Health Assessment Exam 3 Questions
The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction? 1. It is the most efficient pathway for hearing. 2. It is caused by the vibrations of bones in the skull. 3. The amplitude of sound determines the pitch that is heard. 4. A loss of air conduction is called a conductive hearing loss.
Air conduction is the normal pathway for hearing. Conductive hearing loss results from a mechanical dysfunction of the external or middle ear. The frequency of sound waves is what determines pitch, not the amplitude. Vibrations of the bones in the skull are bone conduction. Conductive hearing loss is caused by impacted cerumen, foreign bodies, a perforated tympanic membrane, pus or serum in the middle ear, and otosclerosis, not loss of air conduction.
When examining the nares of a 45-year-old patient who is experiencing rhinorrhea, itching of the nose and eyes, and sneezing, the nurse notices the following: pale turbinates, swelling of the turbinates, and clear rhinorrhea. Which of these conditions is most likely the cause? a. Nasal polyps b. Acute rhinitis c. Acute sinusitis d. Allergic rhinitis
Allergic rhinitis
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. Fixed mobility b. Boggy with a soft consistency c. 1 cm protrusion into the rectum d. Flat shape with no palpable groove e. Heart-shaped with a palpable central groove f. Smooth surface, elastic, and rubbery consisteny
C E F
While discussing the history of a 6-month-old infant, the mother tells the nurse that she took a significant amount of aspirin while she was pregnant. What question would the nurse want to include in the history? 1. "Does your baby seem to startle with loud noise?" 2. "Has the baby had any surgeries on the ears?" 3. "Have you noticed any drainage from her ears?" 4. "How many ear infections has your baby had since birth?"
"Does your baby seem to startle with loud noises?" rationale: Children exposed in utero to a variety of conditions, such as maternal rubella or to maternal ototoxic drugs are at risk for hearing deficits. Aspirin can be ototoxic, so the nurse should ask if the baby seems to startle with loud noises.
The nurse is examining a patient's retina with an ophthalmoscope. Which finding is considered normal? a. Optic disc that is yellow-orange color b. Optic disc margin blurred around edges c. pigmented crescents in macular area d. macula located on nasal side of retina
Optic disc that is a yellow-orange color rationale: The optic disc is located on the nasal side of the retina. Its color is a creamy yellow-orange to a pink, and the margins are distinct and sharply demarcated, not blurred. A pigmented crescent is black and is due to the accumulation of pigment in the choroid. Presence of pigmented crescents in the macular area is an abnormal finding. macula is located on the temporal side of the fundus of the eye, not on the nasal side of the retina.
The nurse is obtaining a health history on a 3-month-old infant. During the interview, the mother states, "I think she is getting her first tooth because she has started drooling a lot." What is the best response by the nurse? a. "You're right, drooling is usually a sign of the first tooth." b. "It would be unusual for a 3-month-old to be getting her first tooth." c. "This could be the sign of a problem with the salivary glands." d. "She is just starting to salivate and hasn't learned to swallow the saliva."
"She is just starting to salivate and hasn't learned to swallow the saliva." rationale: salivation starts at 3 months.
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 and 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) "The enlargement of your prostate is caused by hormone changes and not cancer."
"The enlargement of your prostate is caused by hormonal changes, and not cancer." Rationale: present in men over 60, hormonal component required, urinary problems
During the assessment of an 18-month-old infant, the mother expresses concern to the nurse about the infant's inability to toilet train. What would be the best response by the nurse? A) "Some children are just more difficult to train, so I wouldn't worry about it yet." B) "Have you considered reading any of the books on toilet training? They can be very helpful." C) "This could mean there is a problem in your baby's development. We'll watch her closely for the next few months." D) "The nerves that will allow your baby to have control over the passing of stools are not developed until at least 18 to 24 months of age."
"The nerves that allow your baby to have control over the passing of stools are not developed until at least 18 to 24 months of age rationale: The infant passes stools by reflex. Voluntary control of the external anal sphincter cannot occur until the nerves supplying the area have become fully myelinated, usually around 1 to 2 years of age. Toilet training usually starts after the age of 2 years.
A mother is concerned because her 18-month-old toddler has 12 teeth. She is wondering if this is normal for a child of this age. Which is the best response by the nurse? a. "How many teeth did you have at this age?" b. "This is a normal number of teeth for an 18 month old." c. "Normally, by age 2 1/2 years, 16 deciduous teeth are expected." d. "All 20 deciduous teeth are expected to erupt by age 4 years."
"This is a normal number of teeth for an 18 month old." teeth erupt 5-27 months The guidelines for the number of teeth for children younger than 2 years old are as follows: the child's age in months minus the number 6 should be equal to the expected number of deciduous teeth. Normally all 20 teeth are in by 2 years old. In this instance, the child is 18 months old, minus 6, equals 12 deciduous teeth expected
- In trying to find the cause of the rash on breast, which question would be important for the nurse to ask? - clear discharge ?
"Where did the rash first appear—on the nipple, the areola, or the surrounding skin?" Ask the patient some additional questions about the medications she is taking.
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 to decrease the inflammation and maintain mobility in the knee."
"Your disease is due to repeated stress on the patellar tendon. It is usually self-limited, and your symptoms should resolve with rest." rationale: 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 boy
What women are at higher risk of getting breast cancer?
- AA more than whites - Asian and Pacific Islander women have highest survival rates, non-Hispanic black women have lowest survival rates - Women who inherit a mutation in BRCA1 or 2 genes - Ashkenazi Jewish women have higher prevalence
During an oral examination of a 4-year-old American-Indian child, the nurse notices that her uvula is partially split. Which of these statements is accurate? a. A bifid uvula may occur in some American-Indian groups. b. This condition is a cleft palate and is common in American Indians. c. A bifid uvula is torus palatinus, which frequently occurs in American Indians.
A bifid uvula may occur in some American-Indian group
During an examination of a patient in her third trimester of pregnancy, the nurse notices that the patient's thyroid gland is slightly enlarged. What does the nurse suspect?
A normal enlargement of the thyroid gland during pregnancy rationale: The thyroid gland enlarges slightly during pregnancy because of hyperplasia of the tissue and increased vascularity.
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. Regular border c. Hard, dense, and immobile d. Rubbery texture and mobile e. Dull, heavy pain on palpation f. Irregular, poorly delineated border
A. nontender mass C. hard, dense, and immobile F. irregular, poorly delineated border 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 assessing a patient with a history of intravenous drug abuse. In assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of what disease or disorder? a. Measles b. Leukemia c. A carcinoma d. Acquired immunodeficiency syndrome (AIDS)
Acquired immunodeficiency syndrome (AIDS)
A 65-year-old patient remarks that she just cannot believe that her breasts "sag so much." She states it must be from a lack of exercise. What explanation should the nurse offer her? a. After menopause, sagging is usually due to decreased muscle mass within the breast. b. After menopause, a diet that is high in protein will help maintain muscle mass, which keeps the breasts from sagging. c. After menopause, the glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag.
After menopause, the glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag. Rationale : Breast tissue atrophies as a result of estrogen and progesterone declining in menopause. Breast size and elasticity decline more noticeable in kyphosis.
The nurse is reviewing causes of increased intraocular pressure. Which of these factors determines intraocular pressure? a. Thickness or bulging of lens b.Posterior chamber as it accommodates increased fluid. c. Contraction of ciliary body in response to aqueous within eye d. Amount of aqueous produced and resistance to outflow at angle of anterior chamber
Amount of aqueous produced and resistance to its outflow at the angle of the anterior chamber (papilledema) rationale: Intraocular pressure is determined by a balance between the amount of aqueous produced and the resistance to its outflow at the angle of the anterior chamber.
The nurse notices that a patient's submental lymph nodes are enlarged. In an effort to identify the cause of the node enlargement, what should the nurse assess?
Area proximal to the enlarged node
The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. What should the nurse do next? a. Check for presence of exophthalmos. b. Suspect patient has hyperthyroidism. c. Ask patient if they have a hx of heart failure. d. Assess for blepharitis, associated with periorbital edema
Ask the patient if he or she has a history of heart failure. Periorbital edema occurs with local infections, crying, and systemic conditions such as heart failure, renal failure, allergy, and hypothyroidism. Periorbital edema is not associated with blepharitis. Exophthalmos is associated with hyperthyroidism or thyrotoxicosis and hyperthyroidism is not associated with periorbital edema
A patient has been identified as having a sensorineural hearing loss. What would be important for the nurse to do during the assessment of this patient? 1. speak loudly so he can hear the questions. 2. assess for middle ear infection as a possible cause. 3. ask the patient what medications he is currently taking..
Ask the patient what medications he is currently taking Sensorineural hearing loss may be caused by presbycusis, which is a gradual nerve degeneration that occurs with aging and by ototoxic drugs, which affect the hair cells in the cochlea. .
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, fixed prostate gland B) Occult blood and perianal pain to palpation C) Symmetrically enlarged, soft prostate gland D) A soft nodule protruding from rectal mucosa
Asymmetric, hard, and fixed prostate gland
The nurse is using an otoscope to assess the nasal cavity. Which of these techniques is correct? a. Avoiding touching the nasal septum with the speculum b. Inserting the speculum at least 3 cm into the vestibule c. Gently displacing the nose to the side that is being examined d. Keeping the speculum tip medial to avoid touching the floor of the nares
Avoiding touching the nasal septum with the speculum
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." What should the nurse include in his or her response to this patient?
BSEs may detect lumps that appear between mammograms.
During a group discussion on men's health, what group should the nurse inform them has the highest incidence of prostate cancer? A) Asian Americans. B) African-Americans. C) American Indians. D) Hispanics.
Black people Rationale: more at risk - age, AA, family history, and inherited mutation of BRCA1 and BRCA2 genes. Diets heavy in red meat or high-fat dairy products. Exam- firm nodule(s), induration, gland asymmetry
The nurse is assessing a 16-year-old patient who has suffered head injuries from a recent MVA. Which of these statements indicates the most important reason for assessing for any drainage from the ear canal 1. Bloody or clear watery drainage can indicate a basal skull fracture. 3. The auditory canal many be occluded from increased cerumen. 4. There may be occlusion of the canal caused by foreign bodies from the accident.
Bloody or clear watery drainage can indicate a basal skull fracture rationale: Frank blood or clear watery drainage (cerebrospinal fluid) after a trauma suggests a basal skull fracture and warrants immediate referral. Purulent drainage indicates otitis externa or otitis media. An ear canal occluded from cerumen would not be draining, and it is not likely a foreign body from an accident would cause occlusion of the ear canal.
When reviewing the musculoskeletal system, the nurse should recall that hematopoiesis takes place where?
Bone marrow
patient's vertebra prominens is tender, What area of the body will the nurse assess?
C7 vertebra has a long spinous process, called the vertebra prominens, which is palpable when the head is flexed.
What 2 CN are usually evaluated together and uses a tongue blade and informs pt to say AHH, and assesses gag reflex?
CN IX (glossopharyngeal) and CN X (vagus) uvula is lifted away from paretic side, absence of gag reflex is common in healthy people. vagus nerve also a parasympathetic nerve
If infant primitive reflexes persist, what does that indicate? As myelinization develops, what is more accurate?
CNS dysfunction sensory and motor skills
The nurse notices that an infant has a large, soft lump on the side of his head and that his mother is very concerned. The mother tells the nurse that she noticed the lump approximately 8 hours after her baby's birth and that it seems to be getting bigger. What is a possible explanation for this? a. Hydrocephalus. b. Craniosynostosis. c. Cephalhematoma. d. Caput succedaneum.
Cephalhematoma rationale: A cephalhematoma is a subperiosteal hemorrhage that is the result of birth trauma. It appears several hours after birth and gradually increases in size. Hydrocephalus is enlarged head due to increased csf, percussion yields crack pot. Craniosynostosis is a severe deformity of the head with marked asymmetry caused by premature closure of the sutures. Caput succedaneum is edematous swelling and ecchymosis of the presenting part of the head caused by birth trauma that usually causes the skull to look markedly asymmetric.
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
Chorea rationale: 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)
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.
Compress the glans between the examiner's thumb and forefinger, and collect any discharge
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.
Consider this finding as normal, and proceed with the examination.
abnormal posture that happens if theres a lesion on cerebral cortex. Upper extremities flexed, arm adducted. Lower extremities plantar flexed, internal rotation, and extension. "hugs"
Decorticate rigidity
The nurse is palpating the sinus areas. If the findings are normal, then the patient should report which sensation? a. No sensation b. Firm pressure c. Pain during palpation d. Pain sensation behind eyes
Firm pressure rationale: The person should feel firm pressure but no pain. Sinus areas are tender to palpation in persons with chronic allergies or an acute infection (sinusitis). A normal finding when palpating the sinus areas is for the patient to feel firm pressure, not no sensation at all, pain during palpation, or pain behind the eyes.
What equipment do you need for a physical exam for a male?
Gloves, glass slide for urethral specimen, Materials for cytology, Flashlight, use FIRM touches
A 72-year-old patient has a history of hypertension and chronic lung disease. Which is an important question for the nurse to include in this patient's health history? a. "Do you use a fluoride supplement?" b. "Have you had tonsillitis in the last year?" c. "At what age did you get your first tooth?" d. "Have you noticed any dryness in your mouth?"
Have you noticed any dryness in your mouth? With a history of hypertension and chronic lung disease, this patient is likely on medications and a side effect of antihypertensive and bronchodilator medication (and many other drugs such as antidepressants, anticholinergics, antispasmodics, and antipsychotics) is dry mouth
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."
If you notice an enlarged testicle or a painless lump, call your health care provider." rationale: 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 T - timing, once a month S - shower, warm water relaxes scrotal sac E - examine and report changes immediately
A woman who is in the second trimester of pregnancy mentions that she has had "more nosebleeds than ever" since she became pregnant. What is the likely reason for this? a. Inappropriate use of nasal sprays b. A problem with the patient's coagulation system c. Increased susceptibility to colds and nasal irritation d. Increased vascularity in the upper respiratory tract as a result of the pregnancy
Increased vascularity in the upper respiratory tract as a result of the pregnancy rationale: Nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract. Inappropriate use of nasal sprays often causes rebound congestion or swelling, but not usually nosebleeds.
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 b. Direct inguinal c. Indirect inguinal
Indirect inguinal hernia rationale: A femoral hernia usually presents with pain that is constant and may be severe and become strangulated. A direct hernia is usually painless
A patient with a middle ear infection asks the nurse, "What does the middle ear do?" Which is the best response by the nurse? 1. maintain balance. 2. interpret sounds as they enter the ear. 3. conduct vibrations of sounds to the inner ear. 4. increase amplitude of sound for the inner ear to function.
It conducts vibrations of sounds to the inner ear rationale: Among its other functions, the middle ear conducts sound vibrations from the outer ear to the central hearing apparatus in the inner ear. The inner ear, not the middle ear, helps with balance. Sound is interpreted in the cerebral cortex. The middle ear reduces the amplitude of loud sounds, not increase them, to protect the inner ear.
The nurse is performing an oral assessment on a 40-year-old black patient and notices the presence of a 1-cm, nontender, grayish-white lesion on the left buccal mucosa. Which one of these statements is true about this lesion?
It is leukoedema which is common in dark-pigmented people.
What are the benefits of circumcision ?
Lowers risk for HPV, herpes simplex virus, HIV, genital ulcer disease in men and decreased risk for bacterial vaginosis and trichomoniasis in females
A new mother calls the clinic to report that part of her left breast is red, swollen, tender, very hot, and hard. She has a fever of 38.3° C. She also has had symptoms of influenza, such as chills, sweating, and feeling tired. The nurse notices that she has been breastfeeding for 1 month. From her description, what condition does the nurse suspect? a. Mastitis b. Paget's disease c. Plugged milk duct d. Mammary duct ectasia
Mastitis mastitis, stems from an infection or stasis caused by a plugged duct. Plugged milk ducts are red and tender but can lead to Mastitis which is the symptoms the patient possess.
The nurse is reviewing the development of the newborn infant. Regarding the sinuses, which statement is true in relation to a newborn infant? a. Sphenoid sinuses are full size at birth. b. Maxillary sinuses reach full size after puberty. c. Frontal sinuses are fairly well developed at birth. d. Maxillary and ethmoid sinuses are the only sinuses present at birth.
Maxillary and ethmoid sinuses are the only sinuses present at birth. rationale: The sphenoid sinuses are minute at birth and develop after puberty. The frontal sinuses are absent at birth, are fairly well developed at age 7 to 8 years, and reach full size after puberty. Only the maxillary and ethmoid sinuses are present at birth but the maxillary sinus does not reach full size until all permanent teeth have erupted (not after puberty).
A patient, an 85-year-old woman, is complaining about the fact that the bones in her face have become more noticeable. What explanation should the nurse give her? a. Diets low in protein and high in carbohydrates may cause enhanced facial bones. b.. More noticeable facial bones are probably due to a combination of factors related to aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin
More noticeable facial bones are probably due to a combination of factors r/t aging, such as decreased elasticity, subcutaneous fat, and moisture in her skin
When performing an otoscopic examination of a 5-year-old child with a history of chronic ear infections, the nurse sees that his right tympanic membrane is amber-yellow in color and that air bubbles are visible behind the tympanic membrane. The child reports occasional hearing loss and a popping sound with swallowing. Based on this data, what does the nurse conclude? 1. this is most likely a serous otitis media. 2. the child has an acute purulent otitis media. 3. there is evidence of a resolving cholesteatoma. 4. the child is experiencing the early stages of perforation.
Most likely a serous otitis media ratioanle: An amber-yellow color to the tympanic membrane suggests serum or pus in the middle ear. Air or fluid or bubbles behind the tympanic membrane are often visible. The patient may have feelings of fullness, transient hearing loss, and a popping sound with swallowing. These findings most likely suggest that the child has serous otitis media. The manifestation of otitis media is a sticky, yellow discharge (not an amber-yellow tympanic membrane). Cholesteatoma is an overgrowth of epidermal tissue in the middle ear or temporal bone that has a pearly white, cheesy appearance. A perforation typically begins with ear pain and stops with a popping sensation and then drainage occurs.
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. 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
Myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated. rationale: 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 1-month-old infant at his well-baby checkup. Which assessment findings are appropriate for this age? (Select all that apply.) a. Head circumference equal to chest circumference b. Head circumference greater than chest circumference c. Head circumference less than chest circumference d. Fontanels firm and slightly concave e. Absent tonic neck reflex f. Nonpalpable cervical lymph nodes
Nonpalpable cervical lymph nodes, Fontanels firm and slightly concave, Head circumference greater than chest circumference rationale: An infant's head circumference is larger than the chest circumference. At age 2 years, both measurements are the same. During childhood, the chest circumference grows to exceed the head circumference. The tonic neck reflex is present until between 3 and 4 months of age, and cervical lymph nodes are normally non-palpable in an infant.
A patient who is visiting the clinic reports having "stomach pains for 2 weeks" and describes his stools as being "soft and black" for approximately the last 10 days. He denies taking any medications. What do these symptoms suggest? A) excessive fat caused by malabsorption. B) increased iron intake resulting from a change in diet. C) occult blood resulting from gastrointestinal bleeding. D) absent bile pigment from liver problems.
Occult blood, resulting from gastrointestinal bleeding Black stools may be tarry as a result of occult blood (melena) from gastrointestinal bleeding or nontarry from ingestion of iron medications (not diet). Excessive fat causes the stool to become frothy. The absence of bile pigment causes clay-colored stools.
burning/tingling pain
Parathesia
When examining the face of a patient, what are the two pairs of salivary glands that are accessible for examination?
Parotid; submandibular rationale: parotid glands, in the cheeks over the mandible, anterior to and below the ear; submandibular glands, which are beneath the mandible at the angle of the jaw. The parotid glands are normally nonpalpable.
skin over her right breast is thickened and the hair follicles are exaggerated. What is this condition called?
Peau d'orange rationale: In peau d'orange, lymphatic obstruction produces edema, which thickens the skin and exaggerates the hair follicles. The skin has a pig-skin or orange-peel appearance. This condition suggests cancer.
What is the nurse assessing for when she directs a light across the iris of a patient's eye from the temporal side? a. Drainage from dacryocystitis. b. Presence of conjunctivitis over iris. c. Presence of shadows, indicates glaucoma. d. Scattered light reflex, indicates cataracts
Presence of shadows, which may indicate glaucoma rationale: The presence of shadows in the anterior chamber may be a sign of acute angle-closure glaucoma. The normal iris is flat and creates no shadows.
Who is more at risk for kidney disease?
Prevalence of diabetes and hypertension is higher in AA, American Indians and Hispanics. Contributing factors: low socioeconomic status, presence of comorbidities, and limited access to care
During an oral assessment of a 30-year-old black patient, the nurse notices bluish lips and a dark line along the gingival margin. What action would the nurse perform in response to this finding? a. Check the patient's Hb for anemia. b. Assess for other signs of insufficient oxygen supply. c. Proceed with the assessment, this appearance is a normal finding. d. Ask if he has been exposed to an excessive amount of carbon monoxide.
Proceed with the assessment, this appearance is a normal finding
The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which one of these reflects the correct procedure?
Pulling the pinna down raationale: For an otoscopic examination on an infant or a child under 3 years of age, the pinna is pulled down, and is pulled up for adults. The child's head should be tilted slightly away from the examiner towards the opposite shoulder, not towards the examiner or to their chin.
The nurse is testing a patient's visual accommodation. How is accommodation assessed?
Pupillary constriction when looking at a near object rationale: The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction. The accommodation reaction includes pupillary constriction and convergence of the axes of the eyes.
The nurse is performing a middle ear assessment on a 15-year-old patient who has had a history of chronic ear infections. When examining the right tympanic membrane, the nurse sees the presence of dense white patches. The tympanic membrane is otherwise unremarkable. It is pearly, with the light reflex at 5 o'clock and landmarks visible. What should the nurse do? 1. refer the patient for the possibility of a fungal infection. 2. know that these are scars caused from frequent ear infections. 3. consider that these findings may represent the presence of blood in the middle ear. 4. be concerned about the ability to hear because of this abnormality on the tympanic membrane.
Recognize that these are scars caused from frequent ear infections. rationale: Dense white patches on the TM are sequelae of repeated ear infections. They do not necessarily affect hearing. A fungal infection manifests as a colony of black or white dots on the eardrum or canal walls (not dense white patch). Blood behind the TM would cause the tympanic membrane to appear blue or dark red.
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?
Refer the infant for further testing.
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.
Reflexes will be normal.
A patient is unable to read even the largest letters on the Snellen chart. The nurse should take which action next?
Shorten the distance between the patient and the chart until the letters are seen, and record that distance. rationale: the nurse should shorten the distance to the chart until the letters are seen, and record that distance (e.g., "10/200"). If vision is poorer than 20/30, then a referral to an ophthalmologist or optometrist is necessary, but the nurse must first assess the visual acuity. The nurse should assess whether the person can count fingers when they are spread in front of the eyes or can distinguish light perception from a penlight only if unable to see the letters on the Snellen chart when the distance is shortened. Applying reading glasses will not help with reading the Snellen chart as that is assessing far vision, not near vision.
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. Side effects of medications. b. Decreased libido with aging. c. Decreased sperm production. d. Decreased pleasure from sexual intercourse.
Side effects of medications Rationale: In the absence of disease, withdrawal from sexual activity may be due to loss of spouse, depression, work. marital or family conflicts. side effects of medication, alcohol use. lack of privacy, living with children or in a nursing home. economic or emotional stress. poor nutrition or fatigue.
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. the shape of the lump. b. the lump's consistency. c. the size of the lump. d. whether the lump is solitary or multiple.
Size of the lump rationale: If the nurse feels a lump or mass, then he or she should note these characteristics: (1) location using clock , (2) shape & size judge in cm (width × length × thickness), (3) consistency and mobility (soft, firm, hard, mixable or fixed), (4) tender, nontender (5) skin changes, dimples, retraction, lymphadenopathy (nodes palpable)
The nurse is examining the glans and knows which finding is normal for this area? a. The meatus may have a slight discharge when the glans is compressed. b. Smegma may be present under the foreskin of an uncircumcised male.
Smegma may be present under the foreskin of an uncircumcised male. rationale: Some cheesy smegma may have collected under the foreskin of an uncircumcised male. Skin normally looks wrinkled, hairless, and no lesions; dorsal vein may be apparent. Glans looks smooth and no lesions. Urethral meatus should be central
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's nodes B) Bouchard's nodules C) Swan neck deformities D) Dupuytren's contractures
Swan-neck deformities rationale: Changes in the fingers caused by 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 hyperplasia
"a spot on my lip I think is cancer," nurse notices a group of clear vesicles with an erythematous base around them located at the lip-skin border. The patient mentions that she just returned from Hawaii. What is the most appropriate action by the nurse? a. Tell the patient she needs to see a skin specialist. b. Discuss the benefits of having a biopsy performed on any unusual lesion. c. Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and that they will heal in 4 to 10 days. d. Tell the patient that these vesicles are most likely the result of a riboflavin deficiency and discuss nutrition.
Tell the patient that these vesicles are indicative of herpes simplex I or cold sores and that they will heal in 4 to 10 days rationale: Cold sores are groups of clear vesicles with a surrounding erythematous base. These evolve into pustules or crusts and heal in 4 to 10 days. The most likely site is the lip-skin junction. Infection often recurs in the same site. Recurrent herpes infections may be precipitated by sunlight, fever, colds, or allergy
A patient has a severed spinal nerve as a result of trauma. Which is true about dermatomes, which are supplied by spinal cords, in this situation?
The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve.
A 14-year-old girl is anxious about not having reached menarche (menstration). When taking the health history, the nurse should ascertain which of the following? a. she began to develop breasts b. she began to develop pubic hair d. she began to develop axillary hair.
The age the girl began to develop breasts According to Tanner's five stages of breast development, full development from stage 2-5 takes an average of 3 years, although the range is 1 to 6 years. Pubic hair develops during this time, and axillary hair appears 2 years after pubic hair along with menarche around stages 3-4. The beginning of breast development comes before menarche. - Tanner stage 1: preadolescent & no pubic hair - Tanner stage 2: Breast buds with areolar enlargement & Pubic hair sparse - Tanner Stage 3: Breast an Ariola and large, the nipple is flush with the breast surface - Tanner stage 4: Areola and nipple projects as secondary mound Pubic hair is more coarse - no triangle yet - Tanner stage 5: Mature breasts. Only the nipple protrudes, the Ariola is flush with the breast contour
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?
The cervical surface is granular and red. 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. Abnormal finding: The cervical surface should not be reddened or granular, which may indicate a lesion.
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) The cervical consistency should be soft and velvety—not firm. C) The cervix should move when palpated; an immobile cervix may indicate malignancy. D) Pain may occur during palpation of the cervix.
The cervix should move when palpated; an immobile cervix may indicate malignancy. Rationale: Bimanual Exam Insert two fingers and press up on cervix, gently moving side to side between fingers (cervical motion tenderness). Palpate abdomen with other hand to determine position of uterus. Palpate to the left and right adnexa for the ovaries May or may not be palpable
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 cylindrical columns of erectile tissue. d. The corpus spongiosum expands into a cone of erectile tissue called the glans.
The corpus spongiosum expands into a cone of erectile tissue called the glans. rationale: 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).
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.
The external sphincter is under voluntary control. The external sphincter not only 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. Internal sphincter is under involuntary control
A visitor from Poland who does not speak English seems to be somewhat apprehensive about the nurse examining his neck. How should the nurse proceed that would allow the patient to feel more comfortable with the nurse examining his thyroid gland?
The front with the nurse's thumbs placed on either side of his trachea and his head tilted forward rationale: Examining this patient's thyroid gland from the back may be unsettling for him. It would be best to examine his thyroid gland using the anterior approach, asking him to tip his head forward and to the right and then to the left.
The nurse is conducting a visual examination. Which of these statements regarding visual pathways and visual fields is true? a. right side of brain interprets vision for right eye. b. The image formed on the retina is upside down and reversed from its actual appearance in the outside world c. Light rays are refracted through transparent media of eye before striking pupil. d. Light impulses are conducted through optic nerve to temporal lobes of brain
The image formed on the retina is upside down and reversed from its actual appearance in the outside world rationale: The light rays are refracted through the transparent media of the eye before striking the retina, and the nerve impulses are conducted through the optic nerve tract to the visual cortex of the occipital lobe of the brain. The left side of the brain interprets vision for the O.D
A patient's vision is recorded as 20/30 when the Snellen eye chart is used. How should the nurse interpret these results?
The patient can read at 20 feet what a person with normal vision can read at 30 feet The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see.
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.
The peripheral nerves carry input to the CNS by afferent fibers (sensory) and away from the CNS by efferent (motor) fibers
The nurse is examining a patient's ears and notices cerumen in the external canal. Which of these statements about cerumen is correct? a. Wet, honey-colored cerumen is a sign of infection. b. The presence of cerumen is indicative of poor hygiene. c. The purpose of cerumen is to protect and lubricate the ear.
The purpose of cerumen is to protect and lubricate the ear. rationale: Wet, honey-brown occurs in Caucasians and African Americans, and a dry, flaky white is found in East Asians and American Indians. Cerumen is supposed to be present-to lubricate, waterproof, and clean the external auditory canal. It also is antibacterial, and traps foreign bodies.
The nurse is caring for a newborn infant. Thirty hours after birth, the infant passes a dark green meconium stool. What is the importance of this finding? A) this stool would indicate anal patency. B) the dark green color could indicate occult blood in the stool. C) meconium stool can be reflective of distress in the newborn. D) the newborn should have passed the first stool within 12 hours after birth.
The stool indicates anal patency. The first stool passed by the newborn is dark green meconium and occurs within 24 to 48 hours of birth, indicating anal patency.
While performing a well-child assessment on a 5 year old, the nurse notes the presence of palpable, bilateral, cervical, and inguinal lymph nodes. They are approximately 0.5 cm in size, round, mobile, and nontender. What do these findings lead the nurse to conclude?
These are normal findings for a well child of this age. rationale: These are not signs of chronic allergies or an infection and do not require additional evaluation. Palpable lymph nodes are normal in children until puberty when the lymphoid tissue begins to atrophy, and in aging adults nonpalpable. Lymph nodes may be up to 1 cm in size in the cervical and inguinal areas but are discrete, movable, and nontender.
A 17-year-old student is a swimmer on her high school's swim team. She has had three bouts of otitis externa this season and wants to know what to do to prevent it. What should the nurse include in the instructions? 1. use a cotton-tipped swab to dry the ear canals thoroughly after each swim. 2. use rubbing alcohol or 2% acetic acid eardrops after every swim. 3. irrigate the ears with warm water and a bulb syringe after each swim. 4. rinse the ears with a warmed solution of mineral oil and hydrogen peroxide.
Use rubbing alcohol or 2% acetic acid eardrops after every swim. Otitis externa (swimmers ear) causes external canal to be waterclogged and swell and can be prevented by using rubbing alcohol or 2% acetic acid eardrops after every swim. The rubbing alcohol and acetic acid mix with the water in the ear and then evaporate. The use of cotton-tip swabs in the ears is not recommended as cotton can be left in the ear and it can also impact cerumen. Irrigating the ears is done to clean the ears, not prevent otitis externa.
During an examination, the nurse knows that the best way to palpate the lymph nodes in the neck is described by which statement?
Using gentle pressure, palpate with both hands to compare the two sides
patient's palpebral fissures are not symmetric. damage to what CN?
VII rationale: Facial muscles; asymmetry of palpebral fissures may be Bell palsy.
During an examination, a patient states that she was diagnosed with open-angle glaucoma 2 years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are characteristics of open-angle glaucoma? (Select all that apply.) a. Patient experience sensitivity to light, nausea, and halos around lights. b. Patient experiences tunnel vision in late stages. c. Immediate treatment needed. d. Vision loss begins with peripheral vision. e. Open-angle glaucoma causes sudden attacks of increased pressure that cause blurred vision. f. Virtually no symptoms exhibited.
Virtually no symptoms are exhibited. Vision loss begins with peripheral vision. Patient experiences tunnel vision in the late stages. rationale: Open-angle glaucoma is the most common type of glaucoma; virtually no symptoms are exhibited. Vision loss begins with the peripheral vision, which often goes unnoticed because individuals learn to compensate intuitively by turning their heads. The other characteristics are those of closed angle glaucoma.
While performing an assessment of the mouth, the nurse notices that the patient has a 1-cm ulceration that is crusted with an elevated border and located on the outer third of the lower lip. What other information would be most important for the nurse to assess? a. Nutritional status b. When the patient first noticed the lesion c. Whether the patient has had a recent cold d. Whether the patient has had any recent exposure to sick animals
When the patient first noticed the lesion rationale: With carcinoma, the initial lesion is round and indurated, but then it becomes crusted and ulcerated with an elevated border.
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 at high risk for ovarian cancer should have annual transvaginal ultrasonography for screening. D) Women over age 40 years should have a thorough pelvic examination every 3 years.
Women at high risk for ovarian cancer should have annual transvaginal ultrasonography for screening.
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 your family know you are drinking every day?" b. "Does the tremor change when you drink alcohol?" 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."
a. "Does the tremor change when you drink alcohol?" rationale: 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.
During an assessment, a patient mentions that "I just can't smell like I used to. I can barely smell the roses in my garden. Why is that?" For which possible causes of changes in the sense of smell will the nurse assess? (Select all that apply.) a. Aging b. Chronic allergies c. Cigarette smoking d. Chronic alcohol use e. Herpes simplex virus I f. Frequent episodes of strep throat
a. Aging b. Chronic allergies c. Cigarette smoking
severe pain of sudden onset in the scrotal area. It is somewhat relieved by elevation. 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. Varicocele b. Epididymitis c. Spermatocele d. Testicular torsion
b. Epididymitis rationale: Epididymitis presents as localized pain (in scrotal area) that is somewhat relieved by elevation (+ Prehn sign). scrotum is enlarged, reddened, and exquisitely tender on palpation. Cremasteric reflex is PRESENT.
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."
c. "I have been noticing that I sweat a lot more than I used to, especially at night."
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 some information about the discharge. What color is it?" D) "Have you had any urinary incontinence associated with the discharge?"
c. "I'd like more information about the discharge. What color is it?"
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.
d. Dislocated shoulder Atrophy - occurs from disuse of muscle Dislocated shoulder-ball out of the socket Joint effusion- swelling from excess fluid from RA Tear of rotator cuff- typically in older adults "hunched position", hold arm above head, if positive arm will drip Frozen shoulder—adhesive capsulitis- stiffness. all of these are shoulder abnormalities.
What is a common assessment finding in a boy younger than 2 years old? a. Inflamed and tender spermatic cord. b. Penis that looks large in relation to the scrotum. c. Presence of a hydrocele, or fluid in the scrotum.
d. Presence of a hydrocele, or fluid in the scrotum
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. Presence of dysdiadochokinesia. d. Loss of kinesthesia.
d. Presence of dysdiadochokinesia 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, or position sense ability to perceive passive movement of the extremities or the loss of position sense.
How do you inspect sacrocoocygeal area?
instruct person to hold breath and bear down by performing Valsalva, as an aging person performs this you can note relaxation of perianal musculature and decreased sphincter.
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) stress incontinence. C) hematuria. D) urge incontinence.
Stress incontinence
In performing a voice test to assess hearing, what actions would the nurse perform?
Whisper a set of random numbers and letters, and then ask the patient to repeat them
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. "Do you need to get up at night to urinate?" aka nocturia Other questions not appropriate for age. Nocturnal emissions is for boys around 12-13
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) Endocervical specimen, KOH preparation, and acetic acid wash D) Cervical scrape, acetic acid wash, saline mount ("wet prep")
a. Endocervical specimen, cervical scrape, and vaginal pool
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.
a. Skin on the scrotum is taut. rationale: 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 temperature
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.
a. Urethral meatus and vaginal orifice
During an internal examination of a woman's genitalia, the nurse will use which technique for proper insertion of the speculum? A) Instruct the woman to bear down, open the speculum blades, and apply in a swift, upward movement. B) Insert the blades of the speculum on a horizontal plane, turning them to a 30-degree angle while continuing to insert them. Ask the woman to bear down after the speculum is inserted. C) 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. D) Lock the blades open by turning the thumbscrew. Once the blades are open, apply pressure to the introitus and insert the blades at a 45-degree angle downward to bring the cervix into view.
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.
What is the primary purpose of the ciliated mucous membrane in the nose? a. To warm the inhaled air b. To filter out dust and bacteria c. To filter coarse particles from inhaled air d. To facilitate the movement of air through the nares
To filter coarse particles from inhaled air The nasal hairs, or cilia, filter the coarsest matter from inhaled air. The rich blood supply of the nasal mucosa warms the inhaled air, not the ciliated mucous membrane. The mucous blanket, not the cilia, filters out dust and bacteria. The cilia in the nose do not facilitate the movement of air through the nares. Instead, the nasal hairs, or cilia, filter the coarsest matter from inhaled air.
A 10-year-old is at the clinic for "a sore throat that has lasted 6 days." Which of these findings would be consistent with an acute infection? a. Tonsils 3+/1-4+ with pale coloring b. Tonsils 3+/1-4+ with large white spots c. Tonsils 2+/1-4+ with small plugs of white debris d. Tonsils 1+/1-4+ and pink; the same color as the oral mucosa
Tonsils 3+/1-4+ with large white spots rationale: With an acute infection, tonsils are bright red and swollen and may have exudate or large white spots. Tonsils are enlarged to 2+, 3+, or 4+ with an acute infection.
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) a callus. B) a plantar wart. C) a bunion. D) tophi.
Tophi 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.
- ex of diseases are CVA, cerebral palsy, and MS - ex are corticospinal, corticobulbar, and extrapyramidal tracts
UMNs
The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal? a. Decrease in tear production b. Unequal pupillary constriction in response to light c. Presence of arcus senilis observed around cornea d. Loss of outer hair on eyebrows attributable to decrease in hair follicles
Unequal pupillary constriction in response to light rationale: Pupils are small in the older adult, and the pupillary light reflex may be slowed, but pupillary constriction should be symmetric. The assessment findings in the other responses are considered normal in older people.
The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the nurse proceed? a. Perform confrontation test b. Ask patient to read print on handheld Jaeger card. c. Use Snellen chart positioned 20 feet away from patient. d. Determine patients ability to read newsprint at a distance of 12 to 14 in.
Use the Snellen chart positioned 20 feet away from the patient The Snellen alphabet chart is the most commonly used and most accurate measure of visual acuity. The confrontation test is a gross measure of peripheral vision. The Jaeger card or newspaper tests are used to test near vision.
Opisthotonos
arching of back, with head and heels bent backward, and meningeal irritation
During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? Select all that apply a. Is a normal occurrence. b. its irregular eye movements c. May indicate disease of the cerebellum or brainstem
b & c. nystagmus is extreme lateral gaze (side to side or rotary). Severe nystagmus occurs with disease of the vestibular system (CN VIII), cerebellum, or brainstem
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."
b. "The first sign of puberty is an enlargement of the testes."
what controls humans' ability to perform very skilled movements such as writing? a. Basal ganglia b. Corticospinal tract c. Spinothalamic tract d. Extrapyramidal tract
b. Corticospinal tract
The nurse is testing superficial reflexes on an adult patient. When making a reverse C across the ball of the foot, the nurse notices the plantar flexion (curling) of the toes. How should the nurse document this finding? a. Positive Babinski sign b. Plantar reflex abnormal c. Plantar reflex present
c. Plantar reflex present rationale: 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 reverse c, toes should curl , normal response is plantar flexion of the toes. A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and flaring of all toes. The plantar reflex is not graded on a 0 to 4+ scale. in an infant flaring toes is normal
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
c. Rheumatoid arthritis Rheumatoid arthritis pain is worse in the morning when a person arises and then improves with movement, involves symmetric joints
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) of a dull ache. B) that the pain in her wrist is deep. C) of sharp pain that increases with movement. D) of dull throbbing pain that increases with rest.
c. Sharp pain that increases with movement A fracture causes sharp pain that increases with movement
The nurse is preparing for an internal genitalia examination of a woman. Which order of the examination is correct? A) Bimanual, speculum, rectovaginal B) Speculum, rectovaginal, bimanual C) Speculum, bimanual, rectovaginal D) Rectovaginal, bimanual, speculum
c. Speculum, bimanual, and rectovaginal
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 that feel oval and movable and are slightly sensitive to compression rationale: 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.
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?
c. This reflex should have disappeared between 1 and 4 months of age. 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 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 was 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.
b. Give her an immediate referral to a gynecologist.
The nurse is preparing to examine the external genitalia of a school-age girl. Which position would be most appropriate in this situation?
b. In a frog-leg position on the examining table
The nurse is examining a 62-year-old man and notes that he has bilateral gynecomastia. The nurse should explore his health history for which related conditions? (Select all that apply.) a. Malnutrition b. Liver disease c. Hyperthyroidism d. Type 2 diabetes mellitus e. History of alcohol abuse f. obesity
b. Liver disease c. Hyperthyroidism e. History of alcohol abuse f. obesity rationale: Gynecomastia occurs with Cushing syndrome, liver cirrhosis, adrenal disease, hyperthyroidism, and numerous drugs, such as alcohol and marijuana use, estrogen treatment for prostate cancer, antibiotics (metronidazole, isoniazid), digoxin, angiotensin-converting enzyme (ACE) inhibitors, diazepam, and tricyclic antidepressants
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. Mild, even resistance to movement
The nurse needs to palpate the temporomandibular joint for crepitation. Where is this joint located?
below the temporal artery and anterior to the tragus. Crepitation is an audible and palpable crunching or grating that accompanies rheumatoid arthritis.
Broca's area (expressive aphasia)
broken language; patients can comprehend language, but cannot produce language, located in frontal lobe
breast development
Thelarche age 9 - 10
whats the function of tunica vaginalis?
coat testicles, separate them from the scrotum
what is a hernia ? a. Refer him to his physician for additional consultation because the physician made the initial diagnosis. b. Explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.
"A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles."
Checklist for Anus, rectum, and prostate
- Inspect anus and perineal area -Inspect during valsalva maneuver -Palpate anal canal and rectum on all adults -Test stool for occult blood
sensory loss
- Peripheral neuropathy: Loss of sensation involves all modalities; loss most severe distally at feet and hands. -Individual nerves or roots: Decrease or loss of all sensory modalities; corresponds to distribution of involved nerve - Spinal cord hemisection (Brown-Séquard syndrome) : Loss of pain and temp on contralateral side, loss of vibration and position discrimination on ipsilateral side
What are the tanner stages for male GI?
1 - no pubic hair 2- few hairs, little enlargement 3-curly, darker hair, penis getting longer 4-scrotum darker, penis grows in length and diameter 5- hair on thighs and everything adult size
contains pons, medulla, and midbrain
brainstem
what month does fetus form scale model
3
At what age is a annual mammogram recommended?
40
During an examination of the eye, the nurse would expect what normal finding when assessing the lacrimal apparatus?
Absence of drainage from the puncta when pressing against the inner orbital rim rationale: Lacrimal apparatus irrigates eye. No swelling, redness, or drainage from the puncta should be observed when it is pressed. if thered fluid, indicates duct blockage.
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.
Abduct her hip while she is lying on her back.
A 2-year-old boy has been diagnosed with cryptorchidism. Considering this diagnosis, what does this mean?
Absence of the testis in the scrotum, but the testis can be milked down
The nurse is performing an assessment. Which of these findings would cause the greatest concern? a. A painful vesicle inside the cheek for 2 days b. The presence of moist, nontender Stensen's ducts c. Stippled gingival margins that snugly adhere to the teeth d. An ulceration on the side of the tongue with rolled edges
An ulceration on the side of the tongue with rolled edges rationale: Ulceration on the side or base of the tongue or under the tongue raises the suspicion of cancer and must be investigated. The risk for early metastasis is present because of rich lymphatic drainage. The vesicle may be an aphthous ulcer, which is painful but not dangerous. The presence of moist, nontender Stensen's ducts and stippled gingival margins that snugly adhere to the teeth are normal findings.
The nurse notices that the mother of a 2-year-old boy brings him into the clinic quite frequently for various injuries and suspects there may be some child abuse involved. What should the nurse look for during an inspection of this child's mouth? a. Swollen, red tonsils b. Ulcerations on the hard palate c. Bruising on the buccal mucosa or gums d. Small yellow papules along the hard palate
Bruising on the buccal mucosa or gums rationale: The nurse should notice any bruising or laceration on the buccal mucosa or gums of an infant or young child. Trauma may indicate child abuse from a forced feeding of a bottle or spoon.
What are the two parts of the nervous system?
Central and peripheral
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?
Direct inguinal
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) Fractured clavicle B) Down syndrome C) Spina bifida D) Hip dislocation
Hip dislocation
The nurse is explaining to a student nurse the four areas in the body where lymph nodes are accessible. Which areas should the nurse include in her explanation to the student?
Head and neck, arms, inguinal area, and axillae
A 13-year-old girl is visiting the clinic for a sports physical examination. The nurse should remember to include which of these tests in the examination? A) Test for occult blood B) The Valsalva maneuver C) Internal palpation of the anus D) Inspection of the perianal area
Inspection of the perianal area The perianal region of the school-aged child and adolescent should be inspected during the examination of the genitalia. Internal palpation is not routinely performed at this age. Testing for occult blood and performing the Valsalva maneuver are also not necessary
Which is an accessory glandular structure for the male genital organs? a. Testis. b. Scrotum. c. Prostate. d. Vas deferens.
Prostate Glandular structures accessory to the male genital organs are the prostate, seminal vesicles, and bulbourethral glands
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) A polyp C) Carcinoma of the prostate
Prostatitis
The physician reports that a patient with a neck tumor has a tracheal shift. The nurse should understand that what is occurring to the patient's trachea? a. Pulled to the affected side. b. Pushed to the unaffected side. c. Pulled downward. d. Pulled downward in a rhythmic pattern.
Pushed to the unaffected side. rationale: The trachea is pushed to the unaffected side with an aortic aneurysm, a tumor, unilateral thyroid lobe enlargement, or a pneumothorax. The trachea is pulled to the affected side with large atelectasis, pleural adhesions, or fibrosis. Tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch aneurysm.
An 18-year-old patient is having her first pelvic examination. Which action by the nurse is appropriate?
Raising the head of the examination table and giving her a mirror so that she can view the examination
A patient has been diagnosed with strep throat. The nurse is aware that without treatment, which complication may occur?
Rheumatic fever
A patient comes into the emergency department after an accident at work. A machine blew dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas by shining a light from the side across the cornea. What findings would suggest that he has suffered a corneal abrasion?
Shattered look to the light rays reflecting off the cornea
During an examination, how would the nurse expect the cervical os of a woman who has never had children to appear? A) stellate. B) small and round. C) as a horizontal irregular slit. D) everted.
Small and round
When assessing the tongue of an adult, what finding would be considered abnormal?
Smooth, glossy areas are abnormal and may indicate atrophic glossitis. In the aging adult, the tongue looks smoother because of papillary atrophy. The teeth are slightly yellowed and appear longer because of the recession of gingival margins.
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
cervix
Which of these assessment findings would the nurse expect to see when examining the eyes of a black patient?
dark retinal background
color perception is tested using what
pseudoisochromatic plates - for color blind people
In a patient who has anisocoria, what would the nurse expect to observe?
pupils of unequal size indicative of central ns disease.
Purpose of musculoskeletal examination
to assess function for ADLs and to screen for abnormalities
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.
d. Swelling from fluid in the suprapatellar pouch
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) uterine prolapse, graded first degree. B) uterine prolapse, graded second degree. C) uterine prolapse, graded third degree. D) a normal finding.
d. Uterine prolapse, graded second degree
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.
dysuria Rationale: pain/ burning common with acute cystitis, prostatitis, urethritis
In using the ophthalmoscope to assess a patient's eyes, the nurse notices a red glow in the patient's pupils. Based on this finding, what should the nurse do?
red glow filling the person's pupil is the red reflex and is a normal finding caused by the reflection of the ophthalmoscope light off the inner retina.
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
reflexes rationale: 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?"
What is articulated with the tibia and fibula in the ankle joint? A) talus. B) cuboid. C) calcaneus. D) cuneiform bones.
talus
While palpating the prostate gland through the rectum, which finding would the nurse recognize as abnormal? A) Palpable central groove B) Tenderness to palpation C) Heart shape D) Elastic and rubbery consistency
tenderness to palpation
The nurse is performing the diagnostic positions test. Which result is a normal finding? a. convergence of eyes b. parallel movement of eyes c. nystagmus in extreme superior gaze d. slight amount of lid lag when moving eyes
parallel movement of both eyes rationale: Eye movement that is not parallel indicates a weakness of an extraocular muscle or dysfunction of the CN 3,4,6 "makes your eyes do tricks". The diagnostic positions test assesses for muscle weakness, nystagmus, or lid lag during movement of the eye by leading the eyes through the six cardinal positions of gaze. Which is when pt follows finger clockwise and you stop in between.
A patient has come in for an examination and states, "I have this spot in front of my ear lobe on my cheek that seems to be getting bigger and is tender. What do you think it is?" The nurse notes swelling below the angle of the jaw. What does the nurse suspect inflammation of? a. Thyroid gland. b. Parotid gland. c. Occipital lymph node.
parotid gland rationale: Swelling of the parotid gland is evident below the angle of the jaw and is most visible when the head is extended. Swelling occurs anterior to the lower ear lobe. The parotid gland enlargement associated with mumps, and HIV/ AIDS.
What structure secretes a thin, milky alkaline fluid to enhance the viability of sperm and surrounds bladder neck and urethra? A) Cowper's gland. B) prostate gland. C) median sulcus. D) bulbourethral gland.
prostate gland In men, the prostate gland secretes a thin milky alkaline fluid that enhances sperm viability. The Cowper glands (aka bulbourethral glands) secrete a clear, viscid mucus. The median sulcus is a groove that divides the lobes of the prostate gland and does not secrete fluid.
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
testes-sperm production Epipdymis stores sperm Vas Deferens transport sperm from testicle to uretha
The area of the nervous system that responsible for mediating reflexes? a. Medulla. b. Cerebellum. c. Spinal cord. d. Cerebral cortex.
spinal cord 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, assess this for orientation.
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
summation effect. rationale: 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.
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."
"After age 30 years, if you have three consecutive normal Pap tests, then you may be screened every 2 to 3 years."
The nurse is performing an assessment on a 21-year-old patient and notices that his nasal mucosa appears pale, gray, and swollen. What would be the most appropriate question to ask the patient? a. "Have you had any symptoms of a cold?" b. "Do you have an elevated temperature?" c. "Are you aware of having any allergies?" d. "Have you been having frequent nosebleeds?"
"Are you aware of having any allergies?" With chronic allergies, the mucosa looks swollen, boggy, pale, and gray. Elevated body temperature, colds, and nosebleeds do not cause the nasal mucosa to appear pale, gray, and swollen.
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) "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?"
"Women often have questions about their sexual relationship and how it affects their health. Do you have any questions?"
Which statement by the nurse is correct about breastmilk? a. "Your breast milk is present immediately after delivery of the baby." b. "Breast milk is rich in protein and sugars (lactose) but has very little fat." c. "The colostrum, which is present right after birth, does not contain the same nutrition as breast milk does." d. "You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy."
"You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy."
motor system dysfunctions
1. Cerebral palsy-cant maintain balance or posture 2. Muscular dystrophy-muscles smaller 3. Hemiplegia- one side paralysis 4. Parkinsonism -stooped posture, shuffling walk, short steps, flat facial expression, and pill-rolling finger movements 5. Cerebellar- loss of coordination and balance 6. Paraplegia- paralysis of legs 7. Multiple sclerosis
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 very ominous sign and may indicate brainstem injury
What are the steps in a neuro exam?
mental CN motor system sensory system reflexes
Flaccid Quadriplegia indicates
nonfunctional brain stem, paralysis in all four extremities
lump in her right breast for years. Recently, it has begun to change in consistency and is becoming harder. She reports that 5 years ago her physician evaluated the lump and determined that it was "nothing to worry about." The nurse's examination validates the presence of a mass in the right upper outer quadrant at 1 o'clock, approximately 5 cm from the nipple. It is firm, mobile, and nontender, with borders that are not well defined. What is the best response by the nurse? a. "Because of the change in consistency of the lump, it should be further evaluated by a physician." b. "The changes could be related to your menstrual cycles. Keep track of changes in the mass each month." c. "This is probably nothing to worry about because it has been present for years and was determined to be noncancerous at that time." d. "Because you are experiencing no pain and the size has not changed, continue to monitor the lump and return to the clinic in 3 months."
"Because of the change in consistency of the lump, it should be further evaluated by a physician." A lump that has been present for years and is not exhibiting changes may not be serious but should still be explored. Any recent change or a new lump should be evaluated. The other responses are not correct.
During a checkup, a 22-year-old woman tells the nurse that she uses an over-the-counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she first started using it. Which is the best response by the nurse? a. "You should never use over-the-counter nasal sprays because of the risk for addiction." b. "You should try switching to another brand of medication to prevent this problem." c. "Continuing to use this spray is important to keep your allergies under control." d. "Frequent use of these nasal medications irritates the lining of the nose and may cause rebound swelling."
"Frequent use of these nasal medications irritates the lining of the nose and may cause rebound swelling." rationale: The misuse of over-the-counter nasal medications irritates the mucosa and causes the blood vessels to become swollen, rebound swelling, which is a common problem.
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?
"Girls your age often have questions about sexual activity. Do you have any questions?"
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) "Hormone replacement therapy is at such a low dose that side effects are very unusual." B) "Hormone replacement therapy has several side effects, including fluid retention, breast tenderness, and vaginal bleeding." C) "It would be very unusual to have vaginal bleeding with hormone replacement therapy, and I suggest you come in to 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."
"HRT has several side effects, including fluid retention, breast tenderness, and vaginal bleeding."
The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation? 1. "Do you ever notice ringing or crackling in your ears?" 2. "When was the last time you had your hearing checked?" 3. "Have you ever been told you have any type of hearing loss?" 4. "Was there any relationship between the ear pain and the discharge you mentioned?"
"Is there any relationship between the ear pain and the discharge you mentioned?" rationale: Typically with perforation, ear pain occurs first and resolves after a popping sensation, then drainage occurs
A pregnant woman states that she is concerned about her gums because she has noticed they are swollen and have started to bleed. What would be an appropriate response by the nurse? a. "Your condition is probably due to a vitamin C deficiency." b. "I'm not sure what causes swollen and bleeding gums, but let me know if it's not better in a few weeks." c. "You need to make an appointment with your dentist as soon as possible to have this checked." d. "Swollen and bleeding gums can be caused by a change in hormonal balance during pregnancy."
"Swollen and bleeding gums can be caused by a change in hormonal balance during pregnancy." rationale: Although with gingivitis (which can be caused by a vitamin C deficiency) gum margins are red and swollen and easily bleed, a changing hormonal balance during puberty or pregnancy may also cause these symptoms. Since this patient is pregnant, a change in hormonal balance is likely the cause.
A 32-year-old woman is at the clinic for "little white bumps in my mouth." During the assessment, the nurse notes that she has a 0.5-cm white, nontender papule under her tongue and one on the mucosa of her right cheek. What would the nurse tell the patient? a. "These spots indicate an infection such as strep throat." b. "These bumps could be indicative of a serious lesion, so I will refer you to a specialist." c. "This condition is called leukoplakia and can be caused by chronic irritation such as with smoking." d. "These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition."
"These bumps are Fordyce granules, which are sebaceous cysts and are not a serious condition." rationale: In strep throat, the examiner would see tonsils that are bright red, swollen, and may have exudates or white spots and leukoplakia would appear as chalky white, thick, raised patches. These findings are not indicative of a serious lesion but are fordyce granules. Fordyce granules are small, isolated white or yellow papules on the mucosa of the cheek, tongue, and lips. These little sebaceous cysts are painless and are not significant.
A mother brings her 4-month-old infant to the clinic with concerns regarding a small pad in the middle of the upper lip that has been there since 1 month of age. The infant has no health problems. On physical examination, the nurse notices a 0.5-cm, fleshy, elevated area in the middle of the upper lip. No evidence of inflammation or drainage is observed. What would the nurse tell this mother? a. "This area of irritation is caused from teething and is nothing to worry about." b. "This finding is abnormal and should be evaluated by another health care provider." c. "This area of irritation is the result of chronic drooling and should resolve within the next month or two." d. "This elevated area is a sucking tubercle caused from the friction of breastfeeding or bottle-feeding and is normal."
"This elevated area is a sucking tubercle caused from the friction of breastfeeding or bottle-feeding and is normal." rationale: A normal finding in infants is the sucking tubercle, a small pad in the middle of the upper lip from the friction of breastfeeding or bottle-feeding. This condition is not caused by irritation, teething, or excessive drooling, and evaluation by another health care provider is not warranted.
The mother of a 2-year-old is concerned because her son has had three ear infections in the past year. What would be an appropriate response by the nurse 1. "It is unusual for a small child to have frequent ear infections unless there is something else wrong." 2. "We need to check the immune system of your son to see why he is having so many ear infections." 3. "Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily."
"Your son's eustachian tube is shorter and wider than yours because of his age, which allows for infections to develop more easily." rationale: The infant's eustachian tube is relatively shorter and wider than the adult's eustachian tube, and its position is more horizontal; consequently, pathogens from the nasopharynx can more easily migrate through to the middle ear. The other responses are not appropriate. It is not unusual for a small child to have frequent ear infections, thus, it is not necessary to check the immune system. The reason that ear infections in infants and toddlers is not uncommon is not due to more cerumen.
DTR 5 components
(1) sensory nerve (afferent), (2) synapse in the cord, (3) motor nerve (efferent), (4) the neuromuscular junction (5) a competent muscle
what are 2 cultural considerations for female GI?
-black women have higher incidence and lower survival rates than white women esp in south -genital mutilation
What are 6 benign breast conditions?
-fibrocystic: multiple masses on both breasts -fibroadenoma: breast mast -abscess -mammy duct: (clogged, swollen, hot) -intraductal papilloma: mass in nipple -lactation abnormalities
automatic NS
-peripheral ns compose of CN and spinal. -somatic fibers innervate skeletal (voluntary) -autonomic fibers innervate smooth (involuntary & unconscious), ex. walking, breathing
3 types of reflex arcs
-stretch/DTR ex. knee jerk -superficial ex. Babinski/ plantar reflex -visceral ex. accommodation
when assessing health history for boys what do you say or avoid saying?
Start with a permission statement: "Often boys your age experience . . . " "When did you . . . " rather than "Do you . . . " and avoid saying "having sex"
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?
Before testing, the nurse would assess the patient's mental status and ability to follow directions.
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?
Dysfunction of the cerebellum Rationale: Cerebellum coordinates movement, suppose to be quick.
A 92-year-old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?
Dysphagia rationale: dysphagia is difficulty with swallowing and may occur with a variety of disorders, including stroke and other neurologic diseases.
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 estrogen.
Estrogen dependent
hereditary factors that lead to colorectal cancer (CRC)
Family history, inherited genetic syndromes, personal history of inflammatory bowel disease, or type 2 diabetes
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. greater trochanter B. Iliac crest C. Ischial tuberosity
Greater trochanter Palpation of bony landmarks of hip: -Iliac crest—anterior superior spine to posterior -Ischial tuberosity- lies under the gluteus maximus muscle and is palpable when the hip is flexed -Greater trochanter of the femur
To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate?
Have the child hop on one foot.
connects one bone to another, strengthen the joint, and help prevent movement in undesirable directions called? A) bursa. B) tendons. C) cartilage. D) ligaments.
Ligaments Rationale: Fibrous, cartilaginous and synovial joints are joints or articulations of two or more bones. Bursa is an enclosed fluid filled sac that serves as a cushion. Muscle/skeletal, voluntary control connected by tendon to bone.
The nurse recognizes which statement about benign breast disease to be true?
It makes it more difficult to examine the breasts.
- Located in PNS - enter and exit brain - final common pathway, providing final contact with muscle - Located in anterior gray column of spinal cord, but nerve fibers extend to muscle -Ex. CN and spinal nerves -Ex. of diseases are spinal cord lesions, poliomyelitis, and amyotrophic lateral sclerosis.
LMN
The nurse is examining only the rectal area of a woman and should place the woman in what position? A) Lithotomy position B) Prone position C) Left lateral decubitus position D) Bending over the table while standing
Left lateral decubitus The left lateral decubitus position is used when examining only the rectal area. If the genitalia are also going to be examined, the nurse should place the female patient in the lithotomy. Male can be in both or standing.
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.
Polydactyly Polydactyly is the presence of extra fingers or toes. Syndactyly is webbing between adjacent fingers or toes
When assessing the pupillary light reflex, the nurse should use which technique?
Shine a light across the pupil from the side, and observe for direct and consensual pupillary constriction. rationale: To test the pupillary light reflex, the nurse should shine a bright light in from the side and note constriction of both pupils. shine light directly in on eye and get constriction (Ipsilateral) and you get a lessen constriction of the opposite eye indirectly (contralateral)
The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has a "lazy eye". What should the nurse do next?
Test for strabismus by performing the corneal light reflex test.
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.
The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere. rationale: 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.
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) intervertebral disks.
d. Intervertebral disks Nucleus propulposus—disk center composed of soft, semifluid, mucoid material Allow for compensatory expansion on each side
The nurse is performing an assessment on a 7-year-old child who has symptoms of chronic watery eyes, sneezing, and clear nasal drainage. The nurse notices the presence of a transverse line across the bridge of the nose, dark blue shadows below the eyes, and a double crease on the lower eyelids. What does the nurse suspect is the cause of these signs and symptoms? a. Allergies. b. Sinus infection. c. Nasal congestion. d. Upper respiratory infection.
chronic allergies rationale: Chronic allergies often develop chronic facial characteristics and include blue shadows below the eyes, a double or single crease on the lower eyelids, open-mouth breathing, and a transverse line on the nose. Although nasal congestion and upper respiratory infections may present with watery eyes and sneezing, people with nasal congestion usually state congestion or a pressure feeling in their head and people with upper respiratory infections often have a cough and/or sore throat
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.
circumduction
A 46-year-old man requires an assessment of his sigmoid colon. Which instrument or technique is most appropriate for this examination? A) Proctoscope B) Ultrasound C) Colonoscope D) Rectal exam with an examining finger
colonscope
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.Syphilitic chancres. b. Genital herpes. c. Genital warts.
genital warts
How do you describe abnormalities in perianal area?
in clock face terms, 12:00 as the anterior point toward symphysis pubis and 6:00 toward coccyx.
What is dysmetria?
inability to control the distance, power, and speed of a muscular action
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? Postmenopausal women .... 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."
"You should be aware that you're at increased risk for dyspareunia because of decreased vaginal secretions." Rationale: aging adults go through -menopause -loss of fertility -uterus, ovaries, cervix shrink, ovaries atrophy which leads to incontinence, infections, dyspareunia (painful sex) -Ovaries are NOT palpable after menopause -pelvic wall weakens -vagina atrophy (small, thin, dry)
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?
Decreased LOC
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
5 5 - Full ROM against gravity, full resistance 4 - Full ROM against gravity, some resistance 75% poor 3 - Full ROM with gravity 50% fair 2 - Full ROM with gravity eliminated (passive motion) - 25% poor 1 - Slight contraction - 10 % trace 0 - No contraction
Of the 33 vertebrae in the spinal column, which is correct? A) 5 lumbar. B) 5 thoracic. C) 7 sacral. D) 12 cervical.
5 lumbar There are 7 cervical, 12 thoracic, 5 sacral, and 1 coccygeal . mixture of sensory and motor fibes
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
6 A fully alert, normal person has a score of 15, whereas a score of 8 or less reflects coma on the Glasgow Coma Scale.
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
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.
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
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.
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 controls body temperature and regulates sleep. The hypothalamus is major respiratory center. and coordinator of autonomic nervous system activity and emotional status. cerebellum controls motor coordination, and muscle tone of voluntary movements ex. swimming. basal ganglia control autonomic movements of the body.
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 d. Digital rectal examination (DRE) e. Blood test for prostate-specific antigen (PSA)
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.
A patient is unable to differentiate between sharp and dull stimulation to both sides of her face. What does the nurse suspect?
Damage to the trigeminal nerve
This is an abnormal posture, more ominous than decorticate. Upper extremities stiff, adducted, internally rotated, palms pronated. Lower extremities stiff, plantar flexed, teeth clenched, and hyperextended back
Decerebrate rigidity
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
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.
When examining children affected with Down syndrome (trisomy 21), what should the nurse look for r/t this disorder? a. Ear dysplasia. b. Long, thin neck. c. Protruding thin tongue. d. Narrow and raised nasal bridge.
Ear dysplasia rationale: trisomy 21, also known as Down syndrome, head and face characteristics may include upslanting eyes with inner epicanthal folds, a FLAT nasal bridge, a small broad flat nose, a protruding THICK tongue, ear dysplasia, a SHORT broad neck with webbing, and small hands with a single palmar crease
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.
a. Anteverted and anteflexed The uterus is freely movable, not fixed, and usually tilts forward and superior to the bladder (a position labeled as anteverted and anteflexed).
vulva and vagina are erythematous and edematous with thick, white, curdlike discharge adhering to the vaginal walls. 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
a. Candidiasis 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. Candidiasis can also be a white, cheesy, curdlike patch on the buccal mucosa and tongue. It scrapes off, leaving a raw, red surface that easily bleeds.
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. Long bones tend to shorten with age B. The vertebral column C. Significant loss of subcutaneous fat occurs D. A thickening of the intervertebral disks develops
a. The vertebral column shortens. Postural changes are evident with aging and decreased height is most noticeable due to shortening of the vertebral column.
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 is a positive Allis sign and suggests hip dislocation. B) This is a normal finding for the Allis test for an infant of this age. C) The infant should return to the clinic in 2 weeks to see if this has changed.
a. This finding is a positive Allis sign and suggests hip dislocation. Finding one knee significantly lower than the other is a positive Allis sign and suggests hip dislocation.
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) osteoporosis. B) acute gout. C) ankylosing spondylitis. D) degenerative joint disease.
acute gout
While performing the otoscopic examination of a 3-year-old boy who has been pulling on his left ear, the nurse finds that his left tympanic membrane is bright red and that the light reflex is not visible. What do these findings indicate? 1. fungal infection. 2. acute otitis media. 3. rupture of the drum. 4. blood behind the drum.
acute otitis media rationale: Absent or distorted light reflex and a bright red color of the eardrum are indicative of acute otitis media. Cholesteatoma is an overgrowth of epidermal tissue in the middle ear or temporal bone that has a pearly white, cheesy appearance (not bright red). A fungal infection manifests as a colony of black or white dots on the eardrum or canal walls (not bright red). A perforated eardrum usually appears as a round or oval darkened area on the drum.
Whos at higher risk for breast cancer?
age (65+), hyperplasia, dense breasts, history of BC, relative with BC, high estrogen/testosterone, radiation from surgeries, alcohol
The portion of the ear that consists of movable cartilage and skin is called the: 1. auricle. 2. concha. 3. outer meatus.
auricle
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) your subacromial bursa." B) your acromion process." C) your glenohumeral joint." D) the greater tubercle of your humerus."
b. "That is the acromion process." Rationale: 3 palpable landmarks for examination : 1) Scapula and clavicle form shoulder girdle 2) Can feel the bump of the scapula's acromion process at very top of shoulder 3)The next bump is the greater tubercle. The Subacromial bursa:Assists with abduction of the arm
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) herpes simplex virus type 2 (herpes genitalis). C) human papillomavirus (HPV), or genital warts. D) pediculosis pubis (crab lice).
b. HPV or genital warts
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. Consider this finding normal, and proceed with the examination.
b. Suspect the presence of serous fluid in the scrotum. Rationale: Transillumination done if mass or swelling detected. If contents are solid, no light seen. If fluid, it will illuminate as a red glow as seen with hydroceles. Keep in mind hernias and tumors are solid structures that do not transilluminate.
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) 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?"
c. "Do you have any unusual vaginal discharge or itching?"
A patient has had three pregnancies and two live births. How should the nurse record this information?
c. G3; P2; AB1 Gravida (G) is the number of pregnancies. Para (P) is the number of births. Abortions (AB) are interrupted pregnancies, including elective abortions and spontaneous miscarriage
In performing an assessment of a woman's axillary lymph system, the nurse should assess which of these nodes? a. Central, axillary, lateral, and sternal nodes b. Pectoral, lateral, anterior, and sternal nodes c. Central, lateral, pectoral, and subscapular nodes d. Lateral, pectoral, axillary, and suprascapular nodes
c. Central, lateral, pectoral, and subscapular Rationale: When palpating nodes, you palpate Lateral, Cervical, Subscapular, Pectoralis, and Infraclavicular chain. Shouldnt be palpable unless enlarged (means BC or infection). If you find unilateral swelling ask about vaccines, injury, sickness
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
c. Complete neurologic examination 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. Screening used just to check but dont expect deficits. recheck is for people who have neuro deficits and require assessments.
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) genu valgum. C) pes planus. D) metatarsus adductus.
c. Genu valgum rationale: 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.
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.
c. Herniated nucleus pulposus Lateral tilting and sciatic pain with straight leg raising are findings that occur with a herniated nucleus pulposus.
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 thought this choice through carefully?" D) "If you smoke, how many cigarettes do you smoke per day?"
d. "If you smoke, how many cigarettes do you smoke per day?"
The nurse should use which test to check for large amounts of fluid around the patella? A) Ballottement B) Tinel sign C) Phalen's test D) McMurray's test
d. Ballottement rationale: Ballottement of the patella is reliable when large amounts of fluid are present. The McMurray test is used to test the knee for a torn meniscus.
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) pediculosis pubis. B) contact dermatitis. C) human papillomavirus. D) herpes simplex virus type 2.
d. Herpes simplex virus type 2
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) a negative Allis test. B) a positive Ortolani's sign. C) limited range of motion during the Moro's reflex. D) limited range of motion during Lasègue's test
d. Limited range of motion during the Moro reflex For a fractured clavicle, the nurse should observe for limited arm range of motion and unilateral response to the Moro reflex.
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.
d. Medial and lateral epicondyle The epicondyles, the head of the radius, and the tendons are common sites of inflammation and local tenderness, commonly referred to as tennis elbow.
order of musculoskeletal exam
inspection, palpation, ROM (active-passive if limits- measure with goniometer), muscle testing
The nurse is explaining the mechanism of the growth of long bones to a mother of a toddler. Where does lengthening of the bones occur? A) Bursa B) Calcaneus C) Epiphyses D) Tuberosities
epiphyses
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.
flexion Rationale: Flexion: bending Extension: straightening Abduction: moving away from body Adduction: moving toward body Pronation: face down Supination: face up Circumduction: moving arm in circle around shoulder Inversion: foot inward at ankle Eversion: foot outward at ankle Rotation: moving head around central axis Protraction: moving body part forward Retraction: moving body part backward Elevation: raising a body part
change in 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
frontal 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.
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) structural scoliosis. B) functional scoliosis. C) herniated nucleus pulposus. D) dislocated hip.
functional scoliosis 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
Which of the following statements concerning the eustachian tube is true? 1. It is responsible for the production of cerumen. 2. It remains open except when swallowing or yawning. 3. It allows passage of air between the middle and outer ear. 4. It helps equalize air pressure on both sides of the tympanic membrane.
helps equalize air pressure on both sides of TM normally closed but opens when you swallow or yawn
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.
hesitancy dribbling is involuntary loss or urine
elbow joint
hinge joint formed by humerus, ulna, and radius
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
hyperreflexia 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.
nurse notices that the patient's eyelid margins approximate completely. What does the nurse understand about this assessment finding?
it is expected The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid margins approximate completely, which is a normal finding. This is a normal finding and does not result in problems with tearing or indicate problems with increase intraocular pressure or extraocular muscles.
A patient says that she has recently noticed a lump in the front of her neck below her "Adam's apple" that seems to be getting bigger. During the assessment, what finding would lead the nurse to suspect that this may not be a cancerous thyroid nodule? a. Is tender. b. Is mobile and not hard. c. Disappears when the patient smiles. d. Is hard and fixed to the surrounding structures.
it is mobile and soft rationale: Painless, rapidly growing nodules may be cancerous, especially the appearance of a single nodule in a young person. cancerous nodules tend to be hard and fixed to surrounding structures
When testing stool for occult blood, the nurse is aware that a false-positive result may occur with: A) absent bile pigment. B) increased fat content. C) increased ingestion of iron medication. D) a large amount of red meat within the last 3 days.
large amount of red meat within the last 3 days
A woman who is 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?
lordosis Lordosis compensates for the enlarging fetus, which would shift the center of balance forward. creates a low back pain during late pregnancy by some women
The nurse is reviewing the age-related changes in the eye for a class. What physiologic changes is responsible for presbyopia?
loss of lens elasticity and decreases its ability to change shape to accommodate for near vision which is observed by convergence (motion toward) of the axes of the eyeballs and pupillary constriction and is tested by having the person focus on a distant object.
What are 2 things to keep in mind when measuring muscle extremities?
measure each in cm, a difference of 1cm or less is not significant and its also hard to assess muscle mass in obese people
A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. What should the nurse do?
normal finding. By 2- 4 weeks an infant can fixate on an object. by 1 month, should establish binocularity and should be able to fixate simultaneously on a single image with both eyes.
The patient states, "It feels like the room is spinning!" What do this signs and symptoms indicate?
objective vertigo rationale: objective, room spins; subjective, the person is spinning. labyrinth responsible for this, which is vestibular dysfunction
How do you palpate posterior labia majora and perineum?
palpate posterior labia majora at 5 & 7 to assess Bartholin glands (should be soft & nontender), Separate labia to view opening of vagina. Palpating perineum should feel thick, smooth, and muscular in nulliparous woman & thin and rigid in multiparous woman.
The nurse is performing an otoscopic examination on an adult. Which action is correct? a. Tilt the person's head forward during the examination. b. Once the speculum is in the ear, releasing the traction. c. Pulling the pinna up and back before inserting the speculum. d. Using the smallest speculum to decrease the amount of discomfort.
pulling the pinna up and back before inserting the speculum. The nurse should tilt the patient's head slightly away from them and toward the opposite shoulder, not forward. The largest speculum that fits comfortably in the ear, not the smallest. The correct action is to pull the pinna up and back on an adult or older child (down and back on an infant or child under the age of 3).
explain ipsilateral functioning of the cerebral hemispheres
same side, left cortex receives sensory into from left and right receives sensory info from right.
Which is a structure of the external male genital? a. Testis. b. Scrotum. c. Epididymis. d. Vas deferens.
scrotum The external male genital structures include the penis and scrotum. The testis, epididymis, and vas deferens are internal structures
a patient has hyperthyroidism, and the laboratory data indicate that the patient's T4 and T3 hormone levels are elevated. Which of these findings would the nurse most likely find on examination? a. Tachycardia b. Constipation c. Rapid dyspnea d. Atrophied nodular thyroid gland
tachycardia rationale: T4 and T3 are thyroid hormones that stimulate the rate of cellular metabolism, resulting in tachycardia. With an enlarged thyroid gland as in hyperthyroidism, expect to find enlargement (goiter), graves disease, exopthalmas but not an atrophied gland.
Who is more at risk for bladder cancer?
white men, smokers, and assess for hematuria (blood in urine)
Wernicke's area (receptive aphasia)
word salad, person can hear but cant comprehend; usually in the left temporal lobe
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) "If you suspect that you have a vaginal infection, please gather a sample of the discharge to bring with you." D) "We would like you to use a mild saline douche before your examination. You may pick this up in our office."
"Avoid intercourse, inserting anything into the vagina, or douching within 24 hours of your appointment."
The nurse is assessing a patient in the hospital who has received numerous antibiotics for a lung infection and notices that his tongue appears to be black and hairy. In response to his concern, what would the nurse say? a. "We will need to get a biopsy to determine the cause." b. "This is an overgrowth of hair and will go away in a few days." c. "Black, hairy tongue is a fungal infection caused by all the antibiotics you have received." d. "This is probably caused by the same bacteria you had in your lungs."
"Black, hairy tongue is a fungal infection caused by all the antibiotics you have received." rationale: A black, hairy tongue is not really hair but the elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue. It occurs after the use of antibiotics, which inhibit normal bacteria and allow a proliferation of fungus. It is not caused by the same bacteria as his lung infection but occurred after the use of antibiotics, which inhibit normal bacteria and allow a proliferation of fungus. There is no need to get a biopsy.
postmenopausal woman is being seen in the clinic for her annual examination. She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem "flat and flabby." Which is the best reply by the nurse? a. "This change occurs most often because of long-term use of bras that do not provide enough support to the breast tissues." b. "This is a normal change that occurs as women get older. It is due to the increased levels of progesterone during the aging process." c. "Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast. This is a normal process of aging." d. "Postural changes in the spine make it appear that your breasts have changed in shape. Exercises to strengthen the muscles of the upper back and chest wall will help to prevent the changes in elasticity and size."
"Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast and is a normal process of aging." rationale: This change in the breasts is not due to long-term use of unsupportive bras, increased levels of progesterone with aging, or postural changes in the spine. Rather, the hormonal changes of menopause cause the breast glandular tissue to atrophy, making the breasts more pendulous, flattened, and sagging
A mother brings her 2-month-old daughter in, and says, "My daughter rolled over against the wall, and now I have noticed that she has this spot that is soft on the top of her head. Is something terribly wrong?" How should the nurse respond?
"That 'soft spot' is normal, and actually allows for growth of the brain during the first year of your baby's life." rationale: Membrane-covered "soft spots" allow for growth of the brain during the first year of life. They gradually ossify; the triangular-shaped posterior fontanel closed by 1 to 2 months, and diamond-shaped anterior fontanel closes between 9 months and 2 years.
test done for prostate, CRC, and HPV
*PSA—effective earl screening test *FIT—Fecal Immunochemical test—start at age 40 *HPV vaccine—Men under 26 years of age
How do you palpate breasts ?
- use supine position while pt in "fainting" position (arms over head) - use three fingers and palpate in circular motions (light, medium, deep) - use bimanual technique for larger breasts - can use vertical strip method (best way) or pinwheel
When assessing CN V what test do you do?
-Corneal Reflex (blink) -Palpate temporal and masseter (chewing and speaking) -Try to separate jaws- normally you can't Migraines can start here 3 sensory divisons ophthalmic & maxillary & mandibular
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?
1 rationale: 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 teaching a class on osteoporosis prevention to a group of postmenopausal woman. A participant shows that she needs more instruction when she states, "I will: A) start swimming to increase my weight-bearing exercise." B) try to stop smoking as soon as possible." C) check with my doctor about taking calcium supplements." D) get a bone-density test soon." E) performing physical activity
A Rationale: Osteoporosis is the loss of bone density. high BMD=denser bone, more in white women. point 2.5-4 on t score. quitting smoking and taking supplements help with bone density. 1200 mg of calcium for younger ppl 400-800 as you get older, divide it into 2 doses. Body only absorbs about 600 of calcium at a time
During an examination of a 3-year-old child, the nurse notices a bruit over the left temporal area. The nurse should: a. Continue because a bruit is a normal finding for this age. b. Check for the bruit again in 1 hour. c. Notify the parents that a bruit has been detected in their child.
A rationale: Bruits are common in the skull in children under 4 or 5 years of age and in children with anemia. They are heard over the temporal area.
Which of these clinical situations would the nurse consider to be outside normal limits? a. A patient has had one pregnancy. She states that she believes she may be entering menopause. Her breast examination reveals breasts that are soft and sag slightly. b. A patient has never been pregnant. Her breast examination reveals large pendulous breasts that have a firm, transverse ridge along the lower quadrant in both breasts. c. A patient has never been pregnant. She reports that she should begin her period tomorrow. Her breast examination reveals breast tissue that is nodular and somewhat engorged. She states that the examination was slightly painful. d. A patient has had two pregnancies and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft and she has a small amount of thick yellow discharge from both nipples.
A patient has had two pregnancies, and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipples. rationale: If any discharge appears, the nurse should note its color and consistency. Except in pregnancy and lactation, any discharge is abnormal. In nulliparous women, normal breast tissue feels firm, smooth, and elastic; after pregnancy, the tissue feels soft and loose. Premenstrual engorgement is normal, and consists of a slight enlargement, tenderness to palpation, and a generalized nodularity. A firm, transverse ridge of compressed tissue in the lower quadrants (where bra line is), known as the inframammary ridge, is especially noticeable in large breasts and is normal.
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.
A, D, E, F Occasionally forgetting names or appointments, and sometimes having trouble finding the right word are part of normal aging.
While assessing a hospitalized patient who is jaundiced, the nurse notices that the patient has been incontinent of stool. The stool is loose and gray-tan in color. What does this finding indicate?
Absent bile pigment The presence of gray-tan stool indicates the absence of bile pigment, which can occur with obstructive jaundice. The ingestion of iron preparations and the presence of occult blood turn the stools to a black color. Jellylike mucus shreds mixed in the stool would indicate inflammation.
A patient's thyroid gland is enlarged, and the nurse is preparing to auscultate the thyroid gland for the presence of a bruit. What technique should the nurse use to assess for a bruit.
Auscultate the thyroid with the bell of the stethoscope. rationale: bruit is a soft, pulsatile, whooshing, blowing sound heard best with the bell of the stethoscope. occurs with accelerated or turbulent blood flow. It is not able to be palpated.
During an assessment, the nurse notices that an older adult patient has tears rolling down his face from his left eye. Closer examination shows that the lower lid is loose and rolling outward. The patient complains of his eye feeling "dry and itchy." Which action by the nurse is correct?
Assessing for other signs of ectropion ratioanle: The condition described is known as ectropion, and it occurs in older adults and is attributable to atrophy of the elastic and fibrous tissues. The lower lid does not approximate to the eyeball, and, as a result, the puncta cannot effectively siphon tears; excessive tearing results.
what happens in adult neuro system as they age
Atrophy with steady loss of neuron structure in brain and spinal cord- thinning of cerebral cortex Velocity of nerve conduction decreases making reaction time slower in some older persons. Increased delay at synapse results in diminished sensation of touch, pain, taste, and smell. Motor system may show general slowing down of movement, muscle strength, and agility decrease. Progressive decrease in cerebral blood flow and oxygen consumption may cause dizziness and loss of balance.
A mother brings in her newborn infant for an assessment and tells the nurse that she has noticed that whenever her newborns head is turned to the right side, she straightens out the arm and leg on the same side and flexes the opposite arm and leg. After observing this on examination, the nurse tells her that this reflex is: a. Abnormal and is called the atonic neck reflex. b. Normal and should disappear by the first year of life. c. Normal and is called the tonic neck reflex, which should disappear between 3 and 4 months of age. d. Abnormal. The baby should be flexing the arm and leg on the right side of his body when the head is turned to the right.
C
A patient reports excruciating headache pain on one side of his head, especially around his eye, forehead, and cheek that has lasted approximately to 2 hours, occurring once or twice each day. What should the nurse suspect? a. Hypertension. b. Cluster headaches. c. Tension headaches. d. Migraine headaches.
Cluster headaches rationale: Cluster headaches produce pain around the eye, temple, forehead, and cheek, unilateral and always on the same side of the head. excruciating and occur 1-2 times per day and last to 2 hrs each. hypertension may cause headaches, the bp needs to be severely elevated and would likely not occur 1-2 a day and last for to 2 hrs. Tension headaches are occipital, frontal, or with bandlike tightness. Migraine headaches are supraorbital, retro-orbital, or frontotemporal, relieved when you lay down, throbbing quality, pain behind eyes, temple, & forehead and also associated with a family history of migraine headaches. Triggers can also be food.
During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly. What additional finding would the nurse assess for to confirm this suspicion? a. Exophthalmos. b. Bowed long bones. c. Coarse facial features.
Coarse facial features rationale: Acromegaly is the excessive secretion of growth hormone that creates an enlarged skull and thickened cranial bones. Patients will have elongated heads, massive faces, prominent noses and lower jaws, heavy eyebrow ridges, and coarse facial features. Exophthalmos is associated with hyperthyroidism. Bowed long bones and an acorn-shaped cranium result from Paget disease.
After completing an assessment of a 60-year-old white male with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. What should the nurse include in the instructions? A) annual proctoscopy. B) colonoscopy every 10 years. C) fecal test for blood every 6 months. D) digital rectal examinations every 2 years.
Colonoscopy every 10 years
The nurse is performing an assessment on a 65-year-old man. He reports a crusty nodule behind the pinna. It intermittently bleeds and has not healed over the past 6 months. On physical assessment, the nurse finds an ulcerated crusted nodule with an indurated base. Based on these findings, what does the nurse suspect? 1. is most likely a benign sebaceous cyst. 2. is most likely a Darwin's tubercle and is not significant. 3. could be a potential carcinoma and should be referred. 4. is a tophus, which is common in the elderly and is a sign of gout.
Could be a potential carcinoma, and the patient should be referred for a biopsy rationale: An ulcerated crusted nodule with an indurated base that fails to heal is characteristic of a carcinoma. These lesions fail to heal and intermittently bleed. Individuals with such symptoms should be referred for a biopsy. A sebaceous cyst is a nodule filled with waxy sebaceous material, is painful if it becomes infected, and is often multiple of them. A tophus is a hard uric acid deposit under the skin. The ulcerated crusted nodule with an indurated base that fails to heal that this patient has is characteristic of a carcinoma
The nurse is assessing an 80-year-old patient. Which of these findings would be expected for this patient? a. Hypertrophy of the gums b. Increased production of saliva c. Decreased ability to identify odors d. Finer and less prominent nasal hair
Decreased ability to identify odors rationale: The sense of smell may be reduced because of a decrease in the number of olfactory nerve fibers with aging. Nasal hairs grow coarser and stiffer with aging. The gums may recede with aging, not hypertrophy, and saliva production decreases.
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
Decreased penis size rationale: In the aging man, the amount of pubic hair decreases, the penis and testes size decreases, and the rugae over the scrotal sac decreases. The scrotal sac does not enlarge.
During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects which condition? a. Rickets b. Dehydration c. Increased intracranial pressure
Dehydration rationale: Depressed and sunken fontanels occur with dehydration or malnutrition. Increased intracranial pressure would cause tense or bulging and possibly pulsating fontanels.
What test would the nurse use to check the motor coordination of an 11-month-old infant?
Denver II To screen gross and fine motor coordination, the nurse should use the Denver II with its age-specific developmental milestones.
In an individual with otitis externa, which of these signs would the nurse expect to find on assessment? 1. Rhinorrhea 2. Periorbital edema 3. Pain over the maxillary sinuses 4. Enlarged superficial cervical nodes
Enlarged superficial cervical nodes rationale: The lymphatic drainage of the external ear flows to the parotid, mastoid, and superficial cervical nodes. The signs are severe swelling of the canal, inflammation, and tenderness. Rhinorrhea, periorbital edema, and pain over the maxillary sinuses do not occur with otitis externa.
A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot whistle but the nurse notes he can still raise his eyebrows. What does the nurse suspect? a. Cushing syndrome. b. Parkinson disease. c. Bell palsy. d. Experienced a cerebrovascular accident (CVA) or stroke.
Experienced a cerebrovascular accident (CVA) or stroke rationale: With an upper motor neuron lesion, as with a CVA, the patient will have paralysis of lower facial muscles, but the upper half of the face will not be affected. Bell palsy presents as complete paralysis of one side of the face. Cushing syndrome the person develops a rounded, "moonlike" face, prominent jowls, red cheeks, hirsutism on the upper lip, lower cheeks, and chin, and acneiform rash on the chest. The facial features characteristic of Parkinson syndrome are a flat and expressionless, "masklike," with elevated eyebrows, staring gaze, oily skin, and drooling.
During a digital examination of the rectum, the nurse notices that the patient has hard feces in the rectum. The patient complains of feeling "full," has a distended abdomen, and states that she has not had a bowel movement "for several days." The nurse suspects which condition? A) Rectal polyp B) Fecal impaction C) Rectal abscess D) Rectal prolapse
Fecal impaction A fecal impaction is a collection of hard, desiccated feces in the rectum. The obstruction often results from decreased bowel motility, in which more water is reabsorbed from the stool.
The nurse is preparing to palpate the rectum and should use which of these techniques? A) Flex the finger and insert slowly toward the umbilicus. B) Instruct the patient first that this will be a painful procedure. C) Insert an extended index finger at a right angle to the anus. D) Place the finger directly into the anus to overcome the tight sphincter.
Flex the finger, and slowly insert it toward the umbilicus. rationael: The nurse should never approach the anus at right angles with the index finger extended; doing so would cause pain. The nurse should instruct the patient that palpation is not painful but may feel like needing to move the bowels.
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) articular process. C) medial epicondyle. D) glenohumeral joint.
Glenohumeral joint
A mother brings her newborn in for an assessment and asks, "Is there something wrong with my baby? His head seems so big." Which statement is true regarding the relative proportions of the head and trunk of the newborn? a. At birth, the head is one fifth the total length b. Head circumference > chest circumference at birth. c. The head size reaches 90% of its final size when the child is 3 years old.
Head circumference should be greater than chest circumference at birth. rationale: during the fetal period, head growth predominates. Head size is greater than chest circumference at birth, and the head size grows during childhood, reaching 90% of its final size when the child is age 6 years
"pain in my bottom when I have a bowel movement." The nurse should assess for which problem A) Hemorrhoids B) Colon cancer C) Fecal incontinence
Hemorrhoids rationale: Having painful bowel movements, aka dyschezia is (hemorrhoid or fissure) or constipation. Colon cancer often presents with occult blood in the stool. Fecal incontinence is leaking of solid or liquid stool involuntarily
pt has had cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side? a. Lack of reflexes b. Normal reflexes c. Hyperactive reflexes
Hyperactive reflexes rationale: 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)
During a physical education class, a student is hit in the eye with the end of a baseball bat. When examined in the emergency department, the nurse notices the presence of blood in the anterior chamber of the eye. What does this finding indicate? a. Hypopyon. b. Hyphema. c. Corneal abrasion. d. Pterygium.
Hyphema ratioanle: Hyphema is the term for blood in the anterior chamber and is a serious result of blunt trauma or spontaneous hemorrhage and may indicate scleral rupture or major intraocular trauma. Hypopyon is the term for lager of white blood cells in the anterior chamber and often cause pain, red eye, and possibly decreased vision. Pterygium is the term for a triangular opaque wing of bulbar conjunctive overgrows toward the center of the cornea. It looks membranous, translucent, and yellow to white. A corneal abrasion is the term for damage or removal of the top layer of corneal epithelium, usually a result of scratches or poorly fitting or overworn contact lenses. The person with a corneal abrasion usually feels intense pain; a foreign body sensation; and lacrimation, redness, and photophobia.
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
Hyporeflexia With a herniated intervertebral disk or LMN 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.
If a patient reports a recent breast infection, nurse should expect to find what type of node enlargement? a. nonspecific b. ipsilateral axillary c. contralateral axillary
Ipsilateral axillary Most of the lymph, drains into the ipsilateral, or same side, axillary nodes. If there was a recent breast infection, then the same side (ipsilateral) axillary nodes will likely be enlarged.
A woman comes to the clinic and states, "I've been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." For what condition should the nurse assess for other signs and symptoms? a. Cachexia. b. Parkinson syndrome. c. Myxedema.
Myxedema rationale: Myxedema (hypothyroidism) causes a nonpitting edema or myxedema. The patient will have a puffy face, especially around the eyes (periorbital edema); coarse facial features; dry skin; and dry, coarse hair and eyebrows, caused by hashimitos disease. Cachexia accompanies chronic wasting diseases such as cancer, dehydration, and starvation. Features included sunken eyes, hollow cheeks, and exhausted, defeated expression. The facial features characteristic of Parkinson syndrome are a flat and expressionless, "masklike," with elevated eyebrows, staring gaze, oily skin, and drooling.
A 68-year-old woman is in the eye clinic for a checkup. Patient is having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. she has some loss of central vision but her peripheral vision is normal. What do these findings suggest? a. Macular degeneration. b. Vision normal for someone her age. c. beginning stages of cataract formation. d. Increased intraocular pressure or glaucoma.
Macular degeneration It characterized by the loss of central vision and is the most common cause of blindness. Cataracts would show lens opacity. These findings are not consistent with normal vision at this, or any, age. The increased intraocular pressure of chronic open-angle glaucoma, involves a gradual loss of peripheral vision but not central vision in hispanics and blacks
facial pain, fever, and malaise. On examination, the nurse notes swollen turbinates and purulent discharge from the nose. The patient also complains of a dull, throbbing pain in his cheeks and teeth on the right side and pain when the nurse palpates the areas. What do these findings indicate? a. Nasal polyps b. Frontal sinusitis c. Posterior epistaxis d. Maxillary sinusitis
Maxillary sinusitis rationale: NORMALLY NO PAIN Signs of maxillary sinusitis include facial pain, red swollen nasal mucosa, swollen turbinates, and purulent discharge. With maxillary sinusitis, dull throbbing pain occurs in the cheeks and teeth on the same side, and pain with palpation is present. With frontal sinusitis, pain is above the supraorbital ridge (eyebrows). Nasal polyps appear as smooth, pale gray nodules which are overgrowths of mucosa most commonly caused by chronic allergic rhinitis. Epistaxis is a nosebleed and the most common site of bleeding is the Kiesselbach plexus in the anterior septum. ethmoid pain between eyes, loss of smell
A 19-year-old college student is brought to the emergency department with a severe headache he describes as, "Like nothing I've ever had before." His temperature is 40° C, and he has a stiff neck. The nurse looks for other signs and symptoms of which problem? a. Head injury b. Cluster headache c. Migraine headache d. Meningeal inflammation
Meningeal inflammation
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) interphalangeal B) tarsometatarsal C) metacarpophalangeal D) tibiotalar
Metacarpophalangeal rationale: 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. permit finger from flexion and extension
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)?
Motor component of CN VII
Musculoskeletal system needed for what
Needed for support and to stand erect, movement, protect inner vital organs, produce RBCs, WBCs, and platelets in the bone marrow, and storage of essential minerals
In assessing the tonsils of a 30-year-old, the nurse notices that they are involuted, granular in appearance, and appear to have deep crypts. What is the correct response to these findings? a. Refer the patient to a throat specialist. b. No response is needed; this appearance is normal for the tonsils. c. Continue with the assessment, looking for any other abnormal findings. d. Obtain a throat culture on the patient for possible streptococcal (strep) infection
No response is needed; this appearance is normal for the tonsils. rationale: The tonsils are the same color as the surrounding mucous membrane, although they look more granular and their surface shows deep crypts. Tonsillar tissue enlarges during childhood until puberty and then involutes. There is no need to refer the patient to a throat specialist, obtain a throat culture, or look for other abnormal findings because the findings in this question are normal.
A patient has been admitted after an accident at work. During the assessment, the patient is having trouble hearing and states, "I don't know what is the maatter. All of a sudden I can't hear you out of my left ear!" What should the nurse do next?
Notify the patient's health care provider rationale: Any sudden loss of hearing in one or both ears that is not associated with an upper respiratory infection needs to be reported at once to the patient's health care provider.
A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has ptosis of one eye. How should the nurse check for this? a. Perform confrontation test. b. Assess individuals near vision. c. Observe distance between palpebral fissures. d. Perform corneal light test, and look for symmetry of light reflex
Observe the distance between the palpebral fissures rationale: Ptosis is a drooping of the upper eyelid that would be apparent by observing the distance between the upper and lower eyelids. The confrontation test measures peripheral vision.
A 31-year-old patient tells the nurse that he has noticed a progressive loss in his hearing. He says that it does seem to help when people speak louder or if he turns up the volume of a television or radio. What is the most likely cause of this hearing loss?
Otosclerosis
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) an ovarian cyst. B) endometriosis. C) ovarian cancer. D) an ectopic pregnancy.
Ovarian cancer
When performing a musculoskeletal assessment, what is the correct approach?
PROXIMAL TO DISTAL The musculoskeletal assessment should be performed in an orderly approach, head to toe, proximal to distal, from the midline outward.
When examining the ear with an otoscope, how should the tympanic membrane look? 1. light pink with a slight bulge. 2. pearly gray and slightly concave. 3. pulled in at the base of the cone of light. 4. whitish with a small fleck of light in the superior portion.
Pearly gray and slightly concave rationale: A light pink color and a slight bulge of the tympanic membrane indicate otitis media. It should not look white and if there are tiny black flecks or dots, that is indicative of a fungal infection, or otomycosis. The tympanic membrane does not appear pulled in at the base of the cone of light, but should instead appear flat and slightly pulled in at the center.
How should the nurse perform an examination of a 2-year-old child with a suspected ear infection? 1. omit the otoscopic exam if the child has a fever. 2. pull the ear up and back before inserting the speculum. 3. ask the mother to leave the room while examining the child. 4. perform the otoscopic examination at the end of the assessment.
Perform the otoscopic examination at the end of the assessment rationale: In addition to its place in the complete examination, eardrum assessment is mandatory for any infant or child requiring care for an illness or fever. For the infant or young child, the timing of the otoscopic examination is best toward the end of the complete examination because many young children protest vigorously during this procedure and it is difficult to re-establish cooperation afterward. When performing an ear examination on a 2-year-old child, with or without a suspected ear infection, the pinna should be pulled down (not up) and back. Rather than asking the parent to leave the room, the nurse should enlist the parent's help in holding the child to protect the eardrum from injury.
During an assessment of the sclera of a black patient, the nurse would consider which of these an expected finding? a. Yellow fatty deposits over cornea b. Pallor near outer canthus of lower lid c. Yellow color of sclera that extends up to iris d. Presence of small brown macules on sclera
Presence of small brown macules on the sclera Normally in dark-skinned people, small brown macules may be observed in the sclera. Black people may have yellowish fatty deposits beneath the eyelids, away from the cornea, not over the cornea
The nurse is testing the hearing of a 78-year-old man and is reminded of the changes in hearing that occur with aging that include which of the following? (Select all that apply.) a. Progression of hearing loss is slow. b. The aging person has low-frequency tone loss. c. Sounds may be garbled and difficult to localize. d. Hearing loss r/t aging begins in the mid-40s. e. Hearing loss reflects nerve degeneration of the middle ear. f. The aging person may find it harder to hear consonants than vowels.
Progression of hearing loss is slow. Sounds may be garbled and difficult to localize. The aging person may find it harder to hear consonants than vowels. rationale: Presbycusis is a type of hearing loss that occurs with aging in those older than 65 years. gradual sensorineural loss caused by nerve degeneration in INNER EAR or auditory nerve. The person first notices a HIGH-frequency tone loss; it is harder to hear consonants (high-pitched components of speech) than vowels, which makes words sound garbled or mixed up. The ability to localize sound is also impaired. especially in large groups.
Where is the stroke belt?
Southeast US, little of middle west (NC, SC, GA)
During an assessment of the newborn, the nurse expects to see which finding when the anal area is slightly stroked? A) A jerking of the legs B) Flexion of the knees C) A quick contraction of the sphincter D) Relaxation of the external sphincter
Quick contraction of the sphincter
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.
Reassure the patient that this is a normal response and continue with the examination. rationale: 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.
Immediately after birth, the nurse is unable to suction the nares of a crying newborn. An attempt is made to pass a catheter through both nasal cavities with no success. What should the nurse do next? a. Attempt to suction again with a bulb syringe. b. Wait a few minutes, and try again once the infant stops crying. c. Recognize that this situation requires immediate intervention. d. Contact the physician to schedule an appointment for the infant at his or her next hospital visit.
Recognize that this situation requires immediate intervention rationale: Determining the patency of the nares in the immediate newborn period is essential because most newborns are obligate nose breathers. Nares blocked with amniotic fluid are gently suctioned with a bulb syringe. If obstruction is suspected, then a small lumen (5 to 10 Fr) catheter is passed down each naris to confirm patency. The inability to pass a catheter through the nasal cavity indicates choanal atresia, which requires immediate intervention.
A patient in her first trimester of pregnancy is diagnosed with rubella. Which of these statements is correct regarding the significance of this in relation to the infant's hearing? 1. Rubella may affect the mother's hearing but not the infant's. 2. Rubella can damage the infant's organ of Corti, which will impair hearing. 3. Rubella is only dangerous to the infant in the second trimester of pregnancy.
Rubella can damage the infant's organ of Corti, which will impair hearing. rationale: If maternal rubella infection occurs during the first trimester, then it can damage the organ of Corti and impair hearing. Maternal rubella can affect the infant's hearing,
A 40-year-old black man is in the office for his annual physical examination. Which statement regarding the PSA blood test is true? A) should be done with this visit. B) should be done at age 45 years. C) should be done at age 50 years. D) is only necessary if there is a family history of prostate cancer.
Should be performed at age 45 years for black people, 50 for everyone else
During an examination, the nurse finds that a patient's left temporal artery is tortuous and feels hardened and tender, compared with the right temporal artery. The nurse suspects which condition?
Temporal arterirtis
What is the articulation of the mandible and the temporal bone called?
Temporomandibular joint
The nurse is assessing color vision of a male child. Which statement is correct? a. Check color vision annually until age 18 b. Ask child to identify color their clothing. c. Test color vision once between ages 4-8 d. Begin color vision screening at childs 2-year checkup
Testing for color vision should be done once between the ages of 4 and 8 years. Boys should be tested only once for color vision between the ages of 4 and 8 years. Color vision is not tested in girls because it is rare in girls. Testing is performed with the Ishihara test, which is a series of polychromatic cards.
The nurse is performing an examination of the anus and rectum. Which of these statements is correct and important to remember during this examination? A) The rectum is about 8 cm long. B) The anorectal junction cannot be palpated. C) Above the anal canal, the rectum turns anteriorly. D) There are no sensory nerves in the anal canal or rectum.
The anorectal junction cannot be palpated. The anal columns are folds of mucosa that extend vertically down from the rectum and end in the anorectal junction. This junction is not palpable but is visible on proctoscopy. The rectum is 12 cm long; just above the anal canal, the rectum dilates and turns posteriorly. It also pertains valves of Houston which hold feces as flatus passes
The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique? a. The best time to perform BSE is in the middle of the menstrual cycle. b. The woman needs to do BSE only bimonthly unless she has fibrocystic breast tissue. c. The best time to perform BSE is 4 to 7 days after the first day of the menstrual period. d. If she suspects that she is pregnant, the woman should not perform a BSE until her baby is born.
The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. rationale: The best time to conduct a BSE is right after the menstrual period, or the 4-7 day of the menstrual cycle, when the breasts are the smallest and least congested. The pregnant or menopausal woman who is not having menstrual periods should be advised to select a familiar date to examine her breasts each month—for example, her birth date or the day the rent is due. Women do not need to be advised to perform BSEs bimonthly. BSE on a monthly basis will help you feel familiar with your own breasts and their normal variations.
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.
The cremaster muscle contracts in response to cold and draws the testicles closer to the body. When it is cold, the cremaster muscle contracts, which raises the scrotal sac ipsilateral and brings the testes closer to the body to absorb heat necessary for sperm viability. its very strong in infants. The lymphatic vessels of the testes drain into abdomen and penis & scrotal surface drain. (abdominal lymph nodes not accessible in exam) 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.
The nurse assesses the hearing of a 7-month-old by clapping hands. What is the expected response? 1. The infant turns the head to localize sound. 2. No obvious response to noise 3. A startle and acoustic blink reflex 4. The infant stops movement and appears to listen.
The infant turns his or her head to localize the sound rationale: A startle reflex and acoustic blink reflex is expected in newborns; at age 3 to 4 months, the infant stops any movement and appears to listen. With a loud sudden noise, the nurse should notice the infant turning his or her head (not stopping any movement) to localize the sound and to respond to his or her own name.
The nurse is preparing to perform an otoscopic examination of a newborn infant. Which statement is true regarding this examination? 1. Immobility of the drum is a normal finding. 2. An injected membrane would indicate infection. 3. The normal membrane may appear thick and opaque.
The normal membrane may appear thick and opaque. rationale: During the first few days after the birth, the tympanic membrane of a newborn often appears thickened and opaque. It may look injected and have a mild redness from increased vascularity but not from infection. The eardrum of a neonated is more horizontal, making it more difficult to see completely. By one month of age the drum is in the oblique (more vertical) position as in the adult.
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 ask a postmenopausal woman if she ever has vaginal bleeding. B) Once a woman reaches menopause, the nurse does not need to ask any further history questions. C) The nurse should screen for monthly breast tenderness. D) Postmenopausal women are not at risk for contracting sexually transmitted infections and thus these questions can be omitted.
The nurse should ask a postmenopausal woman if she has ever had vaginal bleeding.
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 done. 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 well to avoid a painful examination.
The nurse should plan to lubricate the instruments and the examining hand adequately to avoid a painful examination
The nurse is performing an external eye examination. Which statement regarding the outer layer of the eye is true? a. outer layer of eye is sensitive to touch b. outer layer of eye is darkly pigmented to prevent light from reflecting internally c. Trigeminal nerve CN V and trochlear nerve CV IV are stimulated when the outer surface of eye is stimulated d. visual receptive layer of eye in which light waves are changed into nerves impulses is located in the outer layer of the eye
The outer layer of the eye is very sensitive to touch. rationale: The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to touch. The middle layer, the choroid, has dark pigmentation to prevent light from reflecting internally. The trigeminal nerve (CN V) and the facial nerve (CN VII), not the trochlear nerve (IV), are stimulated when the outer surface of the eye is stimulated. The retina, in the inner layer of the eye, is where light waves are changed into nerve impulses.
Which statement concerning the anal canal is true? A) is about 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.
The outlet for the gastrointestinal tract 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.
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?
This is a normal finding in newborns and should resolve within a few weeks." It is normal for a newborn's genitalia to be engorged and have discharge 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
pigmentation of the anus is darker than the surrounding skin, the anal opening is closed, and a skin sac that is shiny and blue is noted. The patient mentioned that he has had pain with bowel movements and has occasionally noted some spots of blood. What does this assessment and history most likely indicate? A) Anal fistula B) Pilonidal cyst C) Rectal prolapse D) Thrombosed hemorrhoid
Thrombosed hemorrhoid The anus normally looks moist and hairless, with coarse folded skin that is more pigmented than the perianal skin, and the anal opening is tightly closed. pain with stooling (descezia) and blood in stool (hematochezia).The shiny blue skin sac indicates a thrombosed hemorrhoid.
What are the projections in the nasal cavity that increase the surface area are called? a. Meatus b. Septum c. Turbinates d. Kiesselbach plexus
Turbinates The lateral walls of each nasal cavity contain three parallel bony projections: the superior, middle, and inferior turbinates. These increase the surface area, making more blood vessels and mucous membrane available to warm, humidify, and filter the inhaled air. A meatus is the passageway or canal underlying each turbinate that collects drainage. The septum is what divides the nasal cavity into two slitlike air passages. The Kiesselbach plexus is a rich vascular network in the anterior part of the septum.
Which CN is responsible for conducting nerve impulses to the brain from the organ of Corti?
VIII - vestibulocochlear or auditory
female patient has an inverted left nipple. Which statement regarding this is most accurate? a. Normal nipple inversion is usually bilateral. b. A unilateral inversion of a nipple is always a serious sign. c. It should be determined whether the inversion is a recent change. d. Nipple inversion is not significant unless accompanied by an underlying palpable mass.
Whether the inversion is a recent change should be determined. The nurse should distinguish between a recently retracted nipple from one that has been inverted for many years or since puberty. Normal nipple inversion may be unilateral or bilateral and usually can be pulled out; that is, if it is not fixed. Recent nipple retraction signifies acquired disease
A patient comes to the clinic complaining of neck and shoulder pain and is unable to turn her head. Which nerve does the nurse suspect is damaged and how should the nurse proceed with the examination? a. XI; palpating the anterior and posterior triangles b. XI; asking the patient to shrug her shoulders against resistance c. XII; percussing the sternomastoid and submandibular neck muscles
XI; have patient shrug their shoulders against resistance. rationale: The major neck muscles are the sternomastoid and the trapezius. They are innervated by CN XI, the spinal accessory. Identifying the anterior and posterior triangles are helpful guidelines when describing findings in the neck but palpating them does not assess any cranial nerves
What is the cause of Ambiguous genitalia/intersex?
XXY genes or exposed to testosterone or estrogen in utero
For DTR, 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. Complete the examination, and then test these reflexes again. c. Refer the patient to a specialist for further testing.
a. Ask the patient to lock her fingers and pull. Sometimes the reflex response fails to appear. 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.
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. 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 1 years of age
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) obstetric history because it is the most important information. C) urinary system history because there may be problems in this area as well. D) sexual history because it will build rapport to discuss this first.
a. Menstrual history, because it is generally nonthreatening.
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.
a. These findings are normal, resulting from aging. Rationale: Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands when reaching for something, 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.
The nurse is reviewing the changes that occur with menopause. Which changes are expected? A) Uterine and ovarian atrophy along with thinning 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
a. Uterine and ovarian atrophy, along with thinning of vaginal epithelium rationale: 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.
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 behind 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 about 6 inches from the edge of the table to prevent her from feeling as if she will fall off.
b. Elevate her head and shoulders to maintain eye contact. The nurse should elevate her head and shoulders 45 degrees 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 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) Discharge that is sticky and yellow-green D) Gaping and slightly shriveled labia majora
b. Multiple nontender sebaceous cysts
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's contracture.
b. Ulnar deviation
DEXA
bone density test, recommended for females 65+
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 cancer occurs in men. d. Most breast masses in men are diagnosed as gynecomastia.
breast cancer in men rarely spreads to the lymph nodes.
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?"
c. "Do you have any warning sign before your seizure starts?" rationale: 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.
During an examination of a female patient, the nurse notes lymphadenopathy and suspects an acute infection. How do acutely infected lymph nodes typically appear? a. Unilateral. c. Firm but freely movable.
c. Firm but freely movable rationale: Acutely infected lymph nodes are bilateral, enlarged, warm, tender, and firm but freely movable. Unilaterally enlarged nodes that are firm, nontender, and persistant may indicate cancer.
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
c. Increased intracranial pressure 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.
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
c. Lateral spinothalamic tract, thalamus, and sensory cortex The spinothalamic tract contains sensory fibers that transmit the sensations of pain and temp (lateral tract), and crude touch (anterior tract). At the thalamus, the fibers synapse with another sensory neuron, which carries the message to the sensory cortex for full interpretation.
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
c. Level of consciousness, motor function, pupillary response, and vital signs rationale: 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.
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. CN dysfunction. b. Lesion in the cerebral cortex. c. Normal changes attributable to aging. d. Demyelination of nerves attributable to a lesion.
c. Normal changes attributable to aging rationale: 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.
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. Eliciting the cremasteric reflex is recommended. 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.
c. Retracting the foreskin should be avoided until the infant is 3 months old.
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) rotator cuff lesions. C) dislocated shoulder. D) rheumatoid arthritis.
c. Rotator cuff lesions rationale: 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 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.
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) suspect a fractured clavicle. B) suspect that the infant may have a deformity of the spine. C) suspect that the infant may have weakness of the shoulder muscles. D) consider this a normal finding because the musculature of an infant this age is undeveloped.
c. Weakness of the shoulder muscles 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.
When a breastfeeding mother is diagnosed with a breast abscess, which of these instructions from the nurse is correct? The mother needs to: a. continue to nurse on both sides to encourage milk flow. b. discontinue nursing immediately to allow for healing. c. temporarily discontinue nursing on affected breast and manually express milk and discard it. d. temporarily discontinue nursing on affected breast but can manually express milk and give it to the baby.
c. temporarily discontinue nursing on affected breast and manually express milk and discard it.
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?
cervical
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."
d. "You need to get up slowly when you've been lying down or sitting." rationale: 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 man who was found wandering in a park at 2 AM has been brought to the ER for 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
d. Acute alcohol intoxication rationale: 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. Another test is finger to finger and heel down shin. Peripheral neuropathy is loss of sensation thats worse at the feet and hands and gradually improves as the examiner moves up the leg (diabetics and alcoholics)
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?
d. Goodell and Chadwick Rationale: Pregnant women cervix can turn bluish color (chadwick sign) or softens and appears velvety (goodell sign) both are early signs of being pregnant. Another change is increased cervical and vaginal secretions that keep bacteria from growing but increases candidiasis (yeast infection)
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's sign. D) negative Ortolani's sign.
d. Negative Ortolani sign
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.
d. Pelvic inflammatory disease
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. Negative Homans sign. c. Positive Romberg sign.
d. Positive Romberg sign rationale: A positive Romberg sign is a loss of balance, testing vestibular apparatus 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.
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
d. Spastic hemiparesis rationale: 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
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.
d. Subcutaneous nodules. Subcutaneous nodules are raised, firm, and nontender and occur with rheumatoid arthritis in the olecranon bursa and along the extensor surface of the ulna. Olecranon bursitis-most likely - red, hot, swollen Epicondylitis—tennis elbow- doesn't usually make the hot red swelling Gout - usually present unilateral, metabolic disease.all of these are elbow abnormalities
During an assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. What do these findings indicate? a. Dehydration b. A normal oral assessment c. Irritation from gastric juices d. Side effects from nausea medication
dehydration
nipple is flat, broad, and fixed. The patient states it "started doing that a few months ago." What does this finding suggest a. dimpling. b. a retracted nipple. c. nipple inversion. d. deviation in nipple pointing.
dimpling Unilateral abnormal contour of the breast
The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane? 1. Red and bulging 2. Hypomobility 3. Retraction with landmarks clearly visible 4. Flat, slightly pulled in at the center, and moves with insufflation
hypomobility rationale: An early sign of otitis media is hypomobility of the TM. As pressure increases, the TM begins to bulge. A fiery red color and bulging of the entire eardrum is not an early sign of otitis media but occurs a little later. A retracted tympanic membrane with landmarks clearly visible indicates a blocked eustachian tube which is not an early sign of otitis media. A tympanic membrane that is flat, slightly pulled in at the center, and moves with insufflation is a normal eardrum, not a manifestation of otitis media.
Explain contralateral functioning of the cerebral hemispheres
its opposite, left controls motor for right and right controls motor for left
What are the functional units of the musculoskeletal system?
joints
A patient's vision is recorded as 20/80 in each eye. How does the nurse interpret this finding?
poor vision
A patient's laboratory data reveal an elevated thyroxine (T4) level. What gland should the nurse assess? a. Thyroid b. Parotid c. Adrenal d. Parathyroid
thyroid rationale: thyroid gland is a endocrine gland that secretes T4 and T3. The parotid glands are salivary glands and secrete saliva. The adrenal glands secrete corticosteroids, and the parathyroid glands control the body's calcium.
During an examination, the patient states he is hearing a buzzing sound and says that it is "driving me crazy!" What does this indicate? 1. vertigo. 2. pruritus. 3. tinnitus. 4. cholesteatoma.
tinnitus rationale: Tinnitus is a a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders. pruritus is itching; and cholesteatoma is an overgrowth of epidermal tissue in the middle ear or temporal bone that has a pearly white, cheesy appearance.