vigorous shaking or pain.

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.

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

A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. What is the best description of this patient's condition? a. A snake phobia b. A hypochondriac c. An obsession with snakes d. A delusion that snakes are harmful stemming from an early traumatic incident involving snakes

ANS: A This is an example of a phobia. A phobia is a strong, persistent, irrational fear of an object or situation; the person feels driven to avoid it. The situation in the question is not an example of hypochondria, an obsession, or a delusion. A hypochondriac is a person who is morbidly worried about his/her own health and/or feels sick with no actual basis for that assumption. An obsession is an unwanted, persistent thought or impulse in which logic will not purge him/her from his/her consciousness and is intrusive and senseless. A delusion is a firm, fixed, false belief that is irrational and that a person clings to despite objective evidence to the contrary. Instead, the situation in the question is an example of a phobia. A phobia is a strong, persistent, irrational fear of an object or situation; the person feels driven to avoid it.

7. When assessing the patient for risk for deep vein thrombosis (DVT), the nurse should consider which of the following an indicator of increased risk? a. A positive Homans' sign b. Pallor to the distal area c. Edema noted in the extremity d. Fever or dehydration

ANS: D Indicators in Virchow's triad include clotting disorders, fever, and dehydration. Additionally, a swollen extremity, pain, and warm cyanotic skin indicate an elevated risk. Less than 20% of patients exhibit a positive Homans' sign. Edema of the extremity may or may not occur. Pallor to the distal area is a sign of arterial insufficiency, not deep vein thrombosis.

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.

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.

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 nurse notifies the provider immediately if a patient with an indwelling catheter: a. c/o discomfort upon insertion of the catheter b. has not collected any urine in the drainage bag for 2 hours c. places the drainage bag higher than the waist while ambulating d. is incontinent of stool and contaminates the external portion of the catheter

the nurse is assessing a pt whose 24-hr output is 2400 mL. Which finding is accurate? a. increased output b. normal output c. decreased output d. balanced output

the nurse notices that the bladder is firm and distended; the patient has an urge to urinate. which question follows? a. does your urinary problem interfere with any activities? b. when was the last time you voided? c. do you lose urine when you cough or sneeze? d. are you experiencing a fever or chills?

the patient is having lower abdominal surgery and the nurse inserts an indwelling catheter. What is the rationale? a. the patient may void uncontrollably during the procedure b. anesthetics can decrease bladder contractility and cause urinary retention c. local trauma sometimes promotes excessive urine incontinence d. the patient will not interrupt the procedure by asking to get to the toilet

when caring for a patient with urinary retention, the nurse should anticipate an order for: a.limited fluid intake b.urinary catheter c.diuretetic medication d.a renal angiogram

which action by the NAP will cause the nurse to intervene when caring for a patient with an indwelling catheter? a.emptying the drainage bag when half full b. placing the drainage bag on the side rail of the patient's bed c. kinking the catheter tubing to obtain a urine specimen d. securing the catheter tubing to the patients thigh

the nurse anticipates a suprapubic catheter for which patient? a. a pt with recent prostatectomy b. pt with an appendectomy c. pt with a urethral stricture d. pt with menopause

the nurse is informed during report a patient has urinary incontinence. Upon assessment, the nurse would expect to find: a. an indwelling foley catheter b.blood clot in patient's urine c. reddened irritated skin on the buttocks d. foul-smelling discharge indicative of a UTI

which symptom is the patient w fluid overload likely to exhibit? a.oliguria b.increased skin temp c. distended neck veins d. increased urine specific gravity

a patient reports an urgent need to urinate but is unable to urinate on the toiled. What is the priority assessment? a. auscultation to assess circulation through the R and L renal arteries b. calculate the patient's intake and output to check for FVD c. bimanual palpation to assess for possible enlargement of the kidneys d. bladder scan to determine the amount of urine in the bladder.

in assisting a male pt in using a urinal, which of the following actions by the nurse is incorrect? a. assess for othostatic hypotension b. assess for periods of incontinence c. assess the patient's normal elimination habits d. prop the urinal in place if the patient is unable to hold it

what S/S would the nurse expect to observe in a patient with excessive WBC present in the urine? a.difficulty holding in urine b. abnormal blood sugar c. increased blood pressure d. fever and chills

which action will require the nurse to f/u when watching a PVR scan on a female with a previous hysterectomy a. palpate the patient's symphysis pubis b. applies a generous amount of gel c. wipes scanner head with alcohol pad d. sets the scanner to female

A patient is admitted to the medical unit following a cerebrovascular accident (CVA). Evidence of left-sided hemiparesis is noted, and the nurse will be following up on ROM and other exercises performed in physical therapy. The nurse should correctly teach the patient and family members which of the following principles of ROM exercises? A Flex the joint to the point of discomfort. B Medicate the patient after the ROM exercise session. C Move the joints quickly. D Provide support for distal joints.

D. Provide support for distal joints.

During a recent interview, a patient diagnosed with schizophrenia shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. What is the best description of this behavior? a. Confusion b. Ambivalence c. Depersonalization d. Inappropriate affect

NS: D This is an example of inappropriate affect. An inappropriate affect is an affect clearly discordant with the content of the person's speech. The patient's behavior is not an example of confusion, ambivalence, or depersonalization. Confusion is a disturbance of consciousness characterized by inability to engage in orderly thought or by lack of power to distinguish, choose, or act decisively. Ambivalence is the existence of opposing emotions toward an idea, object, or person. Depersonalization is a loss of identity, feeling of being estranged, or perplexed about one's own identity and meaning of existence. The example in the question demonstrates inappropriate affect. An inappropriate affect is an affect clearly discordant with the content of the person's speech.

A patient is recovering from bilateral knee replacements and is prescribed bilateral partial weight bearing. You are asked to reinforce crutch walking and know that the following crutch gait would be most appropriate for this patient. Two-point gait Three-point gait Four-point gait Swing-through gait

a Two-point gait requires at least partial weight bearing on each foot. The patient moves a crutch at the same time as the opposing leg, so that crutch movements are similar to arm motion during normal walking.

Plantar flexion contracture, otherwise known as _____________, is caused when the force of gravity pulls an unsupported, weakened foot into a plantar-flexed position.

footdrop Plantar flexion contracture, or footdrop, is a complication seen in bedridden patients. It is caused when the force of gravity pulls an unsupported, weakened foot into a plantar-flexed position, and calf muscles and heel cords shorten, complicating future attempts at walking.

to stimulate micturition for a female patient, which nursing intervention should the nurse try first?

utilize the power of suggestion by letting the faucet water run. (couldn't read other answer choices on screenshot)

When performing a safety risk assessment for an elderly patient, which obstacles should the nurse recommend removing from the patient's home? A. Throw rugs B. Jacuzzi-type tub C. Metal hangers D. Microwave oven

A. throw rugs Rationale: Removing throw rugs would remove an obstacle that the patient could trip over. Elderly patients are at risk for falls, and throw rugs are a hazard. The other items listed are not necessarily hazards for the patient.

During the assessment of deep tendon reflexes, the nurse finds that a patient's responses are bilaterally normal. What number is used to indicate normal deep tendon reflexes when the documenting this finding? ____+Correct.

ANS: 2 Responses to assessment of deep tendon reflexes are graded on a 4-point scale. A rating of 2+ indicates normal or average response. A rating of 0 indicates no response, and a rating of 4+ indicates very brisk, hyperactive response with clonus, which is indicative of disease.

4. __________ are the most common type of inpatient accident.

ANS: Falls Falls are the most common type of inpatient accident. Approximately 30% of hospital patient falls result in physical injury.

_________________ are sudden, abnormal, and excessive electrical discharges from the brain that change motor or autonomic function, consciousness, or sensation.

ANS: Seizures Seizures are sudden, abnormal, and excessive electrical discharges from the brain that change motor or autonomic function, consciousness, or sensation.

__________________ involves the insertion of a urinary catheter directly into the bladder through the lower abdominal wall. Urine drains from the catheter into a urinary drainage bag.

ANS: Suprapubic catheterization Suprapubic catheterization involves the insertion of a urinary catheter directly into the bladder through the lower abdominal wall. Urine drains from the catheter into a urinary drainage bag. Suprapubic catheters are inserted with local or general anesthetic for short- or long-term use.

4. The patient is performing range of motion (ROM) exercises independently. These are known as __________ exercises.

ANS: active ROM ROM exercises may be active, passive, or active-assisted. They are active if the patient is able to perform the exercises independently and passive if the exercises are performed for the patient by the caregiver. The exercises are active-assisted if the patient is able to perform some of the actions independently with support and assistance from the caregiver.

The risk for catheter-associated urinary tract infection can be reduced by using ___________ when inserting the catheter.

ANS: aseptic technique Numerous studies have confirmed the effect of the use of aseptic technique in the insertion of urinary catheters in reducing the rate of catheter-associated infections.

A ___________________ is a noninvasive alternative for management of male urinary incontinence. Because it is noninvasive, the risk for urinary tract infection (UTI) is decreased. The device fits over the penis and connects to a small collection bag that attaches to the leg with a strap, or to a standard urinary collection bag that hangs on the bedframe below the level of the bladder.

ANS: condom catheter A condom catheter, also referred to as an external catheter or a penile sheath, is a noninvasive alternative for management of male urinary incontinence. Because it is noninvasive, the risk for UTI is decreased. The device is a soft, flexible, condom-like sheath that fits over the penis and connects to a small collection bag that attaches to the leg with a strap, or to a standard urinary collection bag that hangs on the bedframe below the level of the bladder.

5. Virchow's triad (hypercoagulability of blood, venous wall damage, and stasis of blood flow) has been found to contribute to ________________.

ANS: deep vein thrombosis (DVT) deep vein thrombosis Three elements (commonly referred to as Virchow's triad) contribute to the development of DVT: hypercoagulability of the blood, venous wall damage, and stasis of blood flow.

It is important for nurses to understand what patients perceive as ___________ so that patients will become partners in programs to prevent them.

ANS: errors mistakes problems Patients consider falls, communication problems, and lack of nurse responsiveness as errors, along with medication errors and injury from medical equipment. It is important for nurses to understand what patients perceive as errors, so that patients will become partners in programs to prevent errors.

6. An ________________ maintains immobilization of the extremities to protect the patient from accidental removal of a therapeutic device.

ANS: extremity restraint An extremity restraint is made of soft quilted material or sheep-skin with foam padding. An extremity restraint can be wrapped around the ankle or wrist with the padded, soft part towards the skin and secured snuggly in place with Velcro straps. It is designed to immobilize one or all extremities and can be used to prevent accidental removal of therapeutic devices.

6. The nurse is concerned that the patient may fall while he is ambulating. To help her maintain control while the patient walks, the nurse may apply a ______________ around the patient's waist.

ANS: gait belt A gait belt encircles a patient's waist and has space for the nurse to hold while the patient walks. This gives the nurse better control and helps to prevent injury.

7. The patient is immobile and is being placed in the supine position. To reduce extension of the fingers and abduction of the thumb, the nurse places _________________ in the patient's hands.

ANS: hand rolls For this type of patient, place hand rolls in his or her hands. Consider physical therapy referral for the use of hand splints. This is designed to reduce extension of the fingers and abduction of the thumb. This also maintains the thumb slightly adducted and in opposition to the fingers.

4. An ______________ has a separate lumen that is used to inflate a balloon so the catheter remains in the bladder for short- or long-term use.

ANS: indwelling catheter An indwelling catheter has a separate lumen that is used to inflate a balloon so the catheter remains in the bladder for short- or long-term use.

5. The use of physical restraints is one safety strategy that has been used to protect patients from injury. However, physical restraints should be used as a ______________ and are used only when reasonable alternatives have failed.

ANS: last resort The use of physical restraints is one safety strategy that has been used to protect patients from injury. However, efforts have been in place for several years by the Centers for Medicare and Medicaid Services and The Joint Commission to reduce the use of restraints and to use them only under extreme caution. Physical restraints are the last resort and are used only when reasonable alternatives have failed.

3. Health care facilities must provide employees access to information about the properties of particular chemicals and information for handling substances in a safe manner. Facilities do this by providing ______________.

ANS: material safety data sheets (MSDSs) material safety data sheets Health care facilities provide employees access to a material safety data sheet (MSDS) for each hazardous chemical. An MSDS is a form that contains data about the properties of a particular chemical and information for handling a substance in a safe manner (e.g., storage, disposal, protective equipment, and spill handling procedures).

A thumb-less device used to restrain patients' hands to prevent them from dislodging invasive equipment, removing dressings, or scratching is known as a _____________.

ANS: mitten restraint A mitten restraint is a thumb-less mitten device that restrains patients' hands and prevents patients from dislodging invasive equipment, removing dressings, or scratching, yet it allows greater movement than is permitted with a wrist restraint.

A nursing skill that helps a weakened or dependent patient or patients with restricted mobility to attain positions to regain optimal independence is known as ________________.

ANS: transferring Transferring is a nursing skill that helps weakened or dependent patients or patients with restricted mobility to attain positions to regain optimal independence as quickly as possible.

The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma? a. 6 b. 12 c. 15 d. 24

ANS: A A fully alert, normal person has a score of 15, whereas a score of 7 or less reflects coma on the Glasgow Coma Scale.

In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or stimulation. The mother reports that in the last week he has been sleeping all of the time, and when he is awake all he does is cry. The nurse hears that the infant's cries are very high pitched and shrill. What is the most appropriate response by the nurse? a. Refer the infant for further testing. b. Talk with the mother about eating habits. c. Do nothing; these are expected findings for an infant this age. d. Tell the mother to bring the baby back in 1 week for a recheck.

ANS: A A high-pitched, shrill cry or cat-sounding screech occurs with central nervous system damage. Lethargy, hyporeactivity, and hyperirritability, as well as the parent's report of significant changes in behavior all warrant referral. The other options are not correct responses.

A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes? a. Reflexes will be normal. b. Reflexes cannot be elicited. c. All reflexes will be diminished but present. d. Some reflexes will be present, depending on the area of injury.

ANS: A A reflex is a defense mechanism of the nervous system. It operates below the level of conscious control and permits a quick reaction to potentially painful or damaging situations.

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.

When caring for a patient who has been restrained, how often will the nurse perform an assessment? a. Every 15 minutes b. Every 30 minutes c. Every hour d. Every 2 hours

ANS: A After application, evaluate the patient's condition every 15 minutes for signs of injury. Frequent assessments prevent injury to the patient and allow removal of the restraint at the earliest possible time. Observation and frequent assessments prevent complications such as suffocation, skin breakdown, and impaired circulation. The Joint Commission recommends that the patient's condition be evaluated every 15 minutes. If the nurse restrains the patient in an emergency situation because of violent or aggressive behavior that presents an immediate danger, a face-to-face physician assessment within 1 hour is needed to determine the patient's continued need for restraints. Restraints should be removed at least every 2 hours. If the patient is violent or noncompliant, remove one restraint at a time and/or have staff assistance while removing restraints. Removal provides an opportunity to change the patient's position, offer nutrients, perform full range of joint motion (ROJM), and toilet and exercise the patient.

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.

Crepitation is an audible sound that is produced by: a. roughened articular surfaces moving over each other. b. flexion and extension of an inflamed bursa. c. tendons or ligaments that slip over bones during motion. d. joints that are stretched when placed in hyperflexion or hyperextension.

ANS: A Crepitation is an audible and palpable crunching or grating that accompanies movement. It occurs when the articular surfaces in the joints are roughened. Crepitation is not the cracking noise heard when tendons or ligaments slip over bones during motion. Hyperflexion or hyperextension is assessed with range of motion. Bursitis is an inflamed bursa. Pain may occur with motion of the joint involved.

7. A patient is taking a medication that has the potential to cause orthostatic hypotension. Which of the following nursing interventions is appropriate for this patient? a. Have the patient sit slowly and dangle. b. Refer the patient to physical therapy. c. Keep the side rails up at all times. d. Obtain a walker or a cane for patient use.

ANS: A Dangling allows adjustment to orthostatic hypotension, permitting blood pressure to stabilize before ambulating. Have the patient dangle his or her feet for a few minutes before standing, walk slowly, and ask for help if dizzy or weak. The nurse would confer with physical therapy on the feasibility of gait training and muscle-strengthening exercise. Check agency policies regarding side rail use. Side rails are a restraint device if they immobilize or reduce the ability of a patient to move his or her arms, legs, body, or head freely. Keep one side rail up in a two-rail system, and keep three of four rails up (one lower rail down) in a four-rail system, with the bed in low position and wheels locked, when you are not administering patient care. This allows the patient to maneuver and get out of bed safely. Do not assume that the patient requires a walker or a cane. Evaluate the need for assistive devices such as walker, cane, or bedside commode. Assistive devices may provide greater stability and may help the patient to assume a more active role.

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.

An appropriate technique for the nurse to use when performing range of motion (ROM) exercises is to: a. repeat each action 5 times during the exercise. b. perform the exercises quickly and firmly. c. support the proximal portion of the extremity being exercised. d. continue the exercise slightly beyond the point of resistance.

ANS: A Each movement should be repeated 5 times during an exercise period. Be sure that ROM exercises are performed slowly and gently. When performing active-assisted or passive ROM exercises, support the joint by holding the distal portion of the extremity, or by using a cupped hand to support the joint. Discontinue exercise if the patient complains of discomfort, or if you note resistance or muscle spasm.

During morning rounds, the nurse asks a patient, "How are you today?" The patient responds, "You today, you today, you today!" and mumbles the words. This is an example of which speech pattern? a. Echolalia b. Clanging c. Word salad d. Perseveration

ANS: A Echolalia occurs when a person imitates or repeats another's words or phrases, often with a mumbling, mocking, or a mechanical tone. Clanging is word choice based on sound, not meaning, and includes nonsense rhymes and puns. Word salad is an incoherent mixture of words, phrases, and sentences. Perseveration is the persistent repeating of verbal or motor response, even with varied stimuli. The statements in this question describe echolalia.

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.

4. Given the most common causes of hospital fires, which of the following choices are most appropriate in preventing patient injury? a. Assure that all electrical devices are checked by engineering. b. Assist patients who smoke to a safe area to smoke. c. Prop fire doors open for easier patient access. d. Educate patients on the importance of smoking cessation.

ANS: A Fires in health care settings are usually electrical or anesthetic-related, so ensuring all electrical devices are inspected will greatly reduce the risk of fire. Look for inspection labels verifying recent inspection for all electrical devices. Fire door should never be propped open. While educating patients on smoking cessation is a good idea, it will have little impact on immediate hospital safety. Although smoking is no longer allowed in the hospital setting, smoking-related fires continue to pose a risk due to unauthorized smoking in bed or the bathroom.

2. 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.

15. When the four gaits listed below are compared, which is the most stable of the crutch gaits? a. Four-point gait b. Three-point gait c. Two-point gait d. Swing-to gait

ANS: A Four-point gait is the most stable of crutch gaits because it provides at least three points of support at all times. The patient must be able to bear weight on both legs. Each leg is moved alternately with each opposing crutch, so that three points of support are on the floor all the time. This gait is often used when the patient has some form of paralysis, such as for spastic children with cerebral palsy. This is less stable than four-point gait because it requires the patient to bear all weight on one foot. Weight is borne on the uninvolved leg and then on both crutches. The affected leg does not touch the ground during the early phase of three-point gait. This gait may be useful for patients with a broken leg or a sprained ankle. This is less stable than four-point gait because it requires at least partial weight bearing on each foot. It is faster than four-point gait and requires better balance because only two points support the body at any one time. This is the easier of the two swinging gaits. It is less stable than four-point gait because it requires the ability to partially bear body weight on both legs. This gait is frequently used by patients whose lower extremities are paralyzed, or who wear weight-supporting braces on their legs.

The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotypical words or sounds. This finding reflects which type of aphasia? a. Global b. Broca's c. Dysphonic d. Wernicke's

ANS: A Global aphasia is the most common and severe form of aphasia. Spontaneous speech is absent or reduced to a few stereotyped words or sounds, and prognosis for language recovery is poor. Dysphonic aphasia is not a valid condition. The description of the patient in the question does not describe Broca's or Wernicke's aphasia. With Broca's aphasia the person can understand language but cannot express himself using words or language. With Wernicke's or receptive aphasia the person can hear sounds and words but cannot relate them to previous experiences. Speech is fluent, effortless, and well-articulated, but it has many paraphasias (word substitutions that are malformed or wrong) and neologisms (made-up words) and often lacks substantive words. Speech can be totally incomprehensible. Often, a great urge to speak is present. Repetition, reading, and writing also are impaired. Dysphonic aphasia is not a valid condition.

During change of shift report, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination? a. Man believes that his dead wife is talking to him. b. Woman hears the doorbell ring and goes to answer it, but no one is there. c. Child sees a man standing in his closet. When the lights are turned on, it is only a dry cleaning bag. d. Man believes that the dog has curled up on the bed, but when he gets closer he sees that it is a blanket.

ANS: A Hallucinations are sensory perceptions for which no external stimuli exist. They may strike any sense: visual, auditory, tactile, olfactory, or gustatory.

15. When assessing a patient, a nurse notes that the skin distal to a restraint is pale and cool to the touch. Which of the following interventions will the nurse perform first? a. Remove the restraint. b. Loosen the restraint. c. Obtain a larger restraint. d. Reapply the restraint with more padding.

ANS: A If a patient has altered neurovascular status of an extremity, such as cyanosis, pallor and coldness of skin, or complaints of tingling, pain, or numbness, remove the restraint immediately, and notify the physician. Loosening the restraint may not effectively restore adequate circulation. An improperly sized restraint may not provide the protection needed for the patient.

. A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient has dysarthric speech and is lethargic. How should the nurse proceed? a. Defer the rest of the mental status examination. b. Skip the language portion of the examination and proceed onto assessing mood and affect. c. Conduct an in-depth speech evaluation and defer the mental status examination to another time. d. Proceed with the examination and assess the patient for suicidal thoughts because dysarthria is often accompanied by severe depression.

ANS: A In the mental status examination, the sequence of steps forms a hierarchy in which the most basic functions (consciousness, language) are assessed first. The first steps must be accurately assessed to ensure validity of the steps that follow. For example, if consciousness is clouded, then the person cannot be expected to have full attention and to cooperate with new learning. If language is impaired, then a subsequent assessment of new learning or abstract reasoning (anything that requires language functioning) can give erroneous conclusions. Dysarthric speech and lethargy are signs of altered consciousness and answers to questions on the mental status examination may be invalid. The nurse should not proceed with any further part of the mental status examination at this time.

When providing care for a patient in need of an indwelling catheter, the nurse understands that which of the following is an indication for this need? a. Presence of stage III and IV pressure ulcers b. Presence of a yeast infection c. Need for inaccurate measurement of urinary output d. Need to manage urinary elimination

ANS: A Indications for an indwelling catheter include (1) the presence of stage III and IV pressure ulcers that cannot heal because of continual incontinence, and (2) the need for accurate measurement of urinary output in critically ill patients. The incidence of catheter-associated UTI significantly decreases when the nurse gives the prescriber daily reminders to remove unnecessary catheters and suggests the use of alternative noninvasive treatments to manage urinary elimination.

The nurse is assessing the mental status of a child. Which statement about children and mental status is true? a. All aspects of mental status in children are interdependent. b. Children are highly labile and unstable until the age of 2 years. c. A child's mental status is impossible to assess until the child develops the ability to concentrate. d. Children's mental status is largely a function of their parents' level of functioning until the age of 7 years.

ANS: A It is difficult to separate and trace the development of just one aspect of mental status. All aspects are interdependent. For example, consciousness is rudimentary at birth because the cerebral cortex is not yet developed. The infant cannot distinguish the self from the mother's body. The other statements are not true. Options B, C, and D are all false statements. It is difficult to separate and trace the development of just one aspect of mental status. All aspects are interdependent. For example, consciousness is rudimentary at birth because the cerebral cortex is not yet developed. The infant cannot distinguish the self from the mother's body.

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.

The nurse receives an order to insert a Foley catheter. In obtaining a catheter of the right size, the nurse is aware that large catheters can lead to which complication? a. Urethral damage b. Bladder relaxation c. Obstruction of urinary flow d. Decreased risk for infection

ANS: A Large catheters (larger than 16 Fr) can distend the urethra and permanently damage the urethra and bladder neck, as well as cause bladder spasms and leaking around the catheter. Use a catheter of the smallest size possible to minimize trauma and promote adequate drainage of the periurethral glands. This will decrease the risk for infection.

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.

During a mental status examination, the nurse wants to assess a patient's affect. Which question the nurse should ask? a. "How do you feel today?" b. "Would you please repeat the following words?" c. "Have these medications had any effect on your pain?" d. "Has this pain affected your ability to get dressed by yourself?"

ANS: A Mood and affect should be judged by observing body language and facial expression and by directly asking, "How do you feel today?" or "How do you usually feel?" The mood should be appropriate to the person's place and condition and should appropriately change with the topics. Options B, C, and D do not assess affect.

In which of the following groups does osteoporosis primarily occur? a. Postmenopausal white women b. Asian men c.African Americans d. American Indians

ANS: A Osteoporosis primarily occurs in postmenopausal white women. Other risk factors include: smaller height and weight, younger age at menopause, lack of physical activity, and lack of estrogen in women. African American adults have a decreased risk for fractures compared with white adults, and Hispanic women have a decreased risk for fractures compared with white women. The difference in fracture rates may be traced to childhood, where African American and Hispanic children have shown significantly higher bone strength than white children show. There is greater bone density at specific bone sites in African American and Hispanic children.

A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action? a. Perform a complete mental status examination. b. Refer him to a psychometrician. c. Plan to integrate the mental status examination into the history and physical examination. d. Reassure his wife that memory loss after a physical shock is normal and will soon subside.

ANS: A Performing a complete mental status examination is necessary when any abnormality in affect or behavior is discovered or when family members are concerned about a person's behavioral changes (e.g., memory loss, inappropriate social interaction) or after trauma, such as a head injury.

The nurse needs to transfer the patient from the bed to the stretcher. The patient is unable to assist. Of the following, which would be the best technique for transferring the patient? a. Using three nurses and a slide board b. Using the three-person lift technique c. Raising the head 30 degrees d. Having the patient keep arms to the side

ANS: A Physical stress can be decreased significantly by the use of a slide board or a friction-reducing board positioned under a drawsheet beneath the patient. In addition, the patient is more comfortable using this method. The three-person lift for horizontal transfer from bed to stretcher is no longer recommended and, in fact, is discouraged. Lower the head of the bed as much as the patient can tolerate. This maintains alignment of the spinal column. Cross the patient's arms on the chest to prevent injury to the arms during transfer.

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.

During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. No associated rigidity is observed with movement. Which of these statements is most accurate? a. These findings are normal, resulting from aging. b. These findings could be r/t hyperthyroidism. c. These findings are the result of Parkinson disease. d. This patient should be evaluated for a cerebellar lesion.

ANS: A Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and a weakness of voluntary movement. The other responses are incorrect.

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.

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. How should the nurse proceed? a. Ask the patient to lock her fingers and pull. b. Document these reflexes as 0 on a scale of 0 to 4+. c. Refer the patient to a specialist for further testing. d. Complete the examination, and then test these reflexes again.

ANS: A Sometimes the reflex response fails to appear. Documenting the reflexes as absent is inappropriate this soon in the examination. The nurse should try to further encourage relaxation, varying the person's position or increasing the strength of the blow. Reinforcement is another technique to relax the muscles and enhance the response. The person should be asked to perform an isometric exercise in a muscle group somewhat away from the one being tested. For example, to enhance a patellar reflex, the person should be asked to lock the fingers together and pull.

The patient is immobile and has been repositioned in bed using a drawsheet. When finished, the patient is in a supported Fowler's position with the head of the bed elevated 45 degrees. Also important for positioning this patient is to: a. support his calves with pillows. b. place a large pillow behind his head to prevent extension. c. place a pillow behind his upper back. d. avoid using pillows if the patient does not have use of the hands and arms.

ANS: A Support the calves with pillows. Heels should not be in contact with the bed to prevent prolonged pressure of the mattress on the heels. This sometimes is referred to as "floating" heels. Rest the patient's head against the mattress or on a small pillow. This prevents flexion contractures of the cervical vertebrae. A pillow behind the upper back would put the torso out of alignment. Position a pillow at the lower back to support the lumbar vertebrae and decrease flexion of the vertebrae. Use pillows to support the arms and hands if the patient does not have voluntary control or use of the hands and arms. This prevents shoulder dislocation from the effect of downward pull of unsupported arms, promotes circulation by preventing venous pooling, and prevents flexion contractures of arms and wrists.

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.

18. 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 nurse is caring for a patient who is experiencing inadequate bladder emptying. To determine postvoid residual, which technique is most important for the nurse to implement? a. Bladder scanner b. Indwelling catheterization c. Straight/intermittent catheterization d. Foley catheterization

ANS: A The bladder scan is most commonly used to measure postvoid residual (PVR); it is the least invasive method of making this determination.

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries very easily and becomes angry. What part of the cerebral lobe is responsible for these behaviors? a. Frontal b. Parietal c. Occipital d. Temporal

ANS: A The frontal lobe has areas responsible for personality, behavior, emotions, and intellectual function. The parietal lobe has areas responsible for sensation; the occipital lobe is responsible for visual reception; and the temporal lobe is responsible for hearing, taste, and smell.

The functions of the musculoskeletal system include: a. protection and storage. b. propulsion and preservation. c. movement and elimination. d. storage and control.

ANS: A The functions of the musculoskeletal system are as follows: provide support to stand erect; allow movement; encase and protect the inner vital organs; produce the red blood cells in the bone marrow; and act as a reservoir for storage of essential minerals, such as calcium and phosphorus in the bones.

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.

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.

13. The patient has a leg injury and is being fitted for a cane. The patient should be taught to: a. hold the cane on the uninvolved side. b. hold the cane on the weaker side. c. extend the cane 15 inches from the foot when used. d. maintain approximately 60 degrees of elbow flexion.

ANS: A The patient holds the cane on the uninvolved side, 4 to 6 inches (10 to 15 cm) to the side of the foot. This offers the most support when the cane is placed on the stronger side of the body. The cane and the weaker leg work together with each step. The cane extends from the greater trochanter to the floor while the cane is held 6 inches (15 cm) from the foot. Allow approximately 15 to 30 degrees of elbow flexion. As weight is taken on by the hand and the affected leg is lifted off the floor, complete extension of the elbow is necessary.

17. When teaching the use of a three-point crutch gait, the nurse should instruct the patient to move: a. both crutches and the affected leg first, then the stronger leg. b. the right crutch, left foot, left crutch, and right foot in sequence. c. the left crutch and right foot, then move the right crutch and left foot. d. both crutches, then lift and swing the legs forward as far as the crutches.

ANS: A The proper sequence for the three-point crutch gait is: begin in tripod position, advance both crutches and the affected leg, and then move the stronger leg forward, stepping on the floor. This is the proper sequence for the four-point gait, the two-point gait, and the swing-to gait.

During an assessment of a 62-year-old man, the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements. What do these findings suggest? a. Parkinsonism b. Cerebral palsy c. Cerebellar ataxia d. Muscular dystrophy

ANS: A The stooped posture, shuffling walk, short steps, flat facial expression, and pill-rolling finger movements are all found in parkinsonism. Cerebral palsy is dysfunction of a mixed group of paralytic neuromotor disorders of infancy and childhood due to damage to cerebral cortex from a developmental defect, intrauterine meningitis, encephalitis, birth trauma, anoxia, or kernicterus and may present as spasticity or athetosis. The characteristics of cerebellar ataxia include a staggering, wide-based gait; difficulty with turns; and uncoordinated movement with positive Romberg sign. Muscular dystrophy is a chronic, progressive wasting of the musculature, which produces weakness, contractures, and in severe cases respiratory dysfunction and death. Weak pelvis muscles and decreased or absent reflexes are signs of muscular dystrophy.

11. To promote patient safety, government standards regarding mechanical and physical restraints state that: a. alternative measures are to be implemented before restraints are used. b. the nurse's judgment is all that is required for restraint use. c. restraints should be used immediately for all patients who may need them. d. restraints cannot be used except to prevent others from being harmed.

ANS: A The use of mechanical or physical restraints must be part of the prescribed medical treatment, all less-restrictive interventions must be tried first, other disciplines must be applied, and supporting documentation must be provided. If the alternatives fail, the nurse may consider use of a restraint to prevent injury. Determine the patient's need for restraint if other less-restrictive measures fail to prevent interruption of therapy or injury to self or others. Confer with the physician or primary health care provider, who must write the order for restraints. Restraints may be needed for the confused or combative patient to prevent interruption of therapy or injury to self or others. Confer with the physician or primary health care provider.

The nurse is preparing to reposition the patient. Which of the following is a principle of safe patient transfer and positioning? a. The wider the base of support, the greater the stability of the nurse. b. The higher the center of gravity, the greater the stability of the nurse. c. Facing in the opposite direction of movement prevents twisting. d. Using either the arms or the legs reduces the risk for back injury.

ANS: A The wider the base of support, the greater the stability of the nurse. The lower the center of gravity, the greater the stability of the nurse. Facing the direction of movement prevents abnormal twisting of the spine. Dividing balanced activity between arms and legs reduces the risk for back injury.

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.

18. A patient with left hemiparesis is using a quad cane for ambulation. Which of the following is the correct technique for the nurse to use in teaching the patient? a. Use the cane on the right side, with the cane moving forward first. b. Use the cane on the left side, with the left leg moving forward with the cane. c. Use the cane in either hand, with the right leg moving forward first. d. Use the cane in either hand, with the left leg moving beyond the forward placement of the cane.

ANS: A To correctly use a quad cane, the patient places the cane on the side opposite the involved leg. This provides added support for the weak or impaired side. Ambulation then begins by moving the cane forward 6 to 10 inches (15 to 25 cm), keeping body weight on both legs. The weak leg is then brought forward even with the cane while the body weight is supported by the strong leg and the cane. The strong leg is then advanced past the cane. Moving a leg and the cane forward at the same time will compromise balance and increase risk of fall.

Which of these tests would the nurse use to check the motor coordination of an 11-month-old infant? a. Denver II b. Stereognosis c. Deep tendon reflexes d. Rapid alternating movements

ANS: A To screen gross and fine motor coordination, the nurse should use the Denver II with its age-specific developmental milestones. Stereognosis tests a person's ability to recognize objects by feeling them and is not appropriate for an 11-month-old infant. Testing the deep tendon reflexes is not appropriate for checking motor coordination. Testing rapid alternating movements is not appropriate for testing coordination in infants or children. To screen gross and fine motor coordination, the nurse should use the Denver II with its age-specific developmental milestones.

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 the taking of the health history, a patient tells the nurse that "it feels like the room is spinning around me." How should the nurse document this finding? a. Vertigo b. Syncope c. Dizziness d. Seizure activity

ANS: A True vertigo is rotational spinning caused by a neurologic dysfunction or a problem in the vestibular apparatus or the vestibular nuclei in the brainstem. Syncope is a sudden loss of strength or a temporary loss of consciousness. Dizziness is a light-headed, swimming sensation. Seizure activity is characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances.

3. In a long-term care facility, an elderly patient drops his burning cigarette into a trash can and starts a fire. A type _____ fire extinguisher is the most appropriate type of fire extinguisher for the nurse to use in this situation. a. A b. B c. C d. D

ANS: A Type A fire extinguishers are used for ordinary combustibles such as wood, cloth, paper, and plastic. A trash can fire would require a type A fire extinguisher. Type B fire extinguishers are used for flammable liquids such as gasoline, grease, paint, and anesthetic gas. Type C fire extinguishers are used for electrical fires. There is no type D fire extinguisher.

A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual? a. Hyporeflexia b. Increased muscle tone c. Positive Babinski sign d. Presence of pathologic reflexes

ANS: A With a herniated intervertebral disk or lower motor neuron lesion, loss of tone, flaccidity, atrophy, fasciculations, and hyporeflexia or areflexia are demonstrated. No Babinski sign or pathologic reflexes would be observed. The other options reflect a lesion of upper motor neurons.

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.

In assisting a male patient in using a urinal, which of the following actions should the nurse take? (Select all that apply.) a. Assess for orthostatic hypotension. b. Assess the patient's normal elimination habits. c. Assess for periods of incontinence. d. Prop the urinal in place if the patient is unable to hold it. e. Always stay with the patient during urinal use.

ANS: A, B, C To assist the patient in using a urinal, the nurse should assess the patient's normal urinary elimination habits and look for periods of incontinence. Always determine mobility status before having a patient stand to void, and assess for orthostatic hypotension if the patient has been on prolonged bed rest. If the patient is able to handle the urinal himself, allow him privacy. If the patient is unable to handle the urinal, the nurse will assist by holding it.

3. Which of the following fall prevention strategies should the nurse perform on all hospitalized patients? (Select all that apply.) a. Conduct hourly rounds. b. Provide the patient regular toileting. c. Assess the patient's comfort needs. d. Evaluate the effectiveness of pain medication.

ANS: A, B, C, D A recent study shows that hourly nurse rounds are an effective strategy for reducing falls. Combining hourly rounds with activities such as regular toileting and assessing the patient's comfort needs manages those factors that often prompt patients to get out of bed without assistance. In the hospital setting, a variety of fall risk factor screening tools are available. Because multiple risk factors for falls are known, no single assessment tool is sensitive and specific for analyzing fall risk.

1. A safe health care environment is one in which: (Select all that apply.) a. the patient's basic needs are met. b. physical hazards are reduced. c. transmission of microorganisms is reduced. d. sanitary measures are carried out.

ANS: A, B, C, D A safe environment is one in which the patient's basic needs are met, physical hazards are reduced or eliminated, transmission of microorganisms is reduced, and sanitary measures are carried out.

Which of the following risk factors contribute to complications of immobility? (Select all that apply.) a. Paralysis b. Traction c. Arterial insufficiency d. Incontinence e. Constipation

ANS: A, B, C, D Assess for risk factors that contribute to complications of immobility. Increased risk factors require the patient to be repositioned more frequently. Paralysis impairs movement; muscle tone changes and sensation is affected. Because of difficulty in moving and poor awareness of the involved body part, the patient is unable to protect and position the body part for self. Traction, bone fractures, surgery, or arthritic changes of the affected extremity result in decreased ROM. Decreased circulation predisposes the patient to pressure ulcers. Premature and young infants require frequent turning because their skin is fragile. Normal physiological changes associated with aging predispose older adults to greater risks for developing complications of immobility. Constipation is not a risk factor for immobility.

2. Effective fall prevention programs include which of the following? (Select all that apply.) a. Risk assessment b. Medication reviews c. Use of assistive devices d. Exercise and strength training

ANS: A, B, C, D Evidence shows that hospital-based fall prevention programs that focus on a multifactorial approach reduce fall rates (CDC, 2006). Effective fall prevention programs include risk assessment, medication reviews with necessary modifications, use of assistive devices, exercise and strength training, and education for home safety.

The nurse has inserted an indwelling catheter and secured the catheter to the patient's thigh, making sure that there is enough slack that movement will not create tension on the catheter. The nurse understands that the chief purpose of properly securing Foley catheters is to obtain which outcome? (Select all that apply.) a. Minimized risk for bleeding b. Reduced risk for bladder spasm c. Reduced risk for meatal necrosis d. Reduced risk for trauma e. Increased bladder relaxation

ANS: A, B, C, D Securing the catheter will minimize accidental dislodgment. It also will minimize risks for bleeding, trauma, meatal necrosis, and bladder spasms from pressure and traction.

Patients at risk for complications and/or injury from improper positioning include patients with which of the following? (Select all that apply.) a. Poor nutrition b. Loss of sensation c. Impaired muscle development d. Poor circulation

ANS: A, B, C, D Some patients are at high risk for complications from improper positioning and have increased risk for injury during transfer. Examples include patients with poor nutrition, poor circulation, loss of sensation, alterations in bone formation or joint mobility, and impaired muscle development.

5. The use of restraints has been associated with which of the following complications? (Select all that apply.) a. Pressure ulcers b. Pneumonia c. Constipation d. Death

ANS: A, B, C, D The use of restraints is associated with several serious complications, including pressure ulcers, hypostatic pneumonia, constipation, incontinence, and death.

1. The patient had a stroke and is currently immobile. The nurse realizes that increasing mobility is critical because immobility can result in alterations in which of the following? (Select all that apply.) a. Cardiovascular function b. Pulmonary function c. Skin integrity d. Elimination

ANS: A, B, C, D When mobility is altered, many body systems are at risk for impairment. Impaired mobility can result in altered cardiovascular functioning, disruption of normal metabolic functioning, increased risk for pulmonary complications, the development of pressure ulcers, and urinary elimination alterations.

Proper alignment for a patient in sitting position includes which of the following? (Select all that apply.) a. Head erect b. Four-inch space between edge of seat and popliteal space c. Vertebrae straight d. Both feet elevated

ANS: A, C Proper alignment for sitting position: head is erect, and vertebrae are in straight alignment. Body weight is evenly distributed on buttocks and thighs. Thighs are parallel and in horizontal plane. Both feet are supported on the floor, and ankles are comfortably flexed. A 2.5- to 5-cm (1- to 2-inch) space is maintained between the edge of the seat and the popliteal space on the posterior surface of the knee.

4. Which of the following alternatives to physical restraints should the nurse use to promote patient safety? (Select all that apply.) a. Environmental modifications b. Less frequent patient observation c. Involvement of family during visitation d. Frequent reorientation of the patient

ANS: A, C, D Many alternatives to the use of restraints are available, and you should try all of them before using restraints. Modification of the environment is an effective alternative to restraints. More frequent observation of patients, involvement of family during visitation, and frequent reorientation are helpful measures.

The nurse realizes that her patient needs to improve his or her mobility as quickly as possible. This is because the nurse realizes that mobilization: (Select all that apply.) a. improves joint motion. b. decreases circulation. c. increases social activity. d. enhances mental stimulation.

ANS: A, C, D Physical activity maintains and improves joint motion, increases strength, promotes circulation, relieves pressure on the skin, and improves urinary and respiratory functions. It also benefits the patient psychologically by increasing social activity and mental stimulation and providing a change in environment. As a result, mobilization plays a crucial role in the patient's rehabilitation.

The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) a. Correct posture b. Maximal muscle strength c. Effective body mechanics d. Effective lifting techniques

ANS: A, C, D The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting techniques. Consider individual patient problems during transfer.

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 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying "I'm just getting old!" After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer disease? (Select all that apply.) a. Getting lost in one's own neighborhood b. Occasionally forgetting names or appointments c. Sometimes having trouble finding the right word d. Misplacing items, such as putting dish soap in the refrigerator e. Difficulty performing familiar tasks, such as placing a telephone call f. Rapid mood swings, from calm to tears, for no apparent reason.

ANS: A, D, E, F Difficulty performing familiar tasks, misplacing items, rapid mood swings, and getting lost in one's own neighborhood can be warning signs of Alzheimer disease. Occasionally forgetting names or appointments, and sometimes having trouble finding the right word are part of normal aging.

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 assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception, the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this? a. The patient has hyperesthesia as a result of the aging process. b. This response is most likely the result of the summation effect. c. The nurse was probably not poking hard enough with the pin in the other areas. d. The patient most likely has analgesia in some areas of arm and hyperalgesia in others.

ANS: B At least 2 seconds should be allowed to elapse between each stimulus to avoid summation. With summation, frequent consecutive stimuli are perceived as one strong stimulus. The other responses are incorrect.

Which symptom is the patient with fluid overload likely to exhibit? a. Oliguria b. Distended neck veins c. Increased skin temperature d. Increased urine specific gravity

ANS: B Cardiovascular signs of fluid volume excess include bounding pulse rate, normal blood pressure with or without orthostatic changes, third heart sound (S3), and distended neck veins. Oliguria is a renal sign of fluid volume deficit. Increased skin temperature is a sign of fluid volume deficit. Increased urine specific gravity is a renal sign of fluid volume deficit.

The nurse is caring for a patient who has an indwelling catheter attached to a drainage bag. To achieve the desired outcome of this procedure, which nursing action should be taken? a. Make sure the tubing has dependent loops to gather urine. b. Make sure the tubing is coiled and secured to the bed. c. Make sure the tubing is kinked. d. Make sure the collection bag is higher than the bladder.

ANS: B Check the drainage tubing and the bag to make sure that the tubing does not have dependent loops and the bag is not positioned above the level of the bladder. Check to make sure that the tubing is coiled and is secured to the bed linen, is free of kinks, and is not clamped, and that the patient is not lying on it.

Place in appropriate order the following steps related to open intermittent irrigation of a catheter. 1. Remove syringe, lower catheter, and allow solution to drain into basin. 2. Insert tip of syringe into lumen of catheter and gently push plunger to instill solution. 3. Disconnect catheter from drainage tubing, allowing any urine to flow into sterile collection basin. 4. Open sterile irrigation tray, establish sterile field, and pour required amount of sterile solution into sterile solution container. 5. Position sterile drape under catheter. 6. Aspirate into irrigating syringe prescribed volume of irrigation solution (usually 30 mL). Place syringe in sterile solution container until ready to use. 7. Wipe connection point between catheter and drainage tubing with antiseptic wipe before disconnecting.

(in correct order)

9. When using a sequential compression device (SCD), the nurse should: a. apply powder to the patient's skin if redness and itching are present. b. leave a two-finger space between the patient's leg and the compression stocking. c. keep the patient connected to the compression device when transferring into and out of bed. d. remove the elastic stockings before putting on the sequential pneumatic compression stockings.

ANS: B Check the fit of SCD sleeves by placing two fingers between the patient's leg and the sleeve. Observe for signs, symptoms, and conditions that might contraindicate the use of elastic stockings or SCD: Elastic stockings and SCD sleeves may aggravate a skin condition or cause it to spread. Remove SCD sleeves when transferring the patient into and out of bed to prevent injury. If the patient is wearing elastic stockings, eliminate any wrinkles and folds before applying SCD sleeves. Wrinkles lead to increased pressure and alter circulation.

Tanner's Sexual Maturity rating/staging

1. before puberty boys: Stage 2 - Around age 11, Pubic hair starts to form Stage 3 - Around age 13, Voice begins to change or "crack"; muscles get larger Stage 4 - Around age 14, Acne may appear; armpit hair forms Stage 5 - Around age 15, Facial hair comes in girls: Stage 2 - age 8-15, Long downy pubic hair near the labia, often appearing with breast budding or several weeks or months later Stage 3 - age 10-15, Increase in amount and pigmentation of hair Stage 4 - age 10-17, Adult in type but not in distribution Stage 5 - age 12.5-18, Large breast with single contour

Place in proper order the following steps for application of an extremity restraint.1. Adjust the bed to proper working height.2. Identify the patient.3. Pad the skin that will be covered by the restraint.4. Wrap an extremity restraint around the patient's wrist with the soft part toward the skin.5. Secure the restraint with a quick-release buckle.6. Attach the restraint to a portion of the bed frame that will not move as the head of the bed is raised.

2, 1, 3, 4, 6, 5

A patient repeats, "I feel hot. Hot, cot, rot, tot, got. I'm a spot." What term should the nurse use to document this? a. Blocking b. Clanging c. Echolalia d. Neologism

ANS: B Clanging is word choice based on sound, not meaning, and includes nonsense rhymes and puns. This is not an example of blocking, echolalia, or neologism. Blocking is when a person experiences sudden interruption in train of thought and unable to complete sentences which seems r/t strong emotion. Echolalia is an imitation or the repetition of another person's words or phrases. Neologism involves coining a new word, which is inventing or making up words that have no real meaning except for the person. The statement in the question is an example of clanging.

What controls humans' ability to perform very skilled movements such as writing? a. Basal ganglia b. Corticospinal tract c. Spinothalamic tract d. Extrapyramidal tract

ANS: B Corticospinal fibers mediate voluntary movement, particularly very skilled, discrete, and purposeful movements, such as writing. The corticospinal tract, also known as the pyramidal tract, is a newer, "higher" motor system that humans have that permits very skilled and purposeful movements. The other responses are not r/t skilled movements. The basal ganglia are large bands of gray matter buried deep within the two cerebral hemispheres that from the subcortical-associated motor system and help to initiate and coordinate movement and control automatic associated movements of the body (e.g. arm swing alternating with the legs during walking). The spinothalamic tract is one of the major sensory pathways of the CNS and has two parts. The lateral spinothalamic tract carries pain and temperature sensations and the anterior spinothalamic tract carries crude touch. The extrapyramidal tracts include all the motor nerve fibers originating in the motor cortex, basal ganglia, brainstem, and spinal cord that are outside the pyramidal tract and maintains muscle tone and control body movements, especially gross automatic movements such as walking.

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.

50. During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? a. A normal occurrence b. Indicates disease of the cerebellum or brainstem c. A sign that the patient is nervous about the examination d. Indicates a visual problem, and a referral to an ophthalmologist is indicated

ANS: B End-point nystagmus at an extreme lateral gaze normally occurs; however, the nurse should carefully assess any other nystagmuses. Severe nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem.

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.

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.

An appropriate way for the nurse to measure a patient for crutches is to: a. have a flexion of 45 degrees at both of the patient's elbows. b. have a space of two to three fingers between the top of the crutch and the axilla. c. place the crutch tips 1 foot to each side of the patient's feet, and observe the positioning of the crutches. d. place the crutch tips 1 foot to the front of the patient's feet, and observe the positioning of the crutches.

ANS: B Following correct crutch adjustment, two to three fingers should fit between the top of the crutch and the axilla. Following correct crutch adjustment, elbows should be flexed 15 to 30 degrees. Elbow flexion is verified with a goniometer. Position the crutches with the crutch tips at 6 inches (15 cm) to the side and 6 inches in front of the patient's feet, and the crutch pads 2 inches (5 cm) below the axilla.

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.

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.

6. The patient is an elderly gentleman who is admitted for a medical problem. While doing his admission assessment, the nurse learns that the patient gets up 2 to 3 times a night to use the restroom. The institution has only beds with four side rails. Which of the following is the appropriate rationale for leaving one of the lower side rails down? a. Falls rarely happen in the inpatient setting. b. Having all side rails raised increases the occurrence of falling. c. Side rails have no bearing on whether or not a patient falls. d. Patient falls rarely result in physical injury.

ANS: B Having all four side rails raised often increases the occurrence of falling, because patients try to climb over the rails to reach a chair or bathroom and often fall farther as a result. Leaving three side rails up (two upper and one lower) on a bed with four side rails is safer for the patient. Leaving the lower side rail down on the side of the bed the patient will exit the bed from to access the bathroom reduces the risk of falls.

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.

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.

3. 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.

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.

3. Which activities related to urinary elimination may be delegated to a nursing assistive personnel (NAP)? a. Catheterization b. Positioning the patient c. Evaluating alternatives to catheter use d. Assessing urinary drainage

ANS: B Nursing assistive personnel (NAP) may position the patient, focus lighting for the procedure, and enhance the patient's comfort during the procedure through measures such as holding the patient's hand or keeping the patient warm. The nurse uses sterile asepsis when inserting an indwelling or straight catheter to reduce the risk for bladder infection. The nurse evaluates possible alternatives to catheter use, and assessment is the responsibility of the nurse.

8. What should the nurse do to promote patient understanding and security in the health care setting? a. Restrain the patient as necessary. b. Explain all procedures to the patient. c. Allow the patient more time alone. d. Restrict activity as much as possible.

ANS: B Orient patient and family to surroundings, introduce to staff, and explain all treatments and procedures. This promotes patient understanding and cooperation. The use of restraints is one safety strategy that can protect patients from injury, but restraints must be used with extreme caution. Physical restraints should be the last resort and should be used only when reasonable alternatives have failed. Isolation may increase anxiety. Encourage family and friends to stay with the patient. Sitters or companions may be used. In some institutions, volunteers can be effective companions. Patient anxiety is reduced and safety is increased when one person provides care and supervision is constant. Constant activity may irritate the patient, yet the lack of activity may create anxiety and/or boredom. Meaningful diversional activities provide distraction, help to reduce boredom, and provide tactile stimulation. Minimize occurrences of wandering.

The nurse is reviewing a treatment plan with the parents of a newborn with hypospadias. Which statement by the parents indicates their understanding of the plan? 1. "Caution should be used when straddling the infant on a hip." 2. "Vital signs should be taken daily to check for bladder infection." 3. "Catheterization will be necessary when the infant does not void." 4. "Circumcision has been delayed to save tissue for surgical repair."

4. "Circumcision has been delayed to save tissue for surgical repair."

The patient has been admitted for hypertension. His blood pressure is normally in the 160/90 range. He has been on bed rest for the past few days, and the doctor has started him on a new blood pressure medication. The nurse is assisting the patient to move from the bed to the chair for breakfast, but when the patient tries to sit up on the side of the bed, he complains of being dizzy and nauseous. The nurse lays the patient down and takes his vital signs. His pulse is 124. His blood pressure is 130/80. This blood pressure is indicative of what? a. A normal blood pressure for this patient b. Orthostatic hypotension c. Orthostatic hypertension d. Effective baroreceptor functio

ANS: B Orthostatic hypotension is a drop in blood pressure that occurs when the patient changes from a horizontal to a vertical position. It traditionally is defined as a drop in systolic or diastolic blood pressure of 20 or 10 mm Hg, respectively. Those at higher risk are immobilized patients, those undergoing prolonged bed rest, the older-adult patient, those receiving antihypertensive medications, and those with chronic illness, such as diabetes mellitus or cardiovascular disease. Signs and symptoms of orthostatic hypotension include dizziness, light-headedness, nausea, tachycardia, pallor, and even fainting. Orthostatic hypertension would be an increase in blood pressure. Physiological changes associated with aging and prolonged bed rest may reduce the effectiveness of the baroreceptors. In these patients, moving to the dangling position may cause a gravity-induced drop in blood pressure; thus, it is recommended to raise the head of the bed and allow a few minutes before dangling.

3. The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize? a. This patient should be turned onto his back for meals. b. This patient may have to be turned more frequently than every 2 hours. c. This patient may be allowed to remain in his favorite position as long as he doesn't complain of discomfort. d. Skin breakdown is not an issue for this patient.

ANS: B Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient's risk for falling. Dehydration or edema may require more frequent position changes because patients are prone to skin breakdown.

9. As part of an attempt to implement a restraint-free environment, the nurse: a. provides constant activity for the patient. b. covers or camouflages tubes and drains. c. changes caregivers as often as possible. d. reduces visiting hours and times in therapy.

ANS: B Position intravenous (IV) catheters, urinary catheters, and tubes/drains out of patient view, or use camouflage by wrapping the IV site with bandage or stockinette, placing undergarments on patients with a urinary catheter, or covering abdominal feeding tubes/drains with a loose abdominal binder. This helps maintain medical treatment and reduces patient access to tubes/lines. Provide scheduled ambulation, chair activity, and toileting. Organize treatments so the patient has long uninterrupted periods throughout the day. Provide for sleep and rest periods. Constant activity may irritate the patient. Provide the same caregivers to the extent possible. This increases familiarity with individuals in the patient's environment, decreasing anxiety and restlessness. Encourage family and friends to stay with the patient. Sitters or companions may be used. In some institutions, volunteers can be effective companions. Patient anxiety is reduced and safety is increased when one person provides care and supervision is constant.

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.

During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This is an example of what behavior? a. Social phobia b. Compulsive disorder c. Generalized anxiety disorder d. Posttraumatic stress disorder

ANS: B Repetitive ritualistic actions, such as handwashing, that a person feels driven to perform are compulsions. These behaviors are done to decrease anxiety and prevent a catastrophe (e.g. contamination [fear of germs], violence, perfectionism, and superstitions). A social phobia is a persistent and irrational fear of being in social situations. Generalized anxiety disorder is a pattern of excessive worrying and morbid fear about anticipated "disasters" in the job, personal relationships, health, or finances. With PSTD the person relieves the trauma many times, intrusively and unwillingly. The same feelings of helplessness, fear, or horror recur. Avoidance of any trigger associated with the trauma occurs, and the person has hypervigilance, sleep problems, and difficulty concentrating, leading to feelings of being permanently damaged. The repetitive behavior of handwashing in this question is a behavior characteristic of compulsive disorder. People with compulsive disorder feel driven to perform repetitive, ritualistic actions in an attempt to decrease anxiety and prevent a catastrophe (e.g. contamination [fear of germs], violence, perfectionism, and superstitions.

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 places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding? a. Extinction b. Stereognosis c. Graphesthesia d. Tactile discrimination

ANS: B Stereognosis is the person's ability to recognize objects by feeling their forms, sizes, and weights. Astereognosis is an inability to identify objects correctly, and it occurs in sensory cortex lesions. Extinction tests the person's ability to feel sensations on both sides of the body at the same point. Graphesthesia is the ability to "read" a number by having it traced on the skin. Tactile discrimination tests fine touch.

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.

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.

The nurse is preparing to conduct a mental status examination. Which statement is true regarding the mental status examination? a. A patient's family is the best resource for information about the patient's coping skills. b. Gathering mental status information during the health history interview is usually sufficient. c. Integrating the mental status examination into the health history interview takes an enormous amount of extra time. d. To get a good idea of the patient's level of functioning, performing a complete mental status examination is usually necessary.

ANS: B The full mental status examination is a systematic check of emotional and cognitive functioning. The steps described, however, rarely need to be taken in their entirety. Usually, one can assess mental status through the context of the health history interview. A patient's family is not the best resource for information about the patient's coping skills. The nurse can gain ample data to assess mental health and coping skills during the health history with the mental health examination integrated into it.

Which statement concerning the areas of the brain is true? a. The cerebellum is the center for speech and emotions. b. The hypothalamus controls body temperature and regulates sleep. c. The basal ganglia are responsible for controlling voluntary movements. d. Motor pathways of the spinal cord and brainstem synapse in the thalamus.

ANS: B The hypothalamus is a vital area with many important functions: body temperature controller, sleep center, anterior and posterior pituitary gland regulator, and coordinator of autonomic nervous system activity and emotional status. The cerebellum controls motor coordination, equilibrium, and balance. The basal ganglia control autonomic movements of the body. The motor pathways of the spinal cord synapse in various areas of the spinal cord, not in the thalamus.

A mother of a 1-month-old infant asks the nurse why it takes so long for infants to learn to roll over. What is the reason for this? a. A demyelinating process must be occurring with her infant. b. Myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated. c. The cerebral cortex is not fully developed; therefore, control over motor function gradually occurs. d. The spinal cord is controlling the movement because the cerebellum is not yet fully developed.

ANS: B The infant's sensory and motor development proceeds along with the gradual acquisition of myelin, which is needed to conduct most impulses. Very little cortical control exists, and the neurons are not yet myelinated. The other responses are not correct.

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.

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.

What are the two parts of the nervous system? a. Motor and sensory b. Central and peripheral c. Peripheral and autonomic d. Hypothalamus and cerebral

ANS: B The nervous system can be divided into two parts—central and peripheral. The central nervous system includes the brain and spinal cord. The peripheral nervous system includes the 12 pairs of cranial nerves (CNs), the 31 pairs of spinal nerves, and all of their branches. Motor and sensory refer to the two types of nerve tract pathways in the CNS. Peripheral and autonomic both are part of the peripheral part of the nervous system. The peripheral nervous system has two parts, the somatic and autonomic. The hypothalamus and cerebral are parts of the brain.

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.

The nurse is preparing the patient for a bladder scan to determine postvoid residual (PVR). Which of the following is part of the preparation? a. Limit food intake for 2 hours before the scan. b. Begin scan 10 minutes after the patient has voided. c. Limit liquid intake for 30 minutes before the scan. d. Administer an analgesic 30 minutes before the scan.

ANS: B The nurse will assist the patient to void, then wait 10 minutes before administering the bladder scan. There is no need to limit either food or fluids before the test. Since the test is completely noninvasive, there is no need to administer an analgesic beforehand.

During an assessment of the cranial nerves (CNs), the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. These findings indicate dysfunction of which cranial nerve(s)? a. Motor component of CN IV b. Motor component of CN VII c. Motor and sensory components of CN XI d. Motor component of CN X and sensory component of CN VII

ANS: B The nurse's findings all reflect motor dysfunction, none are sensory. The specific cranial nerve affected is the facial nerve (CN VII). Cranial nerve IV, the trochlear nerve, innervates a muscle in the eye muscle and is responsible for eye movement, not the symptoms this patient is experiencing. The nurse's findings all reflect motor dysfunction, none are sensory, therefore options c and d can be eliminated because they each contain a sensory component.

When assessing for the presence of a herniated nucleus pulposus, the examiner would: a.instruct the patient to do a knee bend. b. raise each of the patient's legs straight while keeping the knee extended. c.abduct and adduct the patient's legs while keeping the knee extended. d. dont raise each of the patient's legs straight while keeping the knee extended.

ANS: B The straight leg-raising (Lasègue) test reproduces back and leg pain and helps confirm the presence of a herniated nucleus pulposus. The examiner raises each leg straight while keeping the knee in extension. To assess for a spinal curvature, the examiner has the person bend over and touch the toes with the knee in extension. Muscle extension can be assessed by instructing the person to rise from a squatting position without using the hands for support. To assess range of motion, the leg should be abducted and adducted with the knee extended.

16. The nurse is caring for a patient who has just been treated for a broken leg. She needs to teach the patient how to use crutches. Which crutch gait is most appropriate for this patient? a. Four-point gait b. Three-point gait c. Two-point gait d. Swing-to gait

ANS: B The three-point gait requires the patient to bear all weight on one foot. Weight is borne on the uninvolved leg and then on both crutches. The affected leg does not touch the ground during the early phase of three-point gait. It is useful for patients with a broken leg or a sprained ankle. The four-point gait is the most stable of crutch gaits because it provides at least three points of support at all times. The patient must be able to bear weight on both legs. Each leg is moved alternately with each opposing crutch, so that three points of support are on the floor all the time. The two-point is used when the patient has some form of paralysis, such as for spastic children with cerebral palsy. This gait requires at least partial weight bearing on each foot. It requires better balance because only two points support the body at one time. This is the easier of the two swinging gaits. It requires the ability to partially bear body weight on both legs. The swing-to gait is used by patients whose lowe

The nurse should be aware of safety measures to prevent personal injury when lifting or moving patients. An appropriate principle to follow is to: a. bend at the waist for lifting. b. tighten the stomach muscles and pelvis. c. keep the weight to be lifted away from the body. d. carry or hold the weight 1 to 2 feet above the waist.

ANS: B Tighten the stomach muscles and tuck the pelvis; this provides balance and protects the back. Bend at the knees; this helps to maintain the nurse's center of gravity and lets the strong muscles of the legs do the lifting. Keep the weight to be lifted as close to the body as possible; this action places the weight in the same plane as the lifter and close to the center of gravity for balance.

During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find? a. Firm, rigid resistance to movement b. Mild, even resistance to movement c. Slight pain with some directions of movement d. Hypotonic muscles as a result of total relaxation.

ANS: B Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretching. Normally the nurse will notice a mild, even resistance to movement. The other responses are not correct.

When assessing range of motion, which of the following would be important for the nurse to do to help the patient understand what the nurse is asking? a. Anchor the joint with one hand while other hand slowly moves the joint to its limit. b. Model the movements c. Palpate each joint. d. Familiarize himself or herself with type of each joint and normal range of motion

ANS: B When assessing active range of motion, it's helpful for the nurse to demonstrate the movements to the patient rather than just verbally trying to describe the desired movement. It's important for the nurse to understand the type of joints and expected movement, however, this is not something that will most help the patient understand the assessment techniques being performed. When the nurse notes joint limitation, he or she would anchor the joint with one hand while other hand slowly moves the joint to its limit. Palpation of joints to assess movement and for presence of crepitation is part of the assessment techniques but is not something that will help the patient understand what's asked.

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.

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.

An appropriate procedure to use when moving a patient up in bed is for the nurse to: a. raise the head of the bed. b. start by flexing the patient's knees and hips. c. place a pillow under the patient's shoulders. d. instruct the patient to inhale and hold still.

ANS: B When possible, ask the patient to flex his or her knees with the feet flat on the bed. This decreases friction and enables the patient to use leg muscles during movement. The nurse should place the patient on his or her back with the head of the bed flat. This enables the nurse to assess body alignment and reduces the pull of gravity on the patient's upper body. The nurse should remove the pillow from under the patient's head and shoulders and place the pillow at the head of the bed. This prevents striking the patient's head against the head of the bed. The nurse should instruct the patient to push with the heels and elevate the trunk while breathing out, thus moving toward the head of the bed on the count of three. This prepares the patient for the move, reinforces assistance in moving up in bed, and increases patient cooperation. Breathing out avoids the Valsalva maneuver.

16. A nurse enters the room of a patient who is sitting in a chair and begins to have a seizure. To promote patient safety, which nursing intervention will the nurse initially perform? a. Immediately call for assistance. b. Assist the patient to the floor. c. Put the patient back into the bed. d. Insert a padded tongue blade into the patient's mouth.

ANS: B When the seizure begins, position the patient safely. If the patient is standing or sitting, guide the patient to the floor and protect the head by cradling in the nurse's lap or placing a pillow under the head. Clear the surrounding area of furniture. If the patient is in bed, raise the side rails and pad, and put the bed in a low position. Stay with the patient, and observe the sequence and timing of seizure activity. Continued observation ensures adequate ventilation during and after a seizure and will assist in documentation, diagnosis, and treatment of a seizure disorder. If possible, turn the patient onto one side, with the head tilted slightly forward. This allows the tongue to fall away from the airway, permitting drainage of saliva and vomitus, and prevents aspiration. Do not force any objects such as fingers, medicine or tongue depressor, or airway into the patient's mouth when the teeth are clenched. This could cause injury to the mouth and stimulate gagging, which could lead to aspiration.

To assist the patient to a sitting position on the side of the bed, what should the nurse do first? a. Raise the height of the bed. b. Raise the head of the bed 30 degrees. c. Turn the patient onto the side facing away from the nurse. d. Move the patient's legs over the side of the bed.

ANS: B With the patient in supine position, raise the head of the bed 30 degrees; this decreases the amount of work needed by the patient and the nurse to raise the patient to a sitting position. The bed should be in the low position. The patient is turned to face the nurse after the head of the bed is raised 30 degrees. The patient's legs are positioned over the edge of the bed after the head of the bed is raised and the patient is turned to face the nurse.

2. The nurse is applying a continuous passive motion (CPM) machine to the patient's leg. To do so, she must: (Select all that apply.) a. provide analgesia 1 hour before starting the CPM. b. stop the CPM when in extension and place a sheepskin on the machine. c. align the patient's joint with the CPM's mechanical joint. d. secure the patient's extremity tightly with Velcro straps.

ANS: B, C Provide analgesia 20 to 30 minutes before CPM is needed. Stop the CPM when in extension. Place sheepskin on the CPM to ensure that all exposed hard surfaces are padded to prevent rubbing and chafing of the patient's skin. Align the patient's joint with the mechanical joint of the CPM.

3. Factors that contribute to the development of deep vein thrombosis (DVT) are: (Select all that apply.) a. elevated sodium (Na+) levels. b. hypercoagulability of the blood. c. venous wall damage. d. stasis of blood flow.

ANS: B, C, D Three elements (commonly referred to as Virchow's triad) contribute to the development of DVT: hypercoagulability of the blood, venous wall damage, and stasis of blood flow.

1. 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.

6. When working with a patient who has a new seizure disorder, the nurse is alerted to the need for further instruction when the patient tells the nurse: (Select all that apply.) a. "I will avoid over-the-counter medications that contain alcohol." b. "I have the medications that I take listed on this card that I carry with me." c. "I will be sure to take my medications as prescribed by my provider." d. "I will visit my physician right after I return home from my next trucking job."

ANS: B, D Patients should wear a medical alert bracelet or carry an identification card noting the presence of seizure disorder and listing medications taken. Without a medical alert bracelet or identification noting the presence of seizure disorder and medications taken, just having the medications at work or home will not necessarily mean that the appropriate treatment will be started. A seizure condition usually imposes driving limitations. It is recommended that a waiting period of 1 seizure-free year elapses before the patient attempts to drive or operate dangerous equipment.

6. Positioning of patients to maintain correct body alignment is essential to prevent which of the following complications? (Select all that apply.) a. Thrombus b. Pressure ulcer c. Kyphosis d. contractures

ANS: B, D Positioning of patients to maintain correct body alignment is essential in preventing complications. These complications include pressure ulcers, which can develop in 24 hours and require months to heal, and contractures, which can occur within a few days when muscles, tendons, and joints become less flexible because of lack of mobility and incorrect alignment. Thrombus is a complication of immobility, but it is not prevented with proper body alignment. Kyphosis is a chronic condition that complicates proper body alignment.

While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. What does this finding indicate? a. Great sense of humor b. Uncooperative behavior c. Decreased level of consciousness d. Inability to understand questions

ANS: C A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.

A patient has a severed spinal nerve as a result of trauma. Which statement is true in this situation? a. Because there are 31 pairs of spinal nerves, no effect results if only one nerve is severed. b. The dermatome served by this nerve will no longer experience any sensation. c. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. d. A severed spinal nerve will only affect motor function of the patient because spinal nerves have no sensory component.

ANS: C A dermatome is a circumscribed skin area that is primarily supplied from one spinal cord segment through a particular spinal nerve. The dermatomes overlap, which is a form of biologic insurance; that is, if one nerve is severed, then most of the sensations can be transmitted by the spinal nerve above and the spinal nerve below the severed nerve.

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.

12. 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.

The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident (stroke) and has aphasia. Which of these questions is most important to use when assessing the mental status of this patient? a. "Please count backward from 100 by 7." b. "I will name three items and ask you to repeat them in a few minutes." c. "Please point to articles in the room and parts of the body as I name them." d. "What would you do if you found a stamped, addressed envelope on the sidewalk?"

ANS: C Additional tests for people with aphasia include word comprehension (asking the individual to point to articles in the room or parts of the body), reading (asking the person to read available print), and writing (asking the person to make up and write a sentence). Aphasia is a disorder of language comprehension. To assess the mental status of a patient with aphasia, the nurse should ask questions to assess her comprehension. The other options do not assess a person's comprehension.

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.

To transfer the patient who has normal weight bearing and upper body strength out of bed to a chair, what should the nurse do? a. Grab the patient under the axilla to lift. b. Have the patient move forward with the weak side. c. Have the patient put on shoes with nonskid soles. d. Place the chair in a position 90 degrees opposite the bed.

ANS: C Assist the patient to apply stable nonskid shoes. Nonskid soles decrease the risk of slipping during transfer. Always have the patient wear shoes during transfer; bare feet increase the risk for falls. Patients should never be lifted by or under the arms. If the patient demonstrates weakness or paralysis of one side of the body, place a chair on the patient's strong side. The patient would move forward toward the strong side. Have the chair in position at a 45-degree angle to the bed.

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.

A nurse is reviewing the patient assignment for the day. Of all the patients, which individual has the greatest potential for injury during transfers? a. Diabetes mellitus b. Myocardial infarction c. A cerebrovascular accident d. An upper extremity fracture

ANS: C Certain conditions increase a patient's risk for falling or potential for injury. Neuromuscular deficits, motor weakness, calcium loss from long bones, cognitive and visual dysfunction, and altered balance increase risk for injury. A diagnosis of diabetes mellitus, myocardial infarction, or upper extremity fracture does not increase the patient's risk for injury to the same extent.

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 repeatedly seems to have difficulty coming up with a word. He says, "I was on my way to work, and when I got there, the thing that you step into that goes up in the air was so full that I decided to take the stairs." How should the nurse record this on his chart? a. Blocking b. Neologism c. Circumlocution d. Circumstantiality

ANS: C Circumlocution is a roundabout expression, substituting a phrase when one cannot think of the name of the object. The statement in the question is not an example of blocking, neologism, or circumstantiality. Blocking is when a person experiences sudden interruption in train of thought and unable to complete sentences which seems r/t strong emotion. Neologism involves coining a new word which is inventing or making up words that have no real meaning except for the person. Circumstantiality is when a person talks excessively with unnecessary detail and delays reaching the point. Their sentences have a meaningful connection but are irrelevant. The statement in the question is an example of circumlocution which is a roundabout expression, substituting a phrase when one cannot think of the name of the object.

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.

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.

4. The nurse is planning care for a 12-year-old female patient who needs a Foley catheter inserted. It is most important for the nurse to use a catheter of which size French (Fr)? a. 5 to 6 Fr b. 8 to 10 Fr c. 12 Fr d. 14 to 16 Fr

ANS: C Gender and age determine catheter size. A 12-Fr catheter may be considered for use in young girls. The prescriber may order a larger size. For infants, 5 to 6 Fr is generally used; for children, 8 to 10 Fr with a 3-mL balloon is used; and 14 to 16 Fr is indicated for adult women.

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.

The nurse draws the number 8 on the palm of a patient and he identifies it as the number eight. What term would the nurse use to describe this finding? a. Extinction b. Stereognosis c. Graphesthesia d. Tactile discrimination

ANS: C Graphesthesia is the ability to "read" a number by having it traced on the skin. Stereognosis is the person's ability to recognize objects by feeling their forms, sizes, and weights. Astereognosis is an inability to identify objects correctly, and it occurs in sensory cortex lesions. Extinction tests the person's ability to feel sensations on both sides of the body at the same point. Tactile discrimination tests fine touch.

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.

12. When applying a belt restraint to a patient, it is important for the nurse to: a. apply the belt under the hospital gown. b. place the restraint around the abdomen. c. have the patient in a sitting position. d. apply the belt as tightly as possible.

ANS: C Have the patient in a sitting position. Remove wrinkles or creases in clothing. Bring ties through slots in a belt. Apply a belt over clothes, gown, or pajamas to prevent damage to the skin. Make sure to place the restraint at the waist, not at the chest or abdomen. Avoid applying the belt too tightly.

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.

5. The nurse notes that urine does not flow after a female patient is catheterized. The nurse believes that the catheter has been placed into the vagina. Which action should the nurse take? a. Remove the catheter and reinsert it. b. Irrigate the catheter with saline. c. Leave the catheter in place and insert another one. d. Insert the catheter 9 to 10 inches farther into the patient to verify that it is in the vagina.

ANS: C If no urine appears, check whether the catheter is in the vagina. If misplaced, leave the catheter in the vagina as a landmark indicating where not to insert it, and insert another catheter into the meatus. Reinserting a catheter that has already been contaminated by vaginal exposure could lead to urinary tract infection.

When the balloon on an indwelling urinary catheter is inflated and the patient expresses discomfort, it is essential for the nurse to take which action? a. Remove the catheter. b. Continue to blow up the balloon because discomfort is expected. c. Aspirate the fluid from the balloon and advance the catheter. d. Pull back on the catheter slightly to determine tension.

ANS: C If resistance to inflation is noted, or if the patient complains of pain, the balloon may not be entirely within the bladder. Stop inflation, aspirate any fluid injected into the balloon, and advance the catheter a little farther before attempting again to inflate.

While ambulating, the patient becomes light-headed and starts to fall. What should the nurse do first? a. Call for help. b. Try to reach for a chair. c. Ease the patient down to the floor. d. Push the patient back toward the bed.

ANS: C If the patient begins to fall, gently ease the patient to the floor by holding firmly onto the gait belt; stand with the feet apart to provide a broad base of support, extend the leg, and let the patient gently slide to the floor. As the patient slides, the nurse bends the knees to lower the body. The nurse can cause more damage to self and patient by trying to catch the patient. The nurse certainly will call for help, but this is not the first priority. The nurse must ensure the patient's safety before getting help by easing him to the floor.

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.

During an assessment of a 22-year-old woman who sustained a head injury from an automobile accident 4 hours earlier, the nurse notices the following changes: pupils were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What do these findings suggest? a. Injury to the O.D. b. Test inaccurately performed c. Increased intracranial pressure d. Normal response after a head injury

ANS: C In a person with a brain injury, a sudden, unilateral, dilated, and nonreactive pupil is ominous. CN III runs parallel to the brainstem. When increasing intracranial pressure pushes down the brainstem (uncal herniation), it puts pressure on CN III, causing pupil dilation. The other responses are incorrect.

The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore to assess the mental status during the interview? a. "I sleep like a baby." b. "I have no health problems." c. "I never did too good in school." d. "I am not currently taking any medications."

ANS: C In every mental status examination, the following factors from the health history that could affect the findings should be noted: any known illnesses or health problems, such as alcoholism or chronic renal disease; current medications, the side effects of which may cause confusion or depression; the usual educational and behavioral level, noting this level as the patient's normal baseline and not expecting a level of performance on the mental status examination to exceed it; and responses to personal history questions, indicating current stress, social interaction patterns, and sleep habits. A patient stating that he/she sleeps like a ba by, has no health problems, or is currently not taking any medications are not r/t the patient's mental status.

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.

The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect? a. Hyperalgesia b. Hyperesthesia c. Peripheral neuropathy d. Lesion of sensory cortex

ANS: C Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Peripheral neuropathy is worse at the feet and gradually improves as the examiner moves up the leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome. The other responses are incorrect.

During an examination, the nurse can assess mental status by which activity? a. Examining the patient's electroencephalogram b. Observing the patient as he or she performs an intelligence quotient (IQ) test c. Observing the patient and inferring health or dysfunction d. Examining the patient's response to a specific set of questions

ANS: C Mental status cannot be directly scrutinized like the characteristics of skin or heart sounds. Its functioning is inferred through an assessment of an individual's behaviors, such as consciousness, language, mood and affect, and other aspects. Mental status cannot be directly scrutinized through tests such as an electroencephalogram, intelligence quotient (IQ) test, or responses to questions. Instead, the functioning of mental status is inferred through an assessment of an individual's behaviors, such as consciousness, language, mood and affect, and other aspects.

The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status? a. Mental status assessment diagnoses specific psychiatric disorders. b. Mental disorders occur in response to everyday life stressors. c. Mental status functioning is inferred through the assessment of an individual's behaviors. d. Mental status can be directly assessed, similar to other systems of the body (e.g., heart sounds, breath sounds).

ANS: C Mental status functioning is inferred through the assessment of an individual's behaviors. It cannot be directly assessed like the characteristics of the skin or heart sounds.

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.

2. On the basis of the nurse's assessment of kidney function for an adult patient, which finding is normal? a. 10 mL/hr b. 20 mL/hr c. 30 mL/hr d. 100 mL/hr

ANS: C Minimum average hourly output is 30 mL.

1. 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.

2. The most prevalent and debilitating occupational health hazard among nurses is: a. footdrop. b. pressure ulcers. c. musculoskeletal disorders. d. contractures.

ANS: C Musculoskeletal disorders are the most prevalent and debilitating occupational health hazard among nurses. Little improvement has been noted in the incidence of musculoskeletal injuries among health care workers. In 1989, 4.2 lost-workday injury cases per 100 were reported; in 2000, 4.1 cases per 100 were reported. Plantar flexion contracture or footdrop is a complication seen in bedridden patients. Pressure ulcers and contractures are complications that can develop in patients who do not maintain correct body alignment.

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.

The patient is an elderly man who has just been admitted for a probable cerebrovascular accident. The patient is nonverbal and does not respond to requests but is able to turn himself in bed. The nurse notices that the patient likes to lie on his right side, and soon after being turned by the nursing staff, the patient turns back to his right side. The nurse in this case should: a. allow the patient to lie on his right side continuously because he seems comfortable. b. prevent the patient from lying on his right side until he no longer wishes to lie on that side. c. frequently assess the patient and turn him more frequently. d. allow the patient to lie on his right side until a pressure ulcer develops and he can no longer lie on that side.

ANS: C Patients who have maintained bed rest for a long time may revert back to a favorite position. Frequently assess these patients, and turn them more often as needed. Not turning them places them at greater risk for complications of immobility. Not allowing the patient to lie on his preferred side limits the number of sides available for turning and decreases patient comfort. The purpose of assessment and turning is to prevent complications of immobility.

The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment? a. CNs, motor function, and sensory function b. Deep tendon reflexes, vital signs, and coordinated movements c. Level of consciousness, motor function, pupillary response, and vital signs d. Mental status, deep tendon reflexes, sensory function, and pupillary response

ANS: C People who have a neurologic deficit from a systemic disease process, head trauma, or neurosurgery are at increased risk for developing increased intracranial pressure. These people must be closely monitored for any improvement or deterioration in neurologic status. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.

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 daily

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.

The patient is an elderly gentleman who has been on bed rest for the past several days. When getting the patient up, the nurse should: a. tell the patient not to move his legs when dangling. b. tell the patient to hold his breath while dangling. c. raise the head of the bed and allow a few minutes before dangling. d. have the patient stand without dangling.

ANS: C Physiological changes associated with aging and prolonged bed rest may influence the effectiveness of the baroreceptors. For these patients, moving to the dangling position may cause a gravity-induced drop in blood pressure; thus, it is recommended to raise the head of the bed and allow a few minutes before dangling. Interventions to minimize orthostatic hypotension include movement of the legs and feet in the dangling position to promote venous return via intermittent contraction and relaxation of the skeletal leg muscles, and asking the patient to take several deep breaths before and during dangling. Dangling a patient before standing is an intermediate step that allows assessment of the individual before changing positions to maintain safety and prevent injury to the patient.

In positioning the patient in the prone position, one way to improve breathing is to: a. support the arms in a flexed position level at the shoulders. b. place a pillow under the lower legs. c. place a small pillow under the patient's abdomen. d. support the patient's head with a small pillow.

ANS: C Placing a small pillow under the patient's abdomen below the level of the diaphragm reduces pressure on the breasts of some female patients and decreases hyperextension of the lumbar vertebrae and strain on the lower back; it also improves breathing by reducing mattress pressure on the diaphragm. Supporting the arms in flexed position level at the shoulders maintains proper body alignment and reduces the risk for joint dislocation, but does not improve breathing. Supporting the lower legs with pillows to elevate the toes prevents footdrop, reduces external rotation of the legs, and reduces mattress pressure on the toes, but does not directly improve breathing. Turning the patient's head to one side and supporting it with a small pillow is designed to reduce flexion or hyperextension of the cervical vertebrae. Although it may help with breathing, this is not the primary purpose.

To position a patient with hemiplegia in Fowler's position, the nurse should: a. elevate the head of the bed 15 to 30 degrees. b. place the patient in the prone position. c. position a spastic hand with the fingers extended using hand rolls. d. position the patient's head with slight hyperextension of the neck.

ANS: C Position a spastic hand with the wrist in neutral position or slightly extended; fingers should be extended with the palm down or may be left in relaxed position with the palm up. Position the patient in supine position. Elevate the head of the bed 45 to 60 degrees. This increases comfort, improves ventilation, and increases the patient's opportunity to relax. Adjust the head of the bed according to the patient's condition. For example, those with increased risk for pressure ulcers will remain at a 30-degree angle. Position the head on a small pillow with the chin slightly forward. If the patient is totally unable to control head movement, avoid hyperextension of the neck. Too many pillows under the head may cause or worsen neck flexion contracture.

When assessing aging adults, what is one of the first things the nurse should assess before making judgments about the aging person's mental status? a. Presence of phobias b. General intelligence c. Sensory-perceptive abilities d. Presence of irrational thinking patterns

ANS: C Presence of phobias, general intelligence, and presence of irrational thinking patterns are not one of the first things a nurse should assess before making a judgment about an aging person's mental status. Age-related changes in sensory perception can affect mental status. For example, vision loss (as detailed in Chapter 14) may result in apathy, social isolation, and depression. Hearing changes are common in older adults, which produce frustration, suspicion, and social isolation and make the person appear confused.

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.

When preparing to move a patient in bed, the nurse should: a. expect that the patient's comfort level will decrease. b. make sure that all pillows used in the previous position stay in position. c. raise the bed to a comfortable working height. d. plan on moving the patient herself because other nurses are busy.

ANS: C Raise the level of the bed to a comfortable working height. This raises the level of work toward the nurse's center of gravity and reduces the risk for back injury. Proper positioning reduces stress on the joints. The patient's comfort level should increase. The nurse should remove all pillows and devices used in the previous position. This reduces interference from bedding during the positioning procedure. The nurse should get extra help as needed. This provides for patient and nurse safety.

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 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.

During an assessment of an 80-year-old patient, the nurse notices the following: an inability to identify vibrations at her ankle and to identify the position of her big toe, a slower and more deliberate gait, and a slightly impaired tactile sensation. All other neurologic findings are normal. How should the nurse interpret these findings? a. CNS dysfunction b. Lesion in the cerebral cortex c. Normal changes attributable to aging d. Demyelination of nerves attributable to a lesion

ANS: C Some aging adults show a slower response to requests, especially for those calling for coordination of movements. The findings listed are normal in the absence of other significant abnormal findings. The other responses are incorrect.

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.

The nurse is performing the Denver II screening test on a 12-month-old infant during a routine well-child visit. What should the nurse tell the infant's parents about the Denver II screening test? a. Tests three areas of development: cognitive, physical, and psychological b. Will indicate whether the child has a speech disorder so that treatment can begin c. Is a screening instrument designed to detect children who are slow in development d. Is a test to determine intellectual ability and may indicate whether problems will develop later in school

ANS: C The Denver II is a screening instrument designed to detect developmental delays in infants and preschoolers. It tests four functions: gross motor, language, fine motor-adaptive, and personal-social. The Denver II is not an intelligence test; it does not predict current or future intellectual ability. It is not diagnostic; it does not suggest treatment regimens. The Denver II does not asses cognitive, physical, and psychological domains; is not an intelligence test and it does not predict current or future intellectual ability; and does not diagnose speech disorders or suggest treatment regimens.

A 45-year-old woman is at the clinic for a mental status assessment. Which describes the expecting findings on the Four Unrelated Words Test? a. Invents four unrelated words within 5 minutes b. Invents four unrelated words within 30 seconds c. Recalls four unrelated words after a 30-minute delay d. Recalls four unrelated words after a 60-minute delay

ANS: C The Four Unrelated Words Test tests the person's ability to lay down new memories. It is a highly sensitive and valid memory test. It requires more effort than the recall of personal or historic events. To the person say, "I am going to say four words. I want you to remember them. In a few minutes I will ask you to recall them." After 5 minutes, ask for the four words. The normal response for people under 60 years is an accurate three- or four-word recall after a 5-, 10-, and 30-minute delay.

10. The patient is a paraplegic who possesses good arm and hand strength. When the following devices are compared, which would be most appropriate for this patient? a. Axillary crutch b. Platform crutch c. Lofstrand crutch d. Standard crook cane

ANS: C The Lofstrand crutch has a handgrip and a metal band that fits around the patient's forearm. Both the metal band and the handgrip are adjusted to fit the patient's height. This type of crutch is useful for patients with a permanent disability such as paraplegia. The axillary crutch frequently is used by patients of all ages on a short-term basis. The platform crutch is used by patients who are unable to bear weight on their wrists. It has a horizontal trough on which patients can rest their forearms and wrists and a vertical handle for the patient to grip. The standard crook cane provides the least support and is used by patients who require only minimal assistance to walk.

The nurse is providing instructions to newly hired graduates for the mini-mental state examination (MMSE). Which statement best describes this examination? a. Scores below 30 indicate cognitive impairment. b. The MMSE is a good tool to evaluate mood and thought processes. c. This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness. d. The MMSE is a useful tool for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time.

ANS: C The MMSE is a quick, easy test of 11 questions and is used for initial and serial evaluations and can demonstrate a worsening or an improvement of cognition over time and with treatment. It evaluates cognitive functioning, not mood or thought processes. MMSE is a good screening tool to detect dementia and delirium and to differentiate these from psychiatric mental illness.

The nurse is administering a Mini-Cog test to an older adult woman. When asked to draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of order and with an incorrect time. This result indicates which finding? a. Amnesia b. Delirium c. Cognitive impairment d. Attention-deficit disorder

ANS: C The Mini-Cog is a newer instrument that screens for cognitive impairment, often found with dementia. The result of an abnormal drawing of a clock and time indicates a cognitive impairment.

While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of the arms and legs; fanning of the fingers, and curling of the index finger and thumb in a C position, followed by the infant bringing in the arms and legs to the body. What does the nurse recall about this response? a. This response could indicate brachial nerve palsy. b. This reaction is an expected startle response at this age. c. This reflex should have disappeared between 1 and 4 months of age. d. This response is normal as long as the movements are bilaterally symmetric.

ANS: C The Moro reflex is present at birth and usually disappears at 1 to 4 months. Absence of the Moro reflex in the newborn or its persistence after 5 months of age indicates severe central nervous system injury. The other responses are incorrect.

The nurse is assessing a 75-year-old man. What should the nurse expect when performing the mental status portion of the assessment? a. Will have no decrease in any of his abilities, including response time. b. Will have difficulty on tests of remote memory because this ability typically decreases with age. c. May take a little longer to respond, but his general knowledge and abilities should not have declined. d. Will exhibit a decrease in his response time because of the loss of language and a decrease in general knowledge.

ANS: C The aging process leaves the parameters of mental status mostly intact. General knowledge does not decrease, and little or no loss in vocabulary occurs. Response time is slower than in a youth. It takes a little longer for the brain to process information and to react to it. Recent memory, which requires some processing, is somewhat decreased with aging, but remote memory is not affected.

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.

A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain most concerns the nurse? a. Thalamus b. Brainstem c. Cerebellum d. Extrapyramidal tract

ANS: C The cerebellar system coordinates movement, maintains equilibrium, and helps maintain posture. So the nurse would be most concerned about this area of the brain. The thalamus is the primary relay station where sensory pathways of the spinal cord, cerebellum, and brainstem form synapses on their way to the cerebral cortex. The brainstem consists of the midbrain, pons, and medulla and has various functions, especially concerning autonomic centers. The extrapyramidal tract maintains muscle tone for gross automatic movements, such as walking. The thalamus is the primary relay station where sensory pathways of the spinal cord, cerebellum, and brainstem form synapses on their way to the cerebral cortex. The brainstem consists of the midbrain, pons, and medulla and has various functions, especially concerning autonomic centers. The extrapyramidal tract maintains muscle tone for gross automatic movements, such as walking. With this patient's unsteady gait and balance problems, the nurse would be most concerned with the cerebellum.

The nurse should test the functioning of which structure(s) when determining whether a person is oriented to his or her surroundings? a. Cerebellum b. Cranial nerves c. Cerebral cortex d. Medulla oblongata

ANS: C The cerebral cortex (the outer layer of the cerebrum) is responsible for thought, memory, reasoning, sensation, and voluntary movement. Thus, determining orientation would assess the functioning of the cerebral cortex. The cerebellum is a coiled structure located under the occipital lobe that is concerned with motor coordination of voluntary movements, equilibrium, and muscle tone, but not a person's thought processes or orientation. The cranial nerves are responsible for relaying sensory and motor information to and from the brain, but are not involved in thought processes or orientation. The medulla oblongata is located in the brainstem and it has vital autonomic (involuntary) centers (respiration, heart, gastrointestinal function) and nuclei of cranial nerves VIII through XII. Pyramidal decussation (crossing of the motor fibers) also occurs here, but the medulla oblongata is not involved in thought or orientation.

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).

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.

17. 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.

A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination. What should the nurse expect during this patient's tests of cognitive function? a. May display some disruption in thought content. b. Will state, "I am so relieved to be out of intensive care." c. Will be oriented to place and person, but the patient may not be certain of the date. d. May show evidence of some clouding of his level of consciousness.

ANS: C The nurse can discern the orientation of cognitive function through the course of the interview or can directly and tactfully ask, "Some people have trouble keeping up with the dates while in the hospital. Do you know today's date?" Many hospitalized people have trouble with the exact date but are fully oriented on the remaining items.

During the taking of the health history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." When assessing his sensory system, which action by the nurse is most appropriate? a. The nurse would perform the tests, knowing that mental status does not affect sensory ability. b. The nurse would proceed with an explanation of each test, making certain that the wife understands. c. Before testing, the nurse would assess the patient's mental status and ability to follow directions. d. The nurse would not test the sensory system as part of the examination because the results would not be valid.

ANS: C The nurse should ensure the validity of the sensory system testing by making certain that the patient is alert, cooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.

A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination? a. Glasgow Coma Scale b. Neurologic recheck examination c. Complete neurologic examination d. Screening neurologic examination

ANS: C The nurse should perform a complete neurologic examination on an individual who has neurologic concerns (e.g., headache, weakness, loss of coordination) or who is showing signs of neurologic dysfunction. The Glasgow Coma Scale is used to define a person's level of consciousness. The neurologic recheck examination is appropriate for those who are demonstrating neurologic deficits. The screening neurologic examination is performed on seemingly well individuals who have no significant subjective findings from the health history.

The nurse plans to use a trochanter roll when repositioning a patient. Where should the nurse place the trochanter roll? a. Under the small of the back b. Behind the knees when supine c. Alongside the ilium to mid-thigh d. In the palm of the hand with fingers flexed

ANS: C The nurse should place the trochanter roll alongside the ilium to mid-thigh. The trochanter roll is a rolled wedge, pillow, or sandbag placed by the lateral aspect of the leg between the iliac crest and the knees to prevent external hip rotation.

6. Graduated compression stockings are ordered for the patient on bed rest after surgery. The nurse explains to the patient that the primary purpose for the elastic stockings is to: a. keep the skin warm and dry. b. prevent abnormal joint flexion. c. apply external pressure. d. prevent bleeding.

ANS: C The primary purpose of graduated compression stockings is to maintain external pressure on the muscles of the lower extremities and thus promote venous return. The primary purpose of graduated compression stockings is not to keep the skin warm and dry, prevent abnormal joint flexion, or prevent bleeding. They are used to prevent clot formation due to venous stasis.

A patient with a lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. The nurse knows that the best explanation why this occurs is which one of these statements? a. A problem exists with the sensory cortex and its ability to discriminate the location. b. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing the pain. c. The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere. d. A lesion has developed in the dorsal root, which is preventing the sensation from being transmitted normally.

ANS: C The sensory cortex is arranged in a specific pattern, forming a corresponding map of the body. Pain in the right hand is perceived at a specific spot on the map. Some organs, such as the heart, liver, and spleen, are absent from the brain map. Pain originating in these organs is referred because no felt image exists in which to have pain. Pain is felt by proxy, that is, by another body part that does have a felt image. The other responses are not correct explanations.

An appropriate technique for the nurse to implement when moving a patient out of bed to a chair with a mechanical lift is to: a. lower the height of the bed. b. lower the head of the bed. c. place the sling from shoulders to knees. d. keep the check valve open when the patient is seated in the chair.

ANS: C The sling should extend from shoulders to knees (hammock) to support the patient's body weight equally. Raise the bed to a high position with the mattress flat. This allows the nurse to use proper body mechanics. Elevate the head of the bed; this places the patient in sitting position. Close the check valve as soon as the patient is down and the straps can be released. If the valve is left open, the boom may continue to lower and injure the patient.

The area of the nervous system that responsible for mediating reflexes? a. Medulla b. Cerebellum c. Spinal cord d. Cerebral cortex

ANS: C The spinal cord is the main highway for ascending and descending fiber tracts that connect the brain to the spinal nerves; it is responsible for mediating reflexes. The medulla is the continuation of the spinal cord in the brain that contains all ascending and descending fiber tracts. Pyramidal decussation (crossing of the motor fibers) occurs here. The cerebellum is a coiled structure located under the occipital lobe that is concerned with motor coordination of voluntary movements, equilibrium, and muscle tone. The cerebral cortex is the outer layer of nerve cell bodies and is the center for a human's highest functions, governing thought, memory, reasoning, sensation, and voluntary movement.

While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact? a. Corticospinal tract, medulla, and basal ganglia b. Pyramidal tract, hypothalamus, and sensory cortex c. Lateral spinothalamic tract, thalamus, and sensory cortex d. Anterior spinothalamic tract, basal ganglia, and sensory cortex

ANS: C The spinothalamic tract contains sensory fibers that transmit the sensations of pain, temperature, and crude or light touch. Fibers carrying pain and temperature sensations ascend the lateral spinothalamic tract, whereas the sensations of crude touch form the anterior spinothalamic tract. At the thalamus, the fibers synapse with another sensory neuron, which carries the message to the sensory cortex for full interpretation. The other options are not correct.

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.

1. The patient is admitted to the hospital with orders for activity as tolerated. He is wheelchair-bound at home and has brought his own electric wheelchair and battery charger to help him maintain mobility. The nurse realizes that: a. patients are not allowed to bring in an electric wheelchair. b. electrical equipment is banned from all hospitals. c. the charger needs to be checked by hospital engineers. d. electrical devices are not a cause for concern.

ANS: C The third (longer) prong in an electrical plug is the ground. If a patient brings an electrical device to the hospital, an engineer inspects the device for safe wiring and function before use. Many patients with disabilities use battery chargers for mobility equipment function. These devices need to be inspected by hospital engineers. Fires in health care settings typically are electrical or anesthetic-related.

10. A patient is well known to the hospital staff from previous admissions and is prone to wandering at night. For patient safety, the physician writes an order for "belt restraint prn." What should the nurse do upon reviewing this order? a. Apply a belt restraint on the patient as needed. b. Have the patient sign an "informed consent" form. c. Inform the physician that "prn" restraint orders are unacceptable. d. Obtain a signed "informed consent" from a family member.

ANS: C The use of mechanical or physical restraints should be part of a patient's prescribed medical treatment. A physician's time-limited order is necessary. The patient's or family member's informed consent is necessary in the long-term care setting.

The nurse is planning to assess new memory with a patient. Which is the best way for the nurse to do this? a. Administer the FACT test. b. Ask him to describe his first job. c. Give him the Four Unrelated Words Test. d. Ask him to describe what television show he was watching before coming to the clinic.

ANS: C To assess new memory, the nurse should ask questions that can be corroborated, which screens for the occasional person who confabulates or makes up answers to fill in the gaps of memory loss. The Four Unrelated Words Test tests the person's ability to lay down new memories and is a highly sensitive and valid memory test. The FACT test, describing his first job, or describing the television show he was watching before coming to the clinic, does not test new memory.

8. An appropriate procedure for the nurse to use when applying an elastic stocking is to: a. remove the stockings every 24 hours. b. keep the tops of the stockings rolled down slightly. c. turn the stocking inside out to apply from the toes up. d. wash stockings daily and dry in a dryer.

ANS: C Turn elastic stocking inside out by placing one hand into the sock, holding the toe of the sock with the other hand, and pulling. This allows easier application of the stocking. Elastic stockings should be removed and reapplied at least twice a day. Instruct the patient not to roll the socks partially down. Rolling the socks partially down has a constricting effect and can impede venous return. Instruct the patient to launder elastic stockings every 2 days with mild detergent and lay flat to dry.

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.

When evaluating the health care team member's ability to apply a condom catheter, it is most important for the nurse to provide further instruction for which intervention? a. Clipping of hair at the base of the penis b. Applying skin preparation to the penis before catheter placement c. Using regular adhesive tape to hold the catheter in place d. Leaving 1 to 2 inches of space between the tip of the penis and the end of the catheter

ANS: C Use of an adhesive strip not designed for sheath application may be inflexible and may impede circulation to the penis. Clip hair at the base of the penis. Hair adheres to the condom and is pulled during condom removal or may get caught in rubber as the condom catheter is applied. Apply skin preparation to the penis and allow it to dry. Leave 1 to 2 inches of space between the tip of the glans penis and the end of the condom.

The nurse is caring for a patient who has an indwelling urinary catheter. Which intervention is most important to include in this patient's plan of care? a. Maintaining tension on the tubing b. Emptying the urinary collection bag every 24 hours c. Cleaning in a circular motion from the meatus down the catheter d. Keeping the drainage bag on the bed or attached to the side rails

ANS: C Using a clean washcloth, wipe in a circular motion along the length of the catheter for about 10 cm (4 inches). Allow slack in the catheter so movement does not create tension on it. Empty the drainage bag, and record amounts at least every 3 to 6 hours. The drainage bag must be below the level of the bladder; do not place the bag on the side rails of the bed.

2. Upon entering the patient's room, the nurse sees a fire burning in the trash can next to the bed. The nurse removes the patient and reports the fire. What is the nurse's next action? a. Extinguish the fire. b. Remove all other patients from the unit. c. Close all doors of patient rooms. d. Move the trash can into the bathroom.

ANS: C Using the "RACE" acronym, the next action the nurse should take is to confine the fire by closing doors and windows and turning off oxygen and electrical equipment (Rescue, Activate, Contain, and Evacuate). Extinguish the fire by using an extinguisher after ensuring patient and individual safety after closing the doors of patient rooms. After activating the alarm, the nurse should close all the doors, not remove all the other patients from the unit. Moving the trash can would not be an appropriate action, as the nurse could get burned in this attempt.

A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds in the past month. Which of these statements or questions is the nurse's best response in this situation? a. "Do you have a weapon?" b. "How do other people treat you?" c. "Are you feeling so hopeless that you feel like hurting yourself now?" d. "People often feel hopeless, but the feelings resolve within a few weeks."

ANS: C When the person expresses feelings of hopelessness, despair, or grief, assessing the risk for physical harm to him or herself is important. This process begins with more general questions. If the answers are affirmative, then the assessment continues with more specific questions.

The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding? a. Positive Babinski sign b. Plantar reflex abnormal c. Plantar reflex present d. Plantar reflex 2+ on a scale from "0 to 4+"

ANS: C With a reflex hammer, the nurse should draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot, similar to an upside-down J. The normal response is plantar flexion of the toes and sometimes of the entire foot. A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and fanning of all toes. The plantar reflex is not graded on a 0 to 4+ scale.

The nurse is assessing a patient who is admitted with possible delirium. Which of these are manifestations of delirium? (Select all that apply.) a. Person experiences agnosia. b. Person demonstrates apraxia. c. Develops over a short period d. Person exhibits memory impairment or deficits. e. Occurs as a result of a medical condition, such as systemic infection

ANS: C, D, E Delirium is a disturbance of consciousness that develops over a short period and may be attributable to a medical condition. Memory deficits may also occur. Apraxia and agnosia occur with dementia. Agnosia and apraxia are not symptoms of delirium.

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 full mental status examination should be completed if the patient: a. develops dysphagia. b. has a new diagnosis of type 2 diabetes mellitus c. complains of insomnia. d.has a change in behavior and the family is concerned.

ANS: D A full mental status examination is indicated if there is any abnormality in affect or behavior and in the following situations: family members concerned about a person's behavioral changes; brain lesions; aphasia; or symptoms of psychiatric mental illness, especially with acute onset. A full mental status examination is not indicated for dysphagia or difficulty with swallowing. A full mental status examination is not indicated for a medical problem such as type 2 diabetes mellitus. A full mental status examination is not indicated for a symptom such as insomnia.

Which of these statements about the peripheral nervous system is correct? a. The CNs enter the brain through the spinal cord. b. Efferent fibers carry sensory input to the central nervous system through the spinal cord. c. The peripheral nerves are inside the central nervous system and carry impulses through their motor fibers. d. The peripheral nerves carry input to the central nervous system by afferent fibers and away from the central nervous system by efferent fibers.

ANS: D A nerve is a bundle of fibers outside of the central nervous system. The peripheral nerves carry input to the central nervous system by their sensory afferent fibers and deliver output from the central nervous system by their efferent fibers. The other responses are not r/t the peripheral nervous system.

Why does a nurse move a patient who has been confined to bed for a few days slowly from a sitting to a standing position? a. Fatigue b. Muscle injury c. Sensory disorientation d. Orthostatic hypotension

ANS: D A patient who has been immobile for several days or longer may be weak or dizzy or may develop orthostatic hypotension (a drop in blood pressure) when transferred.

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.

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 has been ordered to perform closed intermittent irrigation of a patient's indwelling urinary catheter. Which intervention is indicative of safe practice? a. Applies sterile gloves. b. Instills 100 mL of irrigant. c. Leaves the drainage tubing unclamped irrigation. d. Determines the amount of urinary drainage by subtracting the amount of irrigant from the total output.

ANS: D Calculate the fluid used to irrigate the bladder and catheter, and subtract from the volume drained to determine accurate urinary output. Closed intermittent irrigation does not require the use of sterile gloves. The typical amount of irrigant used is 30 to 50 mL and the tubing is clamped during the process.

When observing a patient for symptoms of dehydration, the nurse should observe which assessment? a. Increased salivation b. Diuresis c. Periorbital edema d. Decreased capillary filling

ANS: D Cardiovascular signs of fluid volume deficit include increased pulse rate, weak pulse, hypotension, decreased pulse volume/pressure, decreased capillary filling, and increased hematocrit. Increased salivation and periorbital edema are signs of fluid volume excess. Diuresis is a renal sign of fluid volume excess.

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.

The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient's toes fan out, and the big toe shows dorsiflexion. How should the nurse interpret these findings? a. Clonus, which is a hyperactive response b. Achilles reflex, which is an expected response c. Negative Babinski sign, which is normal for adults d. Positive Babinski sign, which is abnormal for adults

ANS: D Dorsiflexion of the big toe and fanning of all toes is a positive Babinski sign, also called up-going toes. This response occurs with upper motor neuron disease of the corticospinal (or pyramidal) tract and is an abnormal finding for adults.

A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination; he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurse's finger, then his own nose, then the nurse's finger again (which has been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger. What does the nurse suspect? a. Cerebral injury b. Peripheral neuropathy c. Cerebrovascular accident d. Acute alcohol intoxication

ANS: D During the finger-to-finger test, if the person has clumsy movement with overshooting the mark, either a cerebellar disorder or acute alcohol intoxication should be suspected. The person's movements should be smooth and accurate. The other options are not correct.

When providing care for a patient with a suprapubic catheter who has acquired a urinary tract infection (UTI), which intervention is most important for the nurse to implement? a. Using clean technique b. Securing the tube to the inner thigh c. Cleansing the insertion site in a direction toward the drain d. Promoting intake of 2200 mL of fluid per day

ANS: D Encourage the patient with a UTI to drink at least 2200 mL of fluid per day. The insertion site is cleansed in a circular swabbing pattern so as not to disturb the tubing. Standard care requires the use of clean gloves and securing the catheter to the abdomen.

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.

During an examination, the nurse notes that a patient is exhibiting flight of ideas. Which statement by the patient is an example of flight of ideas? a. "My stomach hurts. Hurts, spurts, burts." b. "Kiss, wood, reading, ducks, onto, maybe." c. "I wash my hands, wash them, wash them. I usually go to the sink and wash my hands." d. "Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby's bottom."

ANS: D Flight of ideas is demonstrated by an abrupt change, rapid skipping from topic to topic, and practically continuous flow of accelerated speech. Topics usually have recognizable associations or are plays on words. Options A, B, and C are not examples of a flight of ideas that have an association.

A 26-year-old woman was robbed and beaten a month ago. She is returning to the clinic today for a follow-up assessment. The nurse will want to ask her which of these questions? a. "How are things going with the trial?" b. "How are things going with your job?" c. "Tell me about your recent engagement!" d. "Are you having any disturbing dreams?"

ANS: D Following a traumatic event outside the range of usual human experience that involves actual or threatened death or violence, such as rape, many people experience posttraumatic stress disorder (PTSD). One of the symptoms of PTSD is sleep problems. With PTSD the person relieves the trauma many times, intrusively and unwillingly. The same feelings of helplessness, fear, or horror recur. Avoidance of any trigger associated with the trauma occurs, and the person has hypervigilance, sleep problems, and difficulty concentrating, leading to feelings of being permanently damaged. The nurse should assess for symptoms of PTSD and options A, B, and C do not assess for those symptoms.

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.

A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. Which is an appropriate conclusion for the nurse draw? a. She probably does not have any problems. b. She is only trying to shock people and that her dress should be ignored. c. She has a manic syndrome because of her abnormal dress and grooming. d. More information should be gathered to decide whether her dress is appropriate.

ANS: D Grooming and hygiene should be noted—the person is clean and well groomed, hair is neat and clean, women have moderate or no makeup, and men are shaved or their beards or moustaches are well groomed. Care should be taken when interpreting clothing that is disheveled, bizarre, or in poor repair because these sometimes reflect the person's economic status or a deliberate fashion trend.

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.

17. What should the nurse do to prevent a patient from aspirating during a seizure? a. Insert an oral airway. b. Restrain the patient securely. c. Sit the patient upright. d. Turn the patient onto his/her side.

ANS: D If possible, turn the patient onto the side, with the head flexed slightly forward. This position prevents the tongue from blocking the airway and promotes drainage of secretions, thus reducing the risk for aspiration. Do not force any objects such as fingers, medicine or tongue depressor, or airway into the patient's mouth when the teeth are clenched. This could cause injury to the mouth and could stimulate gagging, leading to possible aspiration. Do not restrain the patient. Loosen clothing to prevent musculoskeletal injury and airway obstruction. When a seizure begins, position the patient safely. If the patient is standing or sitting, guide the patient to the floor and protect the head by cradling in the nurse's lap or placing a pillow under the head. Clear the surrounding area of furniture. If the patient is in bed, raise the side rails and pad, and put the bed in a low position.

A postoperative patient has been instructed by a nurse about the importance of moving in bed but is still avoiding movement. The nurse should: a. avoid moving the patient until he or she is motivated. b. have family members move the patient around. c. decrease the frequency of movement to be performed. d. medicate the patient with a prescribed analgesic before moving.

ANS: D If the patient avoids moving, medicate with analgesia as ordered by the physician to ensure the patient's comfort before moving. Allow pain medication to take effect before proceeding. If the patient does not move, he or she is at risk for developing complications of immobility. Family members are not trained in proper moving techniques and can cause injury to the patient and/or themselves. Decreasing the frequency of movement increases the risk of developing complications of immobility.

5. After recognizing that a patient has received an electrical shock and removing the source of the shock, what should the nurse do next? a. Call for assistance. b. Immediately start CPR. c. Obtain emergency equipment. d. Assess for the presence of a pulse.

ANS: D If the patient receives an electrical shock, immediately assess for the presence of a pulse. Electrical shock can cause cardiac arrest, asystole. Do not leave the patient. Only if the patient is pulseless will the nurse institute cardiopulmonary resuscitation. If the patient has a pulse and remains alert and oriented, obtain vital signs and assess the skin for signs of thermal injury. Electrical current will cause burn at points of entry and exit from the body.

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.

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.

12. The patient has been using crutches for the past 2 weeks. When she comes for her follow-up examination, she complains of tingling and numbness in her hands and upper torso. Possible causes of these symptoms are: a. the patient's elbows are flexed 15 to 30 degrees when using the crutches. b. crutch pad is approximately 2 inches below the patient's axilla. c. patient holds the cane 4 to 6 inches to the side of her foot. d. handgrip does not allow for elbow flexion.

ANS: D Instruct the patient to report any tingling or numbness in the upper torso, which may mean that the crutches are being used incorrectly, or that they are the wrong size. If the handgrip is too low, radial nerve damage can occur even if overall crutch length is correct, because the extra length between the handgrip and the axillary bar can force the bar up into the axilla as the patient stretches down to reach the handgrip. After correct crutch adjustment, two to three fingers must fit between the top of the crutch and the axilla. Adequate space prevents crutch palsy. Proper fit is when the crutch pad is approximately 2 inches or two to three finger widths under the axilla, with the crutch tips positioned 6 inches (15 cm) lateral to the patient's heel.

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 assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented? a. "I know my name is John. I couldn't tell you where I am. I think it is 2010, though." b. "I know my name is John, but to tell you the truth, I get kind of confused about the date." c. "I know my name is John; I guess I'm at the hospital in Spokane. No, I don't know the date." d. "I know my name is John. I am at the hospital in Spokane. I couldn't tell you what date it is, but I know that it is February of a new year—2010."

ANS: D Many aging people experience social isolation, loss of structure without a job, a change in residence, or some short-term memory loss. These factors affect orientation, and the person may not provide the precise date or complete name of the agency. You may consider aging people oriented if they generally know where they are and the present period. They should be considered oriented to time if the year and month are correctly stated. Orientation to place is accepted with the correct identification of the type of setting (e.g., hospital) and the name of the town.

The nurse is assessing orientation in a 84-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented? a. "I know my name is Amy. I couldn't tell you where I am. I think it is 2020, though." b. "I know my name is Amy, but to tell you the truth, I get kind of confused about the date." c. "I know my name is Amy; I guess I'm at the hospital in Spokane. No, I don't know the date." d. "I know my name is Amy. I am at the hospital in Spokane. I couldn't tell you what date it is, but I know that it is February of a new year—2020."

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%.

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.

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.

A nurse encourages a patient to prevent venous stasis by: a. crossing the legs when sitting in a chair. b. wearing thigh-length nylon stockings or garters. c. elevating the legs on pillows while in bed. d. increasing early ambulation.

ANS: D Prevention is the best method to reduce the risk for deep vein thrombosis (DVT) secondary to immobility. Early ambulation remains the most effective preventive measure. Discourage patients from activities that promote venous stasis (e.g., crossing legs, wearing garters, and elevating legs on pillows).

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.

14. When caring for a patient who has an arm or leg restraint in place, how often will the nurse remove the restraint? a. Every 15 minutes b. Every 30 minutes c. Every hour d. Every 2 hours

ANS: D Restraints should be removed at least every 2 hours (Joint Commission on Accreditation of Healthcare Organizations [JCAHO], 2004). If the patient is violent or noncompliant, remove one restraint at a time and/or have staff assistance while removing restraints. Removal provides an opportunity to change the patient's position, offer nutrients, perform full ROJM, and toilet and exercise the patient. After application, evaluate the patient's condition for signs of injury every 15 minutes. Frequent assessments prevent injury to the patient and allow removal of the restraint at the earliest possible time. If the patient shows no sign of impaired circulation or other complications, the restraint does not need to be removed at this time. If the nurse restrains a patient in an emergency situation because of violent or aggressive behavior, this presents an immediate danger; a face-to-face physician assessment is needed within 1 hour to determine the patient's need for the restraint.

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 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.

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).

The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? a. Patient demonstrates the ability to hear normal conversation. b. When patient sticks out tongue it is midline and without tremors or deviation. c. Patient follows an object with his or her eyes without nystagmus or strabismus. d. Patient moves the head and shoulders against resistance with equal strength.

ANS: D The following normal findings are expected when testing the spinal accessory nerve (CN XI): The patient's sternomastoid and trapezius muscles are equal in size; the person can forcibly rotate the head both ways against resistance applied to the side of the chin with equal strength; and the patient can shrug the shoulders against resistance with equal strength on both sides. Checking the patient's ability to hear normal conversation checks the function of CN VIII. Having the patient stick out the tongue checks the function of CN XII. Testing the eyes for nystagmus or strabismus is performed to check CNs III, IV, and VI.

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 the nurse is testing the triceps reflex, what is the expected response? a. Flexion of the hand b. Pronation of the hand c. Flexion of the forearm d. Extension of the forearm

ANS: D The normal response of the triceps reflex is extension of the forearm. The normal response of the biceps reflex causes flexion of the forearm. The other responses are incorrect.

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 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. When conducting the mental status examination for this patient, what should the nurse assess first? a. Affect and mood b. Memory and affect c. Cognitive abilities d. Level of consciousness

ANS: D The sequence of steps for a mental status examination forms a hierarchy in which the most basic functions (consciousness, language) are assessed first. The first steps must be assessed accurately to ensure validity for the steps that follow (i.e., if consciousness is clouded, the person cannot be expected to have full attention and to answer accurately or cooperate with new learning).

During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion. Which statement concerning these findings is most accurate? What do these findings indicate? a. A lesion of the cerebral cortex b. A completely nonfunctional brainstem c. Normal findings that will resolve in 24 to 48 hours d. A very ominous sign and may indicate brainstem injury

ANS: D These findings are all indicative of decerebrate rigidity, which is a very ominous condition and may indicate a brainstem injury.

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.

When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. How should the nurse document this finding? a. Ataxia b. Lack of coordination c. Negative Homan sign d. Positive Romberg sign

ANS: D This is an abnormal, or positive, Romberg test. Abnormal findings for the Romberg test include swaying, falling, and a widening base of the feet to avoid falling. A positive Romberg sign is a loss of balance that is increased by the closing of the eyes. Ataxia is an uncoordinated or unsteady gait. Homan sign is used to test the legs for deep-vein thrombosis. Ataxia is an uncoordinated or unsteady gait. Homan sign is used to test the legs for deep-vein thrombosis. These findings are an abnormal, or positive, Romberg test. Abnormal findings for the Romberg test include swaying, falling, and a widening base of the feet to avoid falling.

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.

A 23-year-old patient in the clinic appears anxious. Her speech is rapid, and she is fidgety and in constant motion. Which of these questions or statements would be most appropriate for the nurse to use in this situation? a. "How do you usually feel? Is this normal behavior for you?" b. "I am going to say four words. In a few minutes, I will ask you to recall them." c. "Describe the meaning of the phrase, 'Looking through rose-colored glasses.'" d. "Pick up the pencil in your left hand, move it to your right hand, and place it on the table."

ANS: D This patient appears to have symptoms of attention-deficit/hyperactivity disorder (ADHD) (restless, fidgeting, excess talking). The nurse should assess the patient's attention span. Attention span is evaluated by assessing the individual's ability to concentrate and complete a thought or task without wandering. Giving a series of directions to follow is one method used to assess attention span. Options A, B, and C do not assess attention span.

A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting for a while, she gets "really dizzy" and feels like she is going to fall over. What is the best response by the nurse? a. "Have you been extremely tired lately?" b. "You probably just need to drink more liquids." c. "I'll refer you for a complete neurologic examination." d. "You need to get up slowly when you've been lying down or sitting."

ANS: D This patient's symptoms are unlikely r/t being tired or dehydration and would not require a complete neurological examination at this time. Instead, they are likely due to normal aging. Aging is accompanied by a progressive decrease in cerebral blood flow. In some people, this decrease causes dizziness and a loss of balance with a position change. These individuals need to be taught to get up slowly. The other responses are incorrect.

A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, "I buy obie get spirding and take my train." What is the best description of this patient's problem? a. Echolalia b. Global aphasia c. Broca's aphasia d. Wernicke's aphasia

ANS: D This type of communication illustrates Wernicke's or receptive aphasia. The person can hear sounds and words but cannot relate them to previous experiences. Speech is fluent, effortless, and well-articulated, but it has many paraphasias (word substitutions that are malformed or wrong) and neologisms (made-up words) and often lacks substantive words. Speech can be totally incomprehensible. Often, a great urge to speak is present. Repetition, reading, and writing also are impaired. Echolalia is an imitation or the repetition of another person's words or phrases. With global aphasia, spontaneous speech is absent or reduced to a few stereotyped words or sounds and comprehension is absent or reduced to only a person's own name and a few select words. With Broca's aphasia the person can understand language but cannot express himself using words or language.

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.

4. A patient is admitted to the medical unit following a cerebrovascular accident (CVA). Evidence of left-sided hemiparesis is noted, and the nurse will be following up on ROM and other exercises performed in physical therapy. The nurse should correctly teach the patient and family members which of the following principles of ROM exercises? a. Flex the joint to the point of discomfort. b. Medicate the patient after the ROM exercise session. c. Move the joints quickly. d. Provide support for distal joints.

ANS: D When performing active-assisted or passive ROM exercises, support the joint by holding the distal portion of the extremity, or by using a cupped hand to support the joint. The joint should be flexed to the point of resistance, not to the point of discomfort. Assess the patient's level of comfort (on a scale of 0 to 10, with 10 being the worst pain) before performing exercises. Before beginning ROM exercises, determine whether the patient would benefit from pain medication. Joints should be moved slowly through the ROM. Quick movement could cause injury.

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.

Which of these individuals would the nurse consider at highest risk for a suicide attempt? a. Man who jokes about death b. Woman who, during a past episode of major depression, attempted suicide c. Adolescent who just broke up with her boyfriend and states that she would like to kill herself d. Older adult man who tells the nurse that he is going to "join his wife in heaven" tomorrow and plans to use a gun

ANS: D When the person expresses feelings of sadness, hopelessness, despair, or grief, assessing any possible risk for physical harm to him or herself is important. The interview should begin with more general questions. If the nurse hears affirmative answers, then he or she should continue with more specific questions. A precise suicide plan to take place in the next 24 to 48 hours with use of a lethal method constitutes high risk.

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 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing? a. Scissors gait b. Cerebellar ataxia c. Parkinsonian gait d. Spastic hemiparesis

ANS: D With spastic hemiparesis, the arm is immobile against the body. Flexion of the shoulder, elbow, wrist, and fingers occurs, and adduction of the shoulder, which does not swing freely, is observed. The leg is stiff and extended and circumducts with each step. Causes of this type of gait include cerebrovascular accident. With scissors gait the knees cross or are in contact, like holding an orange between the thighs, and the person uses short steps, and walking requires effort. The characteristics of cerebellar ataxia include a staggering, wide-based gait; difficulty with turns; and uncoordinated movement with positive Romberg sign. Parkinsonian gait presents with a stooped posture with trunk pitched forward. Elbows, hips and knees are flexed. Steps are short and shuffling. The gait disturbance of this patient is spastic hemiparesis. With spastic hemiparesis, the arm is immobile against the body. Flexion of the shoulder, elbow, wrist, and fingers occurs, and adduction of the shoulder, which does not swing freely, is observed. The leg is stiff and extended and circumducts with each step. Causes of this type of gait include cerebrovascular accident.

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.

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.

4. 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.

The patient has been admitted for hypertension. His blood pressure is normally in the 160/90 range. He has been on bed rest for the past few days, and the doctor has started him on a new blood pressure medication. The nurse is assisting the patient to move from the bed to the chair for breakfast, but when the patient tries to sit up on the side of the bed, he complains of being dizzy and nauseous. The nurse lays the patient down and takes his vital signs. His pulse is 124. His blood pressure is 130/80. This blood pressure is indicative of what? A A normal blood pressure for this patient B Orthostatic hypotension C Orthostatic hypertension D Effective baroreceptor function

Place the following steps in the sequence that promotes safe transfer of a patient from a wheelchair to a bed.1. Adjust the height of the bed to the level of the seat of the wheelchair and position the wheelchair at a 45-degree angle next to the bed.2. Instruct the patient to stand on the count of three.3. Lock the wheelchair. Locks are located above the rims of the wheels. Push forward to lock.4. Raise the footplates.5. Position yourself slightly in front of the patient to guard and protect the patient throughout the transfer.6. Place a transfer belt on the patient and assist the patient to move to the front of the wheelchair. a. 1, 2, 3, 6, 4, 5 b. 2, 1, 3, 4, 5, 6 c. 1, 3, 4, 6, 5, 2 d. 6, 3, 2, 1, 5, 4

C 1, 3, 4, 6, 5, 2

A patient in whom a seizure disorder was recently diagnosed plans to continue a career as a pilot. At this time in the interview, the nurse begins to question the patient's: a.thought process b.intellect c.judgment d.perception

C To assess judgment in the interview, the nurse should notice what the person says about job plans, social or family obligations, and plans for the future. Job and future plans should be realistic and should take into account the person's health situation. Thought processes should be consistent, coherent, relevant, and logical. Perceptions should be congruent; the person should be consistently aware of reality. Intellectual functioning is measured by problem-solving and reasoning abilities.

The nurse is preparing to conduct a physical assessment of a patient's musculoskeletal system. Which techniques should the nurse use for this assessment? Select all that apply. Evaluation Percussion Palpation Inspection Auscultation

C, D

To promote patient safety, government standards regarding mechanical and physical restraints state that: A. alternative measures are to be implemented before restraints are used. B. the nurse's judgment is all that is required for restraint use. C. restraints should be used immediately for all patients who may need them. D. restraints cannot be used except to prevent others from being harmed.

Correct Answer: A Explanation/Rationale:The use of mechanical or physical restraints must be part of the prescribed medical treatment, all less-restrictive interventions must be tried first, other disciplines must be applied, and supporting documentation must be provided. If the alternatives fail, the nurse may consider use of a restraint to prevent injury. Determine the patient's need for restraint if other less-restrictive measures fail to prevent interruption of therapy or injury to self or others. Confer with the physician or primary health care provider, who must write the order for restraints. Restraints may be needed for the confused or combative patient to prevent interruption of therapy or injury to self or others. Confer with the physician or primary health care provider.

The nurse prevents self-injury by using which of the following when transferring a patient? (Select all that apply.) A. Correct posture B. Maximal muscle strength C. Effective body mechanics D. Effective lifting techniques

Correct Answer: A+C+D Explanation/Rationale:The nurse prevents self-injury by using correct posture, minimal muscle strength, and effective body mechanics and lifting techniques. Consider individual patient problems during transfer.

The patient is an elderly male with severe kyphosis who is immobile from a stroke several years earlier. He has been admitted for severe dehydration. The nurse must turn the patient frequently to prevent complications of immobility. What does the nurse realize? A. This patient should be turned onto his back for meals. B. This patient may have to be turned more frequently than every 2 hours. C. This patient may be allowed to remain in his favorite position as long as he doesn't complain of discomfort. D. Skin breakdown is not an issue for this patient.

Correct Answer: B Explanation/Rationale:Patients with underlying chronic conditions are at risk for skin breakdown and other hazards of immobility and as a result require more frequent position changes. A patient with severe kyphosis cannot lie supine or is unable to lift an object safely because the center of gravity is not aligned. Cluttered hallways and bedside areas increase the patient's risk for falling. Dehydration or edema may require more frequent position changes because patients are prone to skin breakdown.

As part of an attempt to implement a restraint-free environment, the nurse: A. provides constant activity for the patient at all times. B. ensure tubes and drains are not tangled under the blankets. C. keep the caregivers/nurses as consistent as possible. D. reduces visiting hours and times in therapy.

Correct Answer: C Explanation/Rationale: Patient anxiety is reduced and safety is increased when one person provides care and supervision is constant. Position intravenous (IV) catheters, urinary catheters, and tubes/drains out of patient view, or use camouflage by wrapping the IV site with bandage or stockinette, placing undergarments on patients with a urinary catheter, or covering abdominal feeding tubes/drains with a loose abdominal binder. This helps maintain medical treatment and reduces patient access to tubes/lines. Provide scheduled ambulation, chair activity, and toileting. Organize treatments so the patient has long uninterrupted periods throughout the day. Provide for sleep and rest periods. Constant activity may irritate the patient. Provide the same caregivers to the extent possible. This increases familiarity with individuals in the patient's environment, decreasing anxiety and restlessness. Encourage family and friends to stay with the patient. Sitters or companions may be used. In some institutions, volunteers can be effective companions. Patient anxiety is reduced and safety is increased when one person provides care and supervision is constant.

What should the nurse do to prevent a patient from aspirating during a seizure? A. Insert an oral airway. B. Restrain the patient securely. C. Sit the patient upright. D. Turn the patient onto his/her side.

Correct Answer: D Explanation/Rationale:If possible, turn the patient onto the side, with the head flexed slightly forward. This position prevents the tongue from blocking the airway and promotes drainage of secretions, thus reducing the risk for aspiration. Do not force any objects such as fingers, medicine or tongue depressor, or airway into the patient's mouth when the teeth are clenched. This could cause injury to the mouth and could stimulate gagging, leading to possible aspiration. Do not restrain the patient. Loosen clothing to prevent musculoskeletal injury and airway obstruction. When a seizure begins, position the patient safely. If the patient is standing or sitting, guide the patient to the floor and protect the head by cradling in the nurse's lap or placing a pillow under the head. Clear the surrounding area of furniture. If the patient is in bed, raise the side rails and pad, and put the bed in a low position.

A nurse encourages a patient to prevent venous stasis by: A crossing the legs when sitting in a chair. B wearing thigh-length nylon stockings or garters. C elevating the legs on pillows while in bed. D increasing early ambulation.

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 an increase in bone matrix." B. "It is new bone growth that is weaker." C."There is a decrease in phagocytic activity." D. "It is the loss of bone density."

The patient is performing range of motion (ROM) exercises independently. These are known as __________ exercises.

Explanation/Rationale:active ROM

The _____________ coordinates movement, maintains equilibrium, and helps maintain posture. a. basal ganglia b. extrapyramidal system c. cerebellum d. upper and lower motor neurons

The cerebellum controls motor coordination of voluntary movements, equilibrium (i.e., posture balance of the body), and muscle tone. The extrapyramidal system maintains muscle tone and controls body movements, especially gross automatic movements such as walking. The upper motor neurons are located within the central nervous system; influence or modify the lower motor neurons; and include the corticospinal, corticobulbar, and extrapyramidal tracts. The lower motor neurons are located mostly in the peripheral nervous system and extend from the spinal cord to the muscles; examples include the cranial nerves and spinal nerves. The basal ganglia control automatic associated movements of the body.

A child with cerebral palsy can experience difficulty with movement, loss of balance, and lack of muscle control. Which gait does the nurse instruct the parents to use for crutch walking? Four-point Three-point Two-point Swing-to

a The four-point gait provides the most support and improves balance.

Which nursing intervention decreases the risk for catheter-associated urinary tract infection (CAUTI)? (Select all that apply.) a. Daily cleansing of the urinary meatus b. Hanging the urinary drainage bag below the level of the bladder c. Changing the urinary drainage bag daily d. Irrigating the urinary catheter with sterile water e. Emptying the drainage bag using a separate receptacle for each patient

a, b, e Evidence-based interventions shown to decrease the risk for CAUTI include ensuring a free flow of urine in the catheter to the bag, daily perineal hygiene and using a separate receptacle for each patient when emptying the Foley. Irrigation and changing the bag will increase the risk for CAUTI through repeated opening of the sterile catheter drainage system.

Positioning a hemiplegic patient in Fowler's position will increase the patient's: (Select all that apply.) a. ventilatory capacity. b. cardiac output. c. ability to swallow. d. risk of aspiration.

a,b,c Fowler's position increases ventilation and cardiac output and improves the patient's ability to swallow. Answer "D" is incorrect; Fowler's position helps to prevent aspiration of food, liquids, and gastric secretions.

an older adult: a. has a slower response time b. has diminished recent and remote memory recall. c. experiences a 10-point decrease in intelligence. d. has difficulty with problem solving

ans: A Response time is slower in an aging adult; it may take longer for the brain to process information and react. Timed intelligence testing may be lower for an aging adult; intelligence has not declined, but it may take longer to respond to questions. Recent memory requires processing and may decrease with aging. Remote memory is not affected by the aging process. Aging does not usually have an impact on mental status (e.g., intelligence, reasoning abilities, and problem solving).

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.

The mental status examination: a. should be completed at the end of the physical examination. b. assesses mental health strengths and coping skills and screens for any dysfunction. c. is usually not assessed in children younger than 2 years of age. d. will not be affected if the patient has a language impairment.

ans: B The purpose of the mental status examination is to assess mental health strengths and coping skills and to screen for any dysfunction. The mental status assessment usually can be completed during the context of the entire health history interview. If basic functions (e.g., language) are abnormal, other assessments (of new learning or abstract reasoning) may be erroneous. A mental status examination can be performed on all patients.

Mental status assessment documents: a. schizophrenia and other mental health disorders b. artistic or writing ability in the mentally ill person. c. emotional and cognitive functioning d. intelligence and educational level.

ans: C Mental status assessment is a systematic check of emotional and cognitive functioning. Intelligence testing measures problem-solving and reasoning abilities; results of intelligence testing should be assessed considering educational and cultural background. Mental status assessment evaluates appearance, behavior, cognition, and thought processes, not artistic or writing ability. Abnormalities in mood and affect may indicate schizophrenia and other mental health disorders.

Although a full mental status examination may not be required for every patient, the health care provider must address the four main components during a health history and physical examination. The four components are: a. language, orientation, attention, and abstract reasoning. b. mood, affect, consciousness, and orientation. c. appearance, behavior, cognition, and thought processes. d. memory, attention, thought content, and perceptions.

ans: C The four main components of a full mental status examination are appearance, behavior, cognition, and thought processes. Select behaviors that are assessed with a mental status examination include memory, attention, thought content, and perceptions. Select behaviors that are assessed with a mental status examination include language, orientation, attention, and abstract reasoning. Select behaviors that are assessed with a mental status examination include mood, affect, consciousness, and orientation.

Which of the following statements about mental status testing of children is correct? a. The behavioral checklist is useful to assess children who are 3 to 5 years old. b. Input from parents and caregivers is discouraged when assessing psychosocial development c. The results of the Denver II screening test are valid for white, middle-class children only. d. Abnormal findings are usually r/t not achieving an expected developmental milestone.

ans: D Abnormalities in mental status in children are often problems of omission; the child does not achieve a milestone that is expected. The validity of the Denver II screening test is based on more than 2000 children in Colorado; the sample represented a broad spectrum of children and was representative of the U.S. population with only minor demographic differences. The behavioral checklist is useful as a mental status assessment for school-age children (7 to 11 years old). A child's psychosocial development and mental status assessment is mostly based on information obtained from the parent.

An abnormal sensation of burning or tingling is best described as: a. paralysis. b. paraphasia. c. paresis. d. paresthesia.

ans: D Paresthesia is an abnormal sensation such as burning or tingling. Paralysis is a loss of motor function as a result of a lesion in the neurologic or muscular system or loss of sensory innervation. Paresis is a partial or incomplete paralysis. Paraphasia is a condition in which a person hears and comprehends words but is unable to speak correctly; incoherent words are substituted for intended words.

The patient tells the nurse she will not cooperate this evening with the physical therapist to perform exercises because she was in pain the entire time during exercise last evening. What question should the nurse ask the patient? A Do you like the therapist who was assigned to you? B Why are you trying to be difficult tonight? C Have you ever liked to exercise in the past? D Did you receive pain medication before you exercised?

ans: D Rationale: Pain may reduce a patient's motivation to perform isometric exercises. Pain relief before attempts at exercise may enhance the patient's participation; it may be appropriate to medicate the patient 30 to 60 minutes before exercise.

The extrapyramidal system is located in the: a. medulla. b. basal ganglia. c. hypothalamus. d. cerebellum.

ans: D The basal ganglia are large bands of gray matter buried deep within the two cerebral hemispheres that form the subcortical associated motor system (the extrapyramidal system).

Automatic associated movements of the body are under the control and regulation of: a. the thalamus. b. the hypothalamus. c. Wernicke's area. d. the basal ganglia.

ans: D The basal ganglia controls automatic associated movements of the body. The thalamus is where sensory pathways of the spinal cord, cerebellum, and brainstem form synapses on their way to the cerebral cortex. The hypothalamus is a major respiratory center with basic vital functions: temperature, appetite, sex drive, heart rate, and blood pressure control; sleep center; anterior and posterior pituitary gland regulation; and coordination of autonomic nervous system activity and stress response. Wernicke's area in the temporal lobe is associated with language comprehension.

The knee joint is the articulation of which three bones? a. Femur, fibula, and patella. b. Femur, radius, and olecranon process. c. Fibula, tibia, and patella. d. Femur, tibia, and patella.

ans: D The knee joint is the articulation of the femur, the tibia, and the patella. The fibula is not involved in articulation of the knee joint. The radius and ulna are bones in the lower part of the upper extremity; the olecranon process is located on the proximal end of the ulna.

Clonus that may be seen when testing deep tendon reflexes is characterized by a(n): a. set of rapid, rhythmic contractions of the same muscle. b. contraction of the muscle that appears after the tendon is hit the second time. c. additional contraction of the muscle that is of greater intensity than the first contraction. d. parallel response in the opposite extremity.

ans: a Clonus is a set of rapid, rhythmic contractions of the same muscle.

Dysmenorrhea is: a. pain associated with menstruation. b. pain with urination. c. pain with defecation. d. painful intercourse.

ans: a Dysmenorrhea is the abdominal cramping and pain associated with menstruation. Dyspareunia is the term to describe painful intercourse. Dyschezia is pain with bowel movements. Dysuria describes pain or burning with urination.

In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect? a. Hyperreflexia b. Fasciculations c. Loss of muscle tone and flaccidity d. Atrophy and wasting of the muscles

ans: a Hyperreflexia, diminished or absent superficial reflexes, and increased muscle tone or spasticity can be expected with upper motor neuron lesions. The other options reflect a lesion of lower motor neurons.

Testing the deep tendon reflexes gives the examiner information regarding the intactness of the: a. reflex arc at specific levels in the spinal cord. b. medulla. c. corticospinal tract. d. upper motor and lower motor neuron synaptic junction.

ans: a Measurement of the deep tendon reflexes reveals the intactness of the reflex arc at specific spinal levels. The corticospinal tract is the higher motor system that permits very skilled and purposeful movements such as writing. The medulla contains all ascending and descending fiber tracts; it has vital autonomic centers for respiration, heart, and gastrointestinal function as well as nuclei for cranial nerves VIII through XII. The upper motor neurons are located within the central nervous system and influence or modify the lower motor neurons and include the corticospinal, corticobulbar, and extrapyramidal tracts. The lower motor neurons are located mostly in the peripheral nervous system and extend from the spinal cord to the muscles; examples include the cranial nerves and spinal nerves.

Cessation of menses is known as: a. menopause. b. menarche. c. adnexa. d. salpingitis.

ans: a Menopause is the cessation of menses. Menarche is the age of the first period. Salpingitis is inflammation of the fallopian tube. The adnexa of uterus (or uterine appendages) refers to the structures most closely related structurally and functionally to the uterus; these structures include the ovaries, fallopian tubes, and ligaments.

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.

Heberden and Bouchard nodes are hard and nontender and are associated with: a. osteoarthritis. b. metacarpophalangeal bursitis. c. Dupuytren contracture. d. rheumatoid arthritis.

ans: a Osteoarthritis is characterized by hard, nontender nodules, 2 to 3 mm or more in size. These osteophytes (bony overgrowths) of the distal interphalangeal joints are called Heberden nodes, and osteophytes of the proximal interphalangeal joints are called Bouchard nodes. Swan neck, boutonnière deformity, and ulnar deviation are conditions associated with rheumatoid arthritis. Dupuytren contracture occurs with diabetes, epilepsy, and alcoholic liver disease. Chronic hyperplasia of the palmar fascia causes flexion contractures of the digits. Bursitis is an inflammation of the bursa.

While obtaining a health history of a 3-month-old infant from the mother, the nurse asks about the infant's ability to suck and grasp the mother's finger. What is the nurse assessing? a. Reflexes b. Intelligence c. Cranial nerves d. Cerebral cortex function

ans: a Questions regarding an infant's ability to suck and grasp are assessing the infant's reflexes. Questions regarding reflexes include such questions as, "What have you noticed about the infant's behavior," "Do the infant's sucking and swallowing seem coordinated," and "Does the infant grasp your finger?" The other responses are incorrect.

What is the most appropriate recommendation to prevent cervical cancer in females? a. Administration of HPV vaccine around 11 and 12 years old b. Start birth control if sexually active c. There is nothing that can prevent cervical cancer. d. Use barrier protection method during sexual intercourse.

ans: a The American Cancer Society recommends HPV vaccine for all boys and girls at 11 and 12 years as HPV causes almost all cervical cancers in addition to other types of cancer. Barrier protection is important to use during intercourse to prevent spread of sexually transmitted infections, but is not the best method to prevent cervical cancer. Use of birth control when sexually active is important to decrease the risk for pregnancy. Studies show that the HPV vaccine at 11 and 12 years old has been linked to steep declines in the presence of HPV which causes almost all cervical cancers in addition to other types of cancer.

The ejaculatory duct is: a.the passage formed by the joining of the vas deferens and the seminal vesicle. b. a narrow tunnel inferior to the inguinal ligament. c.a narrow tunnel superior to the inguinal ligament. d. a muscular duct continuous with the epididymis.

ans: a The ejaculatory duct is the passage formed by the junction of the duct of the seminal vesicles and the vas deferens through which semen enters the urethra. The muscular duct continuous with the epididymis is the vas deferens. The femoral canal is inferior to the inguinal ligament. The inguinal canal is superior to the inguinal ligament and is a narrow tunnel passing obliquely between layers of abdominal muscle.

The first sign of puberty in girls is: a. breast and pubic hair development. b. rapid increase in height. c. the first menstrual cycle (menarche). d. axillary hair development.

ans: a The first signs of puberty are breast and pubic hair development, beginning between 8½ and 13 years of age. These signs usually occur together, but it is not abnormal if they do not develop together. This development takes about 3 years to complete. Menarche occurs during the latter half of the sequence of breast and pubic hair development, just after the peak of growth velocity. Coarse curly hairs develop in the pubic area first and then in the axillae.

A physician writes an order for restraining a patient. What information would the nurse expect to find in the order? (Select all that apply.) a. The time limitation for application of the restraint b. The type of restraint to be applied c. Alternative strategies to be used before a restraint is used d. The purpose for the use of the restraint e. The documentation required while the patient is restrained f. Instructions to notify the patient's next of kin when restraints were applied

ans: a, b, d The agency would outline the alternative strategies that should be tried before restraints are used. Instruction in documentation would be provided before restraints are ordered. It is not required to notify the patient's next of kin when restraints are applied.

Aphasia is best described as: a. a disturbance in executive functioning (planning, organizing, sequencing, abstracting) b. a language disturbance in speaking, writing, or understanding c. the impaired ability to recognize or identify objects despite intact sensory function. d. the impaired ability to carry out motor activities despite intact motor function.

ans: b Aphasia is a language disturbance. Apraxia is an impaired ability to carry out motor activities despite intact motor function. Agnosia is an impaired ability to identify objects correctly despite intact sensory function. A disturbance in executive functioning is a cognitive disturbance. Dementia is the development of multiple cognitive deficits with both memory impairment and a cognitive disturbance.

A 32-year-old woman tells the nurse that she has noticed "very sudden, jerky movements" mainly in her hands and arms. She says, "They seem to come and go, primarily when I am trying to do something. I haven't noticed them when I'm sleeping." What do these symptoms suggest? a. Tics b. Chorea c. Athetosis d. Myoclonus

ans: b Chorea is characterized by sudden, rapid, jerky, purposeless movements that involve the limbs, trunk, or face. Chorea occurs at irregular intervals, and the movements are all accentuated by voluntary actions. A tic is an involuntary, compulsive, repetitive twitching of a muscle group (e.g. wink, grimace, head movement, shoulder shrug); due to a neurologic cause or a psychogenic cause. Athetosis is slow, twisting, writhing, continuous movement, resembling a snake or worm. Myoclonus is rapid, sudden jerk or a short series of jerks at fairly regular intervals (a hiccup is a myoclonus of the diaphragm).

An adolescent male is brought to the emergency department with complaints of excruciating pain in his left testicle. Which of the following would be the nurse's most appropriate action? a. Perform a focused assessment. b. Notify the emergency department physician immediately. c. Document pain assessment and notify physician when he or she is available. d. Tell the adolescent, everything will be fine and there's nothing to worry about.

ans: b Excruciating unilateral testicle pain of sudden onset are signs of testicular torsion which is considered an emergency. The adolescent needs to have emergency surgery to prevent gangrene which can occur in only a few hours. Symptoms indicate an emergent condition; thus the nurse should notify the physician immediately and allow them to perform the needed assessment. Telling a patient and/or his family there is nothing to worry about is non-therapeutic communication and provides false reassurance.

In order to obtain accurate subjective assessment data from a female adolescent, what would be the most appropriate action by the nurse? a. Stand when asking questions. b. Ask parent/caregiver to step out of the room and return to the lobby. c. Share what life was like for the nurse at the patient's age. d. Ask questions such as, "you're not sexually active, right?"

ans: b In order to gain trust and provide privacy for the adolescent female, it would be most appropriate to ask the parent/caregiver to step out of the room. The nurse should rarely share personal information especially r/t female genitalia and sexuality. Asking questions in a negatively worded manner does not provide an open environment for the adolescent female to share concerns. Whenever interviewing/talking with patients, the nurse should use therapeutic communication techniques which includes sitting or being at their eye level.

What does testing kinesthesia assess? a. Fine touch b. Position sense c. Motor coordination d. Perception of vibration

ans: b Kinesthesia, or position sense, is the person's ability to perceive passive movements of the extremities. Fine touch is assessed by the stereognosis, graphesthesia, extinction, and point location tests. Motor coordination is assessed by the Denver II test and reflexes. Perception of vibration is assessed by hitting a tuning fork so that it is vibrating and placing it on boney prominences.

Cerebellar function is tested by: a. muscle strength assessment. b. performance of rapid alternating movements. c. the Phalen maneuver. d. superficial pain and touch assessment.

ans: b The cerebellum controls motor coordination of voluntary movements, equilibrium, and muscle tone. Cerebellar function is tested by balance tests (e.g., gait, Romberg test) and coordination and skilled movements (e.g., rapid alternating movements, finger-to-finger test, finger-to-nose test, heel-to-shin test). Muscle strength assessment examines the intactness of the motor system. The Phalen maneuver reproduces numbness and burning in a patient with carpal tunnel syndrome. Superficial pain and touch assessment examines intactness of the spinothalamic tract.

When performing catheter care, what step helps prevent traction on the catheter and CAUTI? a. Wash the meatus with soap and water. b. Start cleansing at the meatus and move toward the rectum. c. Grasp the catheter with two fingers to stabilize the catheter. d. Retract the foreskin before cleansing.

ans: c All options help prevent CAUTI, but only option "C" prevents unnecessary traction on the catheter. Pulling on the catheter causes discomfort for the patient and can damage the urethra and the bladder neck.

What term is used to describe slow, twisting muscle movements that resemble a snake or worm? a. Ataxia b. Vestibular function c. Athetosis d. Flaccid

ans: c Athetosis is slow, writhing, continuous, and involuntary movements of the extremities. Ataxia is an impaired ability to coordinate movement, often characterized by a staggering gait and postural imbalance. Flaccid is weak, soft, and flabby; lacking normal muscle tone. Vestibular function is the sense of balance.

When taking the health history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information? a. "Does your muscle tone seem tense or limp?" b. "After the seizure, do you spend a lot of time sleeping?" c. "Do you have any warning sign before your seizure starts?" d. "Do you experience any color change or incontinence during the seizure?"

ans: c Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor. The other questions do not solicit information about an aura.

Which of the following are findings r/t testosterone deficiency? a. Increased libido b. Scrotal sac pendulous with less rugae c. Increased fatigue d. Decreased penis size

ans: c Depression, fatigue, loss of muscle mass or strength, and decreased libido are common findings in males with testosterone deficiency. Decreased libido is expected with testosterone deficiency. Pendulous scrotal sac with less rugae is a normal expected finding in an older male. Decreased penis size is a normal expected finding in an older male.

Soft, pointed, fleshy papules that occur on the genitalia caused by human papillomavirus (HPV) are known as: a. chancres b. urethritis. c. genital warts. d. varicoceles.

ans: c Genital warts are soft, pointed, fleshy papules that occur on the genitalia and are caused by HPV. Syphilitic chancres are small, solitary, silvery papules that erode to a red, round or oval, superficial ulcer with a yellowish serous discharge. Urethritis is an infection of the urethra; the meatus edges are reddened, everted, and swollen. A varicocele is a dilated, tortuous varicose vein in the spermatic cord.

Hematuria is a term used for: a. bleeding after intercourse. b. bloody discharge. c. blood in the urine. d. urine in the blood.

ans: c Hematuria is the term used to describe blood in the urine.

Orchitis is (are): a. hard, subcutaneous plaques associated with painful bending of the erect penis. b. a circumscribed collection of serous fluid in the tunica vaginalis surrounding the testes. c. an acute inflammation of the testes. d. a meatus opening on the dorsal side of the glans or shaft.

ans: c Orchitis is an acute inflammation of the testes. Epispadias is a meatus opening on the dorsal side of the glans or shaft. Peyronie disease is a result of hard, nontender, subcutaneous plaques on the penis that cause a painful bending of the penis during an erection. A hydrocele is a circumscribed collection of serous fluid in the tunica vaginalis surrounding the testes.

The presence of primitive reflexes in a newborn infant is indicative of: a. prematurity of the infant. b. mental retardation. c. immaturity of the nervous system. d. spinal cord alterations.

ans: c The nervous system is not completely developed at birth, and motor activity in the newborn is under the control of the spinal cord and medulla. The neurons are not yet myelinated. Movements are directed primarily by primitive reflexes. As the cerebral cortex develops during the first year, it inhibits these reflexes, and they disappear at predictable times. Persistence of the primitive reflexes is an indication of central nervous system dysfunction.

A deep recess formed by the peritoneum between the rectum and the cervix is called: a.a cystocele. b.the Chadwick sign. c.a rectouterine pouch. d. a rectocele.

ans: c The rectouterine pouch (or cul-de-sac of Douglas) is the deep recess between the rectum and the cervix. The cervical mucosa during the second month of pregnancy is blue, which is termed the Chadwick sign. The cervix may also turn blue in any condition causing hypoxia or venous congestion. A cystocele is an abnormality of the pelvic musculature in which the bladder prolapses into the vagina. A rectocele is an abnormality of the pelvic musculature in which the rectum prolapses into the vagina.

The nurse is performing an assessment on a 29-year-old woman who visits the clinic reporting "always dropping things and falling down." While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect? a. Lesion of CN IX b. Vestibular disease c. Dysfunction of the cerebellum d. Inability to understand directions

ans: c The symptoms this patient has been experiencing indicate dysfunction of the cerebellum. The cerebellum is concerned with motor coordination of voluntary movements, equilibrium, and muscle tone. When a person tries to perform rapid, alternating movements, responses that are slow, clumsy, and sloppy are indicative of cerebellar disease. Vestibular disease causes problems with balance and vertigo. Lesions of CN IX cause problems swallowing or gagging. Inability to understand directions would be r/t a problem in Wernicke's area in the brain and is not associated with dropping things or falling down.

Vaginal lubrication during intercourse is produced by: a. sebaceous glands. b. adrenal glands. c. Bartholin glands. d. Skene glands.

ans: c The vestibular (Bartholin) glands secrete clear lubricating mucus during intercourse. Paraurethral (Skene) glands are tiny, multiple glands that surround the urethral meatus. Sebaceous glands are microscopic glands in the skin that secrete an oily/waxy matter, called sebum, to lubricate the skin and hair. The adrenal glands are endocrine glands responsible for releasing hormones in conjunction with stress through the synthesis of corticosteroids and catecholamines.

A caruncle is a(n): a. hard, painless nodule in the uterine wall. b. aberrant growth of endometrial tissue. c. vestibular gland located on either side of the vaginal orifice. d. small, red mass protruding from the urethral meatus.

ans: d A caruncle is a small, deep red mass protruding from the urinary meatus. Bartholin glands are vestibular glands located on either side of and posterior to the vaginal orifice. Endometriosis is a disorder caused by aberrant growths of endometrial tissue scattered throughout the pelvis. Myomas (leiomyomas or uterine fibroids) is a disorder in which the uterus is irregularly enlarged, firm, mobile, and nodular with hard, painless nodules in the uterine wall.

A nurse is conducting a class on fall prevention for staff on the patient care unit. Which statement is appropriate to include in the presentation? a. Falls are most successfully prevented by making the patient's environment safe. b. Early use of restraints in a suddenly restless patient will effectively reduce falls. c. A bed alarm even when used alone will generally prevent falls in most patients. d. The fall prevention strategies used should be targeted to patient risks.

ans: d A safe environment is important, but the patient's behaviors and risks must be matched with the interventions to be used. Restraints are always a last resort and are not considered a safe fall prevention strategy. A bed alarm can be useful in fall prevention but should be combined with appropriate behavioral therapies.

A fire begins in the bathroom of a 200-pound (91-kg) patient who has a cast that extends from his hip to his ankle. What is the best method for evacuating this patient? a. Place him on a blanket on the floor, and drag him out of the room. b. Get another staff member to help using the two-person swing carry technique. c. Use the "back-strap" method to get him out of his room. d. Leave him in bed, and push the bed out of the room.

ans: d Because of his weight and limited mobility, the most appropriate method for evacuating this patient is rolling his bed out of the room with him in it. The other methods would increase the risk for injury to the nurse(s) involved.

A major characteristic of dementia is: a. hallucinations. b. sudden onset of symptoms. c. cognitive deficits that are substance-induced. d. impaired short-term and long-term memory.

ans: d Dementia is the presence of cognitive deficits; the deficits include memory impairment (impaired ability to learn new information or to recall previously learned information). Hallucinations are a form of delirium. Delirium is a disturbance that develops over a short period of time. Delirium may be substance-induced.

During assessment of extraocular movements, two back-and-forth oscillations of the eyes in the extreme lateral gaze occur. This response indicates: a. that the patient needs to be referred for a more complete eye examination. b. this assessment should be repeated in 15 minutes to allow the eyes to rest. c. a disease of the vestibular system, further evaluation is needed. d. an expected movement of the eyes during this procedure.

ans: d Nystagmus is a back-and-forth oscillation of the eyes. End-point nystagmus, a few beats of horizontal nystagmus at extreme lateral gaze, occurs normally.

A patient is unable to perform rapid alternating movements such as rapidly patting her knees. How should the nurse document this finding? a. Ataxia b. Astereognosis c. Loss of kinesthesia d. Presence of dysdiadochokinesia

ans: d Slow clumsy movements and the inability to perform rapid alternating movements occur with cerebellar disease. The condition is termed dysdiadochokinesia. Ataxia is an uncoordinated or unsteady gait. Astereognosis is the inability to identify an object by feeling it. Kinesthesia is the person's ability to perceive passive movement of the extremities or the loss of position sense.

The American Academy of Pediatrics recommends newborn male circumcision because of which of the following benefits? a. Increased risk for HIV b. Increased risk for sexually transmitted infections c. Transmission of trichomoniasis d. Decreased risk for urinary tract infections

ans: d The American Academy of Pediatrics recommends newborn male circumcision as it shows decreased risk for urinary tract infections. Newborn male circumcision decreases the risk for sexually transmitted infection, transmission of trichomoniasis, and decreased risk for HIV transmission among heterosexual partners.

Which of the following is an expected finding of assessment of the male genitourinary system? a. Right testes 1.5 cm, Left testes 3 cm. b. Patient complains of urinary frequency c. Scrotum enlarged, rugae flattened. d. Patient states that he urinates 4 to 5 times per day.

ans: d The adult male typically urinates at least 4 to 5 times per day. An enlarged scrotum with flattened rugae is a sign of edema. Urinary frequency is usually associated with a urinary tract infection. Testes should be equal bilaterally and are freely movable.

When testing for muscle strength, the examiner should: a. observe muscles for the degree of contraction when the individual lifts a heavy object. b. measure the degree of force that it takes to overcome joint flexion or extension. c.estimate the degree of flexion and extension in each joint. d.apply an opposing force when the individual puts a joint in flexion or extension.

ans: d The person should flex or extend muscle groups for each joint while the examiner applies an opposing force. Range of motion can be described by estimating (or measuring) the degree of flexion and extension of a joint.

The term rugae refers to: a. an acute inflammation of the testes. b. a muscle that controls the size of the scrotum. c. a corpus spongiosum cone of erectile tissue. d. folds of thin skin of the scrotal wall.

ans: d The scrotum wall consists of thin skin lying in folds, or rugae, and the underlying cremaster muscle. The penis is composed of three cylindric columns of erectile tissue: two corpora cavernosa on the dorsal side and the corpus spongiosum ventrally. The cremaster muscle controls the size of the scrotum. Orchitis is an acute inflammation of the testes.

What is the safest position for a patient to assume after he has had a grand mal seizure? a.Supine with head elevated 90 degrees b. Reverse Trendelenburg's position c. Trendelenburg's position d. Side-lying position

ans: d The side-lying position keeps the patient's head down so that aspiration cannot occur. Reverse Trendelenburg's position would increase aspiration risk. Trendelenburg's is not a safe position if the patient has a recurrence of the seizure. In the supine position, secretions that have collected in the throat will not drain as well from the mouth.

Which of the following best illustrates an abnormality of thought process? a. Lability b. Compulsion c. aphasia d. Blocking

ans:D Thought process is defined as the way a person thinks or as the logical train of thought. Blocking is a sudden interruption in train of thought. Lability is an abnormality of mood and affect; the person has a rapid shift of emotions. A compulsion is an abnormality of thought content; the person displays unwanted repetitive, purposeful acts. Aphasia is a speech abnormality; the person is unable to comprehend language, produce language, or both.

In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side? a. Normal reflexes b. Lack of reflexes c. Diminished reflexes d. Hyperactive reflexes

ans:d Hyperreflexia is the exaggerated reflex observed when the monosynaptic reflex arc is released from the influence of higher cortical levels. This response occurs with upper motor neuron lesions (e.g., a cerebrovascular accident). The other responses are incorrect.

A patient with a proprioceptive disorder is being assessed for his ability to walk from bed to chair. You notice that the patient is bent forward and is leaning toward the right. Which nursing diagnosis would be the primary one on which to base his care? a. Activity intolerance b. Risk for injury c. Chronic pain d. Nutrition: less than body requirements

b A problem with proprioceptive function interferes with a person's awareness of his posture and changes in balance. Safety issues would be of primary concern during this patient's assessment and care.

What is the best nursing action when there is no urine flow after an indwelling urinary catheter is inserted into a female patient? a. Remove the catheter and start all over with a new kit and catheter. b. Determine whether the catheter is in the vagina, leave it there, and start over with a new catheter. c. If misplaced, pull the catheter back and reinsert at a different angle. d. Ask the patient to bear down, and insert the catheter farther.

b If misplaced, leave the catheter in the vagina as a landmark, indicating where not to insert, and insert another sterile catheter. Pulling the catheter back and reinserting is poor technique, increasing the risk for CAUTI.

Which situation is a contraindication for the use of elastic stockings? Use of stockings within the previous 3 months Recent skin graft to the lower leg Increased circulation in lower extremities Immobility for longer than 1 week

b The success of a skin graft could be compromised by the application of elastic stockings to the site.

The term _____________ refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions.

body alignment The term body alignment refers to the conditions of the joints, tendons, ligaments, and muscles in various body positions. When the body is aligned, whether standing, sitting, or lying, no excessive strain is placed on these structures.

The coordinated effort of the musculoskeletal and nervous systems in maintaining balance, posture, and body alignment is known as _______________.

body mechanics Body mechanics is the coordinated effort of the musculoskeletal and nervous systems to maintain balance, posture, and body alignment during lifting, bending, moving, and performing activities of daily living. Body mechanics also facilitates body movement so that a person can carry out a physical activity without using excessive muscle energy.

Which intervention is appropriate when an indwelling urinary catheter is secured in a male patient? a. Secure the catheter drainage tubing to the lower leg. b. Attach the securement device above the catheter bifurcation. c. Tape the catheter tubing to the lower abdomen, avoiding traction. d. Secure the catheter tubing to the upper inner thigh with slight traction.

c Securing the catheter, not the drainage tubing, reduces the risk of urethral erosion, CAUTI, or accidental catheter removal. Attachment of the securement device at the bifurcation is recommended to prevent catheter occlusion. Securement of the male catheter to the abdomen reduces traction on the urethra and prevents urethral injury. Catheter traction should always be avoided to minimize risk for urethral trauma.

Two assistive personnel ask the nurse for assistance to transfer a patient from the bed to a stretcher using the three-person lift technique. What is the most appropriate response from the nurse? a. "As long as we use proper body mechanics, no one will get hurt." b. "Since the patient weighs only 100 pounds, you can handle the transfer yourselves." c. "Please find the slide board for us to use." d. "Which one of you wants to be at the patient's head?"

c The three-person lift for horizontal transfer from the bed to the stretcher is no longer recommended. Physical stress can be decreased significantly by the use of a slide board.

The patient is being log-rolled onto his right side. The patient's position would be correct if what assessment was observed? a. The patient is left in Sims' position. b. The patient is moved in a smooth, continuous motion. c. Two pillows are placed behind the patient's back while on his side. d. A straight line is evident from the shoulder to the hip.

d This answer focuses on the patient's position, which requires the vertebral column to be straight. No specified numbers of pillows are needed behind the patient's back.

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