HA Test 3

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.

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

The nurse is performing a nutritional assessment on a 15-year-old girl who tells the nurse that she is "so fat." Assessment reveals that she is 5 feet 4 inches and weighs 110 pounds. The nurse's appropriate response would be: a."How much do you think you should weigh?" b."Don't worry about it; you're not that overweight." c."The best thing for you would be to go on a diet." d."I used to always think I was fat when I was your age."

A Adolescents' increased body awareness and self-consciousness may cause eating disorders such as anorexia nervosa or bulimia, conditions in which the real or perceived body image does not favorably compare with an ideal image. The nurse should not belittle the adolescent's feelings, provide unsolicited advice, or agree with her.

During a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking? a.Certain drugs can affect the metabolism of nutrients. b.The nurse needs to assess the patient for allergic reactions. c.Medications need to be documented in the record for the physician's review. d.Medications can affect one's memory and ability to identify food eaten in the last 24 hours.

A Analgesics, antacids, anticonvulsants, antibiotics, diuretics, laxatives, antineoplastic drugs, steroids, and oral contraceptives are drugs that can interact with nutrients, impairing their digestion, absorption, metabolism, or use. The other responses are not correct.

In teaching a patient how to determine total body fat at home, the nurse includes instructions to obtain measurements of: a.Height and weight. b.Frame size and weight. c.Waist and hip circumferences. d.Mid-upper arm circumference and arm span.

A Body mass index, calculated by using height and weight measurements, is a practical marker of optimal weight for height and an indicator of obesity. The other options are not correct.

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

A Normally, a child can hop on one foot and can 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. This finding is: a.Called hypospadias. b.A result of phimosis. c.Probably due to a stricture. d.Often associated with aging.

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.

If a 29-year-old woman weighs 156 pounds, and the nurse determines her ideal body weight to be 120 pounds, then how would the nurse classify the woman's weight? a.Obese b.Mildly overweight c.Suffering from malnutrition d.Within appropriate range of ideal weight

A Obesity, as a result of caloric excess, refers to weight more than 20% above ideal body weight. For this patient, 20% of her ideal body weight would be 24 pounds, and greater than 20% of her body weight would be over 144 pounds. Therefore, having a weight of 156 pounds would be considered obese.

The nurse is discussing BSEs with a postmenopausal woman. The best time for postmenopausal women to perform BSEs is: a.On the same day every month. b.Daily, during the shower or bath. c.One week after her menstrual period. d.Every year with her annual gynecologic examination.

A Postmenopausal women are no longer experiencing regular menstrual cycles but need to continue to perform BSEs on a monthly basis. Choosing the same day of the month is a helpful reminder to perform the examination.

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.CNs d.Cerebral cortex function

A Questions regarding reflexes include such questions as, "What have you noticed about the infant's behavior," "Are the infant's sucking and swallowing seem coordinated," and "Does the infant grasp your finger?" The other responses are incorrect.

A male patient with possible fertility problems asks the nurse where sperm is produced. The nurse knows that sperm production occurs in the: a.Testes. b.Prostate. c.Epididymis. d.Vas deferens.

A Sperm production occurs in the testes, not in the other structures listed.

A 70-year-old man is visiting the clinic for difficulty in passing urine. In the health history, he indicates that he has to urinate frequently, especially at night. He has burning when he urinates and has noticed pain in his back. Considering this history, what might the nurse expect to find during the physical assessment? a.Asymmetric, hard, and fixed prostate gland b.Occult blood and perianal pain to palpation c.Symmetrically enlarged, soft prostate gland d.Soft nodule protruding from the rectal mucosa

A Subjective symptoms of carcinoma of the prostate include frequency, nocturia, hematuria, weak stream, hesitancy, pain or burning on urination, and continuous pain in lower back, pelvis, and thighs. Objective symptoms of carcinoma of the prostate include a malignant neoplasm that often starts as a single hard nodule on the posterior surface, producing asymmetry and a change in consistency. As it invades normal tissue, multiple hard nodules appear, or the entire gland feels stone hard and fixed.

A 62-year-old man is experiencing fever, chills, malaise, urinary frequency, and urgency. He also reports urethral discharge and a dull aching pain in the perineal and rectal area. These symptoms are most consistent with which condition? a.Prostatitis b.Polyps c.Carcinoma of the prostate d.BPH

A The common presenting symptoms of prostatitis are fever, chills, malaise, and urinary frequency and urgency. The individual may also have dysuria, urethral discharge, and a dull aching pain in the perineal and rectal area. These symptoms are not consistent with polyps.

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. The nurse recalls that the cerebral lobe responsible for these behaviors is the __________ lobe. a.Frontal b.Parietal c.Occipital d.Temporal

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.

During an annual physical examination, a 43-year-old patient states that she does not perform monthly breast self-examinations (BSEs). She tells the nurse that she believes that mammograms "do a much better job than I ever could to find a lump." The nurse should explain to her that: a.BSEs may detect lumps that appear between mammograms. b.BSEs are unnecessary until the age of 50 years. c.She is correct—mammography is a good replacement for BSE. d.She does not need to perform BSEs as long as a physician checks her breasts annually.

A The monthly practice of BSE, along with clinical breast examination and mammograms, are complementary screening measures. Mammography can reveal cancers too small to be detected by the woman or by the most experienced examiner. However, interval lumps may become palpable between mammograms.

When considering a nutritional assessment, the nurse is aware that the most common anthropometric measurements include: a.Height and weight. b.Leg circumference. c.Skinfold thickness of the biceps. d.Hip and waist measurements.

A The most commonly used anthropometric measures are height, weight, triceps skinfold thickness, elbow breadth, and arm and head circumferences.

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?"

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.

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

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 lightheaded, swimming sensation. Seizure activity is characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances.

The nurse recognizes which of these persons is at greatest risk for undernutrition? a.5-month-old infant b.50-year-old woman c.20-year-old college student d.30-year-old hospital administrator

A Vulnerable groups for undernutrition are infants, children, pregnant women, recent immigrants, persons with low incomes, hospitalized people, and aging adults.

The nurse is performing a digital examination of a patient's prostate gland and notices that a normal prostate gland includes which of the following characteristics? Select all that apply. a.1 cm protrusion into the rectum b.Heart-shaped with a palpable central groove c.Flat shape with no palpable groove d.Boggy with a soft consistency e.Smooth surface, elastic, and rubbery consistency f.Fixed mobility

A, B, E The size of a normal prostate gland should be 2.5 cm long by 4 cm wide and should not protrude more than 1 cm into the rectum. The prostate should be heart-shaped, with a palpable central groove, a smooth surface, and elastic with a rubbery consistency. Abnormal findings include a flat shape with no palpable groove, boggy with a soft consistency, and fixed mobility.

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.Blood test for prostate-specific antigen (PSA) b.Urinalysis c.Transrectal ultrasound d.Digital rectal examination (DRE) e.Prostate biopsy

A, D 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 the PSA is elevated, then further laboratory work or a transrectal ultrasound (TRUS) and biopsy may be recommended.

The nurse is assessing the breasts of a 68-year-old woman and discovers a mass in the upper outer quadrant of the left breast. When assessing this mass, the nurse is aware that characteristics of a cancerous mass include which of the following? Select all that apply. a.Nontender mass b.Dull, heavy pain on palpation c.Rubbery texture and mobile d.Hard, dense, and immobile e.Regular border f.Irregular, poorly delineated border

A, D, F Cancerous breast masses are solitary, unilateral, and nontender. They are solid, hard, dense, and fixed to underlying tissues or skin as cancer becomes invasive. Their borders are irregular and poorly delineated. They are often painless, although the person may experience pain. They are most common in the upper outer quadrant. A dull, heavy pain on palpation and a mass with a rubbery texture and a regular border are characteristics of benign breast disease.

The nurse is performing a detailed neurological assessment on a client with a suspected brain tumor. When performing the Romberg test, the client sways when the eyes are both open and closed. What does this indicate? A. The problem is probably in the cerebellum. B. It is a position sense abnormality. C. This is not an abnormal test result. D. The client has lost proprioception.

A. The problem is probably in the cerebellum.

During a speculum inspection of the vagina, the nurse would expect to see what 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

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 of these conditions? 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. See Table 26-5 for complete descriptions of each option.

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 postmenopausal woman: A) is not at any greater risk for heart disease than a younger woman is." B) should be aware that she is at increased risk for dyspareunia because of decreased vaginal secretions." C) has only stopped menstruating; there really are no other significant changes with which she should be concerned." D) is likely to 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). The other statements are incorrect.

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 _____ 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.

A nurse is assessing a patient's risk of contracting a sexually transmitted infection (STI). An appropriate question to ask would be: A) "You know that it's important to use condoms for protection, right?" B) "Do you use a condom with each episode of sexual intercourse?" C) "Do you have a sexually transmitted infection?" D) "You are aware of the dangers of unprotected sex, aren't you?"

ANS: B In reviewing a patient's risk for sexually transmitted infections, the nurse should ask, in a nonconfrontational manner, whether condoms are used at each episode of sexual intercourse. Asking a person whether he or she has an infection does not address the risk.

When the nurse is discussing sexuality and sexual issues with adolescents, a permission statement helps to convey that it is normal to think or feel a certain way. Which of these is the best example of a permission statement? A) "It is okay that you have become sexually active." B) "Often girls your age have questions about sexual activity. Have you any questions?" C) "If it is okay with you, I'd like to ask you some questions about your sexual history." D) "Often girls your age engage in sexual activity. It is okay to tell me if you have had intercourse."

ANS: B Start with a permission statement, "Often girls your age experience . . . ." This conveys that it is normal to think or feel a certain way, and it is important to relay that the topic is normal and unexceptional.

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. The nurse suspects that the problem is: A) dysuria. B) stress incontinence. C) hematuria. D) urge incontinence.

ANS: B 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 but it occurs due to an overactive detrusor muscle in the bladder that contracts and causes an urgent need to void

During the interview a patient reveals that she has some vaginal discharge. She is worried that it may be a sexually transmitted infection. The nurse's most appropriate response to this would be: A) "Oh, don't worry. Some cyclic vaginal discharge is normal." B) "Have you been engaging in unprotected sexual intercourse?" C) "I'd like some information about the discharge. What color is it?" D) "Have you had any urinary incontinence associated with the discharge?"

ANS: C Ask questions that help the patient reveal more information about her symptoms in a nonthreatening manner. Assess vaginal discharge further by asking about the amount, color, and odor. Normal vaginal discharge is small, clear or cloudy, and always nonirritating.

A woman states that 2 weeks ago she had a urinary tract infection that was treated with an antibiotic. As a part of the interview, the nurse should ask, "Have you noticed: A) a change in your urination patterns?" B) any excessive vaginal bleeding?" C) any unusual vaginal discharge or itching?" D) any changes in your desire for intercourse?"

ANS: C Several medications may increase the risk of vaginitis. Broad-spectrum antibiotics alter the balance of normal flora, which may lead to the development of vaginitis. The other questions are not correct

Which statement would be most appropriate when the nurse is introducing the topic of sexual relationships during an interview? A) "Now it is time to talk about your sexual history. When did you first have intercourse?" B) "Women often feel dissatisfied with their sexual relationships. Would it be okay to discuss this now?" C) "Often women have questions about their sexual relationship and how it affects their health. Do you have any questions?" D) "Most women your age have had more than one sexual partner. How many would you say you have had?"

ANS: C 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 history, because doing so communicates that the nurse accepts the individual's sexual activity and believes it is important. The nurse's comfort with discussion prompts the patient's interest and possibly relief that the topic has been introduced. This establishes a database for comparison with any future sexual activities and provides an opportunity to screen sexual problems.

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) "This will need to be done annually until you are 65." C) "If you have 2 consecutive normal Pap tests, then you can wait 5 years between tests." D) "After age 30, if you have 3 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. After age 30, if the woman has 3 consecutive normal Pap tests, then women may be screened every 2 to 3 years.

During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's most appropriate response to this would be: a."Don't worry about the pain; breast cancer is not painful." b."I would like some more information about the pain in your left breast." c."Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct." d."Breast pain is almost always the result of benign breast disease."

B Breast pain occurs with trauma, inflammation, infection, or benign breast disease. The nurse will need to gather more information about the patient's pain rather than make statements that ignore the patient's concerns.

The ability that humans have to perform very skilled movements such as writing is controlled by the: a.Basal ganglia. b.Corticospinal tract. c.Spinothalamic tract. d.Extrapyramidal tract.

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 related to skilled movements.

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. The nurse interprets this result as: a.Negative Babinski sign, which is normal for adults. b.Positive Babinski sign, which is abnormal for adults. c.Clonus, which is a hyperactive response. d.Achilles reflex, which is an expected response.

B 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.

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

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. This description is consistent with which of these? a.Varicocele b.Epididymitis c.Spermatocele d.Testicular torsion

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.

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."If you notice an enlarged testicle or a painless lump, call your health care provider." c."The testicle is egg shaped and movable. It feels firm and has a lumpy consistency." d."Perform a testicular examination at least once a week to detect the early stages of testicular cancer."

B 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.

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 right eye b.Increased intracranial pressure c.Test inaccurately performed d.Normal response after a head injury

B 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 knows that testing kinesthesia is a test of a person's: a.Fine touch. b.Position sense. c.Motor coordination. d.Perception of vibration.

B Kinesthesia, or position sense, is the person's ability to perceive passive movements of the extremities. The other options are incorrect.

During an assessment of a patient who has been homeless for several years, the nurse notices that his tongue is magenta in color, which is an indication of a deficiency in what mineral and/or vitamin? a.Iron b.Riboflavin c.Vitamin D and calcium d.Vitamin C

B Magenta tongue is a sign of riboflavin deficiency. In contrast, a pale tongue is probably attributable to iron deficiency. Vitamin D and calcium deficiencies cause osteomalacia in adults, and a vitamin C deficiency causes scorbutic gums.

While inspecting a patient's breasts, the nurse finds that the left breast is slightly larger than the right with the bilateral presence of Montgomery glands. The nurse should: a.Palpate over the Montgomery glands, checking for drainage. b.Consider these findings as normal, and proceed with the examination. c.Ask extensive health history questions regarding the woman's breast asymmetry. d.Continue with the examination, and then refer the patient for further evaluation of the Montgomery glands.

B Normal findings of the breast include one breast (most often the left) slightly larger than the other and the presence of Montgomery glands across the areola.

The nurse is reviewing the nutritional assessment of an 82-year-old patient. Which of these factors will most likely affect the nutritional status of an older adult? a.Increase in taste and smell b.Living alone on a fixed income c.Change in cardiovascular status d.Increase in gastrointestinal motility and absorption

B Socioeconomic conditions frequently affect the nutritional status of the aging adult; these factors should be closely evaluated. Physical limitations, income, and social isolation are frequent problems that interfere with the acquisition of a balanced diet. A decrease in taste and smell and decreased gastrointestinal motility and absorption occur with aging. Cardiovascular status is not a factor that affects an older adult's nutritional status.

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.Astereognosis c.Graphesthesia d.Tactile discrimination

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. Tactile discrimination tests fine touch. Extinction tests the person's ability to feel sensations on both sides of the body at the same point.

The external male genital structures include the: a.Testis. b.Scrotum. c.Epididymis. d.Vas deferens.

B The external male genital structures include the penis and scrotum. The testis, epididymis, and vas deferens are internal structures.

Which statement concerning the sphincters is correct? a.The internal sphincter is under voluntary control. b.The external sphincter is under voluntary control. c.Both sphincters remain slightly relaxed at all times. d.The internal sphincter surrounds the external sphincter.

B The external sphincter surrounds the internal sphincter but also has a small section overriding the tip of the internal sphincter at the opening. The external sphincter is under voluntary control. Except for the passing of feces and gas, the sphincters keep the anal canal tightly closed.

During an assessment of the 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. This would indicate dysfunction of which of these CNs? 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

B The findings listed reflect a dysfunction of the motor component of the facial nerve (CN VII).

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.

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.

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

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.

Which characteristic of the prostate gland would the nurse recognize as an abnormal finding while palpating the prostate gland through the rectum? a.Palpable central groove b.Tenderness to palpation c.Heart shaped d.Elastic and rubbery consistency

B The normal prostate gland should feel smooth, elastic, and rubbery; slightly movable; heart-shaped with a palpable central groove; and not be tender to palpation.

In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason for this is that the upper outer quadrant is: a.The largest quadrant of the breast. b.The location of most breast tumors. c.Where most of the suspensory ligaments attach. d.More prone to injury and calcifications than other locations in the breast.

B The upper outer quadrant is the site of most breast tumors. In the upper outer quadrant, the nurse should notice the axillary tail of Spence, the cone-shaped breast tissue that projects up into the axilla, close to the pectoral group of axillary lymph nodes.

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.Hypotonic muscles as a result of total relaxation d.Slight pain with some directions of movement

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.

A patient tells the nurse that his food simply does not have any taste anymore. The nurse's best response would be: a."That must be really frustrating." b."When did you first notice this change?" c."My food doesn't always have a lot of taste either." d."Sometimes that happens, but your taste will come back."

B With changes in appetite, taste, smell, or chewing or swallowing, the examiner should ask about the type of change and when the change occurred. These problems interfere with adequate nutrient intake. The other responses are not correct.

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.

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.

During a genital examination, the nurse notices that a male patient has clusters of small vesicles on the glans, surrounded by erythema. The nurse recognizes that these lesions are: a.Peyronie disease. b.Genital warts. c.Genital herpes. d.Syphilitic cancer.

C Genital herpes, or herpes simplex virus 2 (HSV-2), infections are indicated with clusters of small vesicles with surrounding erythema, which are often painful and erupt on the glans or foreskin.

An accessory glandular structure for the male genital organs is the: a.Testis. b.Scrotum. c.Prostate. d.Vas deferens.

C Glandular structures accessory to the male genital organs are the prostate, seminal vesicles, and bulbourethral glands.

The nurse has palpated a lump in a female patient's right breast. The nurse documents this as a small, round, firm, distinct, lump located at 2 o'clock, 2 cm from the nipple. It is nontender and fixed. No associated retraction of the skin or nipple, no erythema, and no axillary lymphadenopathy are observed. What information is missing from the documentation? a.Shape of the lump b.Consistency of the lump c.Size of the lump d.Whether the lump is solitary or multiple

C If the nurse feels a lump or mass, then he or she should note these characteristics: (1) location, (2) size—judge in centimeters in three dimensions: width × length × thickness, (3) shape, (4) consistency, (5) motility, (6) distinctness, (7) nipple, (8) the skin over the lump, (9) tenderness, and (10) lymphadenopathy.

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

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.

A patient contacts the office and tells the nurse that she is worried about her 10-year-old daughter having breast cancer. She describes a unilateral enlargement of the right breast with associated tenderness. She is worried because the left breast is not enlarged. What would be the nurse's best response? Tell the mother that: a.Breast development is usually fairly symmetric and that the daughter should be examined right away. b.She should bring in her daughter right away because breast cancer is fairly common in preadolescent girls. c.Although an examination of her daughter would rule out a problem, her breast development is most likely normal. d.It is unusual for breasts that are first developing to feel tender because they haven't developed much fibrous tissue.

C Occasionally, one breast may grow faster than the other, producing a temporary asymmetry, which may cause some distress; reassurance is necessary. Tenderness is also common.

A 54-year-old man comes to the clinic with a "horrible problem." He tells the nurse that he has just discovered a lump on his breast and is fearful of cancer. The nurse knows which statement about breast cancer in men is true? a.Breast masses in men are difficult to detect because of minimal breast tissue. b.Breast cancer in men rarely spreads to the lymph nodes. c.One percent of all breast cancers occurs in men. d.Most breast masses in men are diagnosed as gynecomastia.

C One percent of all breast cancers occurs in men. The early spreading to axillary lymph nodes is attributable to minimal breast tissue.

The nurse notices that a patient has had a pale, yellow, greasy stool, or steatorrhea, and recalls that this is caused by: a.Occult bleeding. b.Absent bile pigment. c.Increased fat content. d.Ingestion of bismuth preparations.

C Steatorrhea (pale, yellow, greasy stool) is caused by increased fat content in the stools, as in malabsorption syndrome. Occult bleeding and ingestion of bismuth products cause a black stool, and absent bile pigment causes a gray-tan stool.

A 45-year-old mother of two children is seen at the clinic for complaints of "losing my urine when I sneeze." The nurse documents that she is experiencing: a.Urinary frequency. b.Enuresis. c.Stress incontinence. d.Urge incontinence.

C Stress incontinence is involuntary urine loss with physical strain, sneezing, or coughing that occurs as a result to weakness of the pelvic floor. Urinary frequency is urinating more times than usual (more than five to six times per day). Enuresis is involuntary passage of urine at night after age 5 to 6 years (bed wetting). Urge incontinence is involuntary urine loss from overactive detrusor muscle in the bladder. It contracts, causing an urgent need to void.

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

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.

During a discussion about BSEs with a 30-year-old woman, which of these statements by the nurse is most appropriate? a."The best time to examine your breasts is during ovulation." b."Examine your breasts every month on the same day of the month." c."Examine your breasts shortly after your menstrual period each month." d."The best time to examine your breasts is immediately before menstruation."

C The best time to conduct a BSE is shortly after the menstrual period when the breasts are the smallest and least congested.

During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding? a.Breasts should always be symmetric. b.Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about. c.Asymmetry is not unusual, but the nurse should verify that this change is not new. d.Asymmetry of breast size and shape is very unusual and means she may have an inflammation or growth.

C The nurse should notice symmetry of size and shape. It is common to have a slight asymmetry in size; often the left breast is slightly larger than the right. A sudden increase in the size of one breast signifies inflammation or new growth.

The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct? a."BSE is more important than ever for you because you have never had any children." b."BSE is so important because one out of nine women will develop breast cancer in her lifetime." c."BSE on a monthly basis will help you become familiar with your own breasts and feel their normal variations." d."BSE will save your life because you are likely to find a cancerous lump between mammograms."

C The nurse should stress that a regular monthly BSE will familiarize the woman with her own breasts and their normal variations. BSE is a positive step that will reassure her of her healthy state. While teaching, the nurse should focus on the positive aspects of BSE and avoid citing frightening mortality statistics about breast cancer, which may generate excessive fear and denial that can obstruct a woman's self-care actions.

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

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.

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. The nurse should: a.Tell him not to worry and that most men his age develop hernias. b.Explain that a hernia is often the result of prenatal growth abnormalities. c.Refer him to his physician for additional consultation because the physician made the initial diagnosis. d.Explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.

D A hernia is a loop of bowel protruding through a weak spot in the musculature. The other options are not correct responses to the patient's question.

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.

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 related to the peripheral nervous system.

A 15-year-old boy is seen in the clinic for complaints of "dull pain and pulling" in the scrotal area. On examination, the nurse palpates a soft, irregular mass posterior to and above the testis on the left. This mass collapses when the patient is supine and refills when he is upright. This description is consistent with: a.Epididymitis. b.Spermatocele. c.Testicular torsion. d.Varicocele.

D A varicocele consists of dilated, tortuous varicose veins in the spermatic cord caused by incompetent valves within the vein. Symptoms include dull pain or a constant pulling or dragging feeling, or the individual may be asymptomatic. When palpating the mass, the examiner will feel a soft, irregular mass posterior to and above the testis that collapses when the individual is supine and refills when the individual is upright.

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. The nurse would document this finding as: a.Ataxia. b.Lack of coordination. c.Negative Homans sign. d.Positive Romberg sign.

D 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. Homans sign is used to test the legs for deep-vein thrombosis.

A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting, she gets "really dizzy" and feels like she is going to fall over. The nurse's best response would be: 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."

D 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.

During a health history, a patient tells the nurse that he has trouble in starting his urine stream. This problem is known as: a.Urgency. b.Dribbling. c.Frequency. d.Hesitancy.

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.

When assessing a patient's nutritional status, the nurse recalls that the best definition of optimal nutritional status is sufficient nutrients that: a.Are in excess of daily body requirements. b.Provide for the minimum body needs. c.Provide for daily body requirements but do not support increased metabolic demands. d.Provide for daily body requirements and support increased metabolic demands.

D Optimal nutritional status is achieved when sufficient nutrients are consumed to support day-to-day body needs and any increased metabolic demands resulting from growth, pregnancy, or illness.

For the first time, the nurse is seeing a patient who has no history of nutrition-related problems. The initial nutritional screening should include which activity? a.Calorie count of nutrients b.Anthropometric measures c.Complete physical examination d.Measurement of weight and weight history

D Parameters used for nutrition screening typically include weight and weight history, conditions associated with increased nutritional risk, diet information, and routine laboratory data. The other responses reflect a more in-depth assessment rather than a screening.

The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place them at a higher risk for breast cancer? a.37 year old who is slightly overweight b.42 year old who has had ovarian cancer c.45 year old who has never been pregnant d.65 year old whose mother had breast cancer

D Risk factors for breast cancer include having a first-degree relative with breast cancer (mother, sister, or daughter) and being older than 50 years of age. (Refer to Table 17- 2 for other risk factors.)

Which statement concerning the anal canal is true? The anal canal: a.Is approximately 2 cm long in the adult. b.Slants backward toward the sacrum. c.Contains hair and sebaceous glands. d.Is the outlet for the gastrointestinal tract.

D The anal canal is the outlet for the gastrointestinal tract and is approximately 3.8 cm long in the adult. It is lined with a modified skin that does not contain hair or sebaceous glands, and it slants forward toward the umbilicus.

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

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.

When the nurse is conducting 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."

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 should be avoided.

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. These lesions are characteristic of: a.Carcinoma. b.Syphilitic chancres. c.Genital herpes. d.Genital warts

D 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. (See Table 24-4 for more information and for the descriptions of the other options.)

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.Screening neurologic examination d.Complete neurologic examination

D 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.

A 60-year-old man has just been told that he has benign prostatic hypertrophy (BPH). He has a friend who just died from cancer of the prostate. He is concerned this will happen to him. How should the nurse respond? a."The swelling in your prostate is only temporary and will go away." b."We will treat you with chemotherapy so we can control the cancer." c."It would be very unusual for a man your age to have cancer of the prostate." d."The enlargement of your prostate is caused by hormonal changes, and not cancer."

D The prostate gland commonly starts to enlarge during the middle adult years. BPH is present in 1 in 10 men at the age of 40 years and increases with age. It is believed that the hypertrophy is caused by hormonal imbalance that leads to the proliferation of benign adenomas. The other responses are not appropriate.

Which statement concerning the testes is true? a.The lymphatic vessels of the testes drain into the abdominal lymph nodes. b.The vas deferens is located along the inferior portion of each testis. 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.

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, the patient has an erection. The nurse's most appropriate action or response is to: 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.

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.

A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for complaints of burning and pain during urination. He is experiencing: a.Dysuria. b.Nocturia. c.Polyuria. d.Hematuria.

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.

During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding? a.Breasts should always be symmetric. b.Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about. c.Asymmetry is not unusual, but the nurse should verify that this change is not new. d.Asymmetry of breast size and shape is very unusual and means she may have an inflammation or growth.

The nurse should notice symmetry of size and shape. It is common to have a slight asymmetry in size; often the left breast is slightly larger than the right. A sudden increase in the size of one breast signifies inflammation or new growth.