NURS 307 Exam 4

The nurse notes thrush on the palate of a client. The most appropriate question the nurse should ask is A) "Have you been on antibiotics recently?" B) "Have you traveled out of the country in the last month?" C) "Do you smoke?" D) "Have you been tested for HIV?"

A) "Have you been on antibiotics recently?"

Functionally, the most important range for hearing is the range of human speech. What is the range of human speech? A) 500 Hz to 3000 Hz B) 450 Hz to 2500 Hz C) 400 Hz to 2000 Hz D) 350 Hz to 1500 Hz

A) 500 Hz to 3000 Hz Rationale: When trying to distinguish between conductive and neurosensory hearing loss, you need a quiet room and a tuning fork, preferably of 512 Hz or possibly 1024 Hz. These frequencies fall within the range of human speech (300 Hz to 3000 Hz)—functionally the most important range.

What are associated manifestations of a headache caused by a traumatic head injury? (Mark all that apply.) A) Attention span deficit B) Apathy C) Seizures D) Gait changes E) Changes in appetite

A) Attention span deficit C) Seizures D) Gait Changes Rationale: Associated manifestations of headache associated with TBI: vision changes; nausea or vomiting; attention span deficits; drainage from the ears, nose, eyes, or mouth; tremors; seizures; or gait changes.

What does the nurse assess the face for? (Select all that apply.) A) Edema B) Hair color C) Affect D) Asymmetry E) Involuntary movements

A) Edema D) Asymmetry E) Involuntary movements Rationale: Note the client's facial expression and contours. Observe for asymmetry, involuntary movements, edema, and masses.

A client presents at the clinic for a routine check-up. The nurse notes that she is dressed in warm clothing even though the temperature outside is 73°F (22.8°C). The nurse also notes that the client has gained 10 pounds (4.5 kg) since her last visit 9 months ago. What might the nurse suspect? A) Hypothyroidism B) Brain tumor C) Hyperthyroidism D) Effects of age-related changes

A) Hypothyroidism Rationale: Intolerance to cold, preference for warm clothing and many blankets, and decreased sweating suggest hypothyroidism; the opposite symptoms, palpitations, and involuntary weight loss suggest hyperthyroidism.

During your physical examination of the client you note an enlarged tender tonsillar lymph node. What would you do? A) Look for a source such as infection in the area that it drains B) Look for involvement of other regions of the body C) Assess for dietary changes D) Assess for meningitis

A) Look for a source such as infection in the area that it drains Rationale: Knowledge of the lymphatic system is important to a sound clinical habit: whenever a malignant or inflammatory lesion is observed, look for involvement of the regional lymph nodes that drain it; whenever a node is enlarged or tender, look for a source such as infection in the area that it drains.

When examining the eye with an ophthalmoscope, where would the nurse look to visualize the optic disc? A) Medially toward the nose B) Laterally toward the ear C) Downward toward the chin D) Upward toward the forehead

A) Medially toward the nose Rationale: Follow the blood vessels as they get wider. Follow the vessels medially toward the nose and look for the round yellowish orange structure which is the optic disc.

What are the glands that are located on the tarsal plates and open on the lid margins? A) Meibomian glands B) Pterygium glands C) Chalazion glands D) Levator glands

A) Meibomian glands Rationale: Within the eyelids lie firm strips of connective tissue called tarsal plates. Each plate contains a parallel row of meibomian glands, which open on the lid margin.

Your client is complaining of nasal stuffiness. What drugs should you ask if she is taking? (Mark all that apply.) A) Oral contraceptives B) Alcohol C) Guanethidine D) Guaifenesin E) Nicotine

A) Oral contraceptives B) Alcohol C) Guanethidine Rationale: Inquire about drugs that might cause stuffiness: oral contraceptives, reserpine, guanethidine, and alcohol.

You note anterior bulging of the physiologic cup when performing a funduscopic examination of your client's eyes. What would you document? A) Papilledema B) Positive axoplasmic sign C) Hyperopia D) Arteriovenous crossings

A) Papilledema Rationale: Papilledema describes swelling of the optic disc and anterior bulging of the physiologic cup.

A 16-year-old white female is brought to the clinic by her mother with a chief complaint of a severe headache lasting more than 24 hours. The mother states, "Just before the headache started my daughter was craving food. I couldn't feed her enough." What is this called? A) Prodrome B) Aberrant sign C) Neurologic onset D) Aura

A) Prodrome Rationale: Is there a prodrome of unusual feelings such as euphoria, craving for food, fatigue, or dizziness? Is there an aura with neurologic symptoms, such as change in vision or numbness or weakness in an arm or leg?

The client tells the nurse that he has little or no interest in sex. He says he is concerned and he knows his wife is unhappy with his lack of libido. What can the nurse tell the client often causes lack of libido? A) Side effects of medications B) Testosterone hypersecretion C) Manic episodes D) Mental illness

A) Side effects of medications Rationale: Lack of libido may arise from psychogenic causes such as depression, endocrine dysfunction, or side effects of medications.

When assessing a client with Graves disease, how would you expect the thyroid gland to be? A) Soft B) Nodular C) Tender D) Firm

A) Soft Rationale: Soft in Graves disease; firm in Hashimoto thyroiditis, malignancy. Benign and malignant nodules, tenderness in thyroiditis.

The nurse observes an inward turning of the lower lid in a 77-year-old client. The nurse documents A) entropion B) exophthalmos C) ectropion D) ptosis

A) entropion

A client has conjunctivitis. The nurses understand that conjunctivitis differs from conjunctival hemorrhage in that conjunctivitis A) has a watery, mucoid discharge. B) is not painful. C) can result from a cough. D) usually follows trauma.

A) has a watery, mucoid discharge.

Prostate cancer is the leading cancer diagnosed in men in the United States. To increase knowledge of risk factors, the nurse would teach men that (Select all that apply.) A) it occurs earlier and is more advanced in African American men B) 15% have an affected first-degree relative C) testicular self-examinations can reduce the risk by 50% D) each decade after age 50 increases the risk E) symptoms are often undetectable

A) it occurs earlier and is more advanced in African American men B) 15% have an affected first-degree relative D) each decade after age 50 increases the risk

A client with hypothyroidism is admitted to the medical unit. The nurse would expect to assess which signs/symptoms? Select all that apply. A) lethargy B) cool skin C) weight loss D) lower systolic blood pressure E) constipation

A) lethargy B) cool skin E) constipation

The nurse would expect to assess which symptoms in a client complaining of migraine headaches? Select all the apply. A) recurrent B) muscle tension C) photophobia D) continuous E) throbbing

A) recurrent C) photophobia E) throbbing

The nurse should ask about or assess which associated factors when a client complains of cluster headaches? Select all that apply. A) rhinorrhea B) photophobia C) ptosis D) miosis E) lacrimation

A) rhinorrhea C) ptosis D) miosis E) lacrimation

It is important to encourage all men to do testicular self-examinations. The nurse would emphasize that the highest incidence of testicular cancer occurs in men aged A) 50-65 B) 15-35 C) 68-82 D) 38-45

B) 15-35

The nurse examines the pharynx of a client and records that the tonsils are touching the uvula. The nurse would grade the tonsils as A) 2+ B) 3+ C) 1+ D) 4+

B) 3+

Prevention of HIV is important in all populations. The nurse is planning a presentation to the population of women that has the highest transmission incidence in the United States. The nurse is presenting to which group of women? A) Latina B) African American C) Caucasian D) Japanese

B) African American

The nurse is taking a sexual history on a new client. What action is considered appropriate at this time? (Select all that apply.) A) Explain to the client what is considered to be normal sexual behavior B) Note that you realize this information is highly personal C) Affirm that your conversation is confidential D) Explain why you are taking the sexual history E) Relate that you gather this history on only high-risk clients

B) Note that you realize this information is highly personal C) Affirm that your conversation is confidential D) Explain why you are taking the sexual history Rationale: Tips for taking the sexual history: explain why you are taking the sexual history; note that you realize this information is highly personal, and encourage the client to be open and direct; relate that you gather this history on all your clients; affirm that your conversation is confidential.

A client arrives in the emergency department by ambulance after falling down his front steps. The nurse notes two soft lumps, approximately 3 cm in diameter, on the side of his head. What would the nurse identify these as? A) Pigmented nevi B) Pilar cysts C) Signs of abuse D) Edema from fall

B) Pilar cysts Rationale: Part the hair in several places and look for scaliness, lumps, nevi, or other lesions. Redness and scaling may indicate seborrheic dermatitis, psoriasis; soft lumps of pilar cysts (wens); pigmented nevi.

What systemic diseases may cause nodular episcleritis? (Mark all that apply.) Multiple sclerosis A) Muscular dystrophy B) Systemic lupus erythematosus C) Rheumatoid arthritis D) Fibromyalgia

B) Systemic lupus erythematosus C) Rheumatoid arthritis Rationale: If you need a fuller view of the eye, rest your thumb and finger on the bones of the cheek and brow, respectively, and spread the lids. The local redness below is from nodular episcleritis, often self-limiting in younger adults; it is also seen in rheumatoid arthritis and system lupus erythematosus.

What structure in the inner ear senses the position and movements of the head and helps to maintain balance? A) The umbo B) The labyrinth C) The ossicle D) The cochlea

B) The labyrinth Rationale: The labyrinth within the inner ear senses the position and movements of the head and helps to maintain balance.

What are the bordering landmarks of the anterior triangle of the neck? (Mark all that apply.) A) The omohyoid muscle B) The mandible C) The sternomastoid D) The clavicle E) The midline of the neck

B) The mandible C) The sternomastoid E) The midline of the neck Rationale: The anterior triangle is bordered by the mandible above, the sternomastoid laterally, and the midline of the neck medially.

What is the primary purpose of the health history in relation to the eyes? A) To test the acuity of central vision B) To identify changes C) To identify if problems are unilateral or bilateral D) To identify a family history of ocular disease

B) To identify changes Rationale: The purpose of the health history is to identify changes in the eyes.

What are the indications for a pelvic examination during adolescence? (Select all that apply.) A) Minimal bleeding during menses B) Vaginal discharge C) Dysmenorrhea D) Onset of menarche at age 13 E) Prescription of contraceptives

B) Vaginal discharge C) Dysmenorrhea E) Prescription of contraceptives Rationale: Indications for a pelvic examination during adolescence include menstrual abnormalities such as amenorrhea, excessive bleeding, or dysmenorrhea; unexplained abdominal pain; vaginal discharge; the prescription of contraceptives; bacteriologic and cytologic studies in a sexually active girl; and the client's own desire for assessment.

While reviewing the medical record before examining a male clinic client, the nurse notes that the urinary meatus is located on the top of the glans of the penis. The nurse understands the correct term for this congenital defect is A) hypospadias B) epispadias C) hydrocele D) varicocele

B) epispadias

The nurse does a health history. The client states he has lost 30 pounds in the last couple months without really trying. The client also states he feels warm all the time and sometimes feels like he has heart palpitations. The nurse would anticipate orders to evaluate the client for A) hyperbilirubinemia B) hyperthyroidism C) hypernatremia D) hyperproteinemia

B) hyperthyroidism

When preparing a presentation for parents of adolescent girls on the need for the HPV vaccine, the nurse should include the fact that by ninth grade the percentage of girls who have been sexually active is A) 66 B) 77 C) 33 D) 55

C) 33

A female client has come to the clinic for her yearly check-up. During the history the client tells the nurse that she does not "feel anything" during sex with her husband. The nurse knows that the most common cause of this type of problem is what? A) A medical factor B) A social factor C) A situational factor D) A physical factor

C) A situational factor Rationale: Sexual problems can be the result of physical or psychological issues. More commonly, however, a sexual problem is related to situational or psychosocial factors.

You are teaching a health class on a college campus. What would you teach the students to use during oral sex to help reduce the transmission of STDs? A) Oral barriers B) Oral condoms C) Dental dams D) Dental prophylactic

C) Dental dams Rationale: Use of dental dams during oral sex will act as a barrier to bodily fluids and help reduce transmission of STDs such as herpes, genital warts, and HIV.

What is a characteristic symptom of Graves hyperthyroidism? A) Episcleritis B) Pterygium C) Exophthalmos D) Pinguecula

C) Exophthalmos Rationale: In exophthalmos the eyeball protrudes forward. When bilateral, it suggests the infiltrative ophthalmopathy of Graves hyperthyroidism.

What is vital in maintaining vision and a healthy outlook for clients? A) Physical exercise B) Monthly eye exams C) Health education D) Emotional support

C) Health education Rationale: Nursing education is vital in maintaining vision and a healthy outlook for clients.

The client states that she does not enjoy sex because she does not attain adequate vaginal lubrication. The nurse should be aware of what potential causes of sexual dysfunction? (Select all that apply.) A) Excessive testosterone B) Amenorrhea C) Psychiatric conditions D) Medical illness E) Lack of estrogen

C) Psychiatric conditions D) Medical illness E) Lack of estrogen Rationale: Sexual dysfunction is classified by the phase of sexual response. A woman may lack desire, she may fail to become aroused and attain adequate vaginal lubrication, or, despite adequate arousal, she may be unable to reach orgasm. Causes include lack of estrogen, medical illness, and psychiatric conditions.

When assessing a client the nurse notes that the tonsils are touching the uvula. How would the nurse document the tonsils? A) Tonsils are T2 B) Tonsils are T1 C) Tonsils are T3 D) Tonsils are T4

C) Tonsils are T3 Rationale: Tonsils are graded based on size: T1: tonsils are visible; T2: tonsils are between the tonsillar pillars and the uvula; T3: tonsils are touching the uvula; T4: tonsils are touching each other.

The nurse notes that the ophthalmologist suspects death of the optic nerve. When looking into the eye, the nurse would expect to see what color if the disc is dead? A) black B) yellow C) white D) red

C) white

A client in the clinic where you work is considered legally blind. The nurse knows that this means the vision in his better eye, corrected by glasses, is what? A) 20/300 or less B) 20/400 or less C) 20/100 or less D) 20/200 or less

D) 20/200 or less Rationale: In the United States, a person is usually considered legally blind when vision in the better eye, corrected by glasses, is 20/200 or less.

A rape victim is being examined in the emergency department. A special rape kit must be used to ensure what? A) Diagnostic imaging is performed B) Anonymity of care C) Only licensed personnel do the examination D) A chain of custody for evidence

D) A chain of custody for evidence Rationale: Often there is a special rape kit, provided in many emergency departments, that must be used to ensure a chain of custody for evidence.

You are assessing visual fields on a client newly admitted for eye surgery. The client's left eye repeatedly does not see your fingers until they have crossed the line of gaze. You would document that the client has what? A) A quadrantic defect B) A homonymous hemianopsia C) A bitemporal hemianopsia D) A left temporal hemianopsia

D) A left temporal hemianopsia Rationale: When the client's left eye repeatedly does not see your fingers until they have crossed the line of gaze, a left temporal hemianopsia is present.

What ethnic group has a significantly higher incidence rate of prostate cancer? A) Native American B) Asian C) Caucasian D) African American

D) African American Rationale: For undetermined reasons, incidence rates are significantly higher in African American men than in Caucasian men: 232 cases per 100,000 compared with 146 cases per 100,000, even after adjustments for access to care. Prostate cancer occurs at an earlier age and more advanced stage in African American men.

An alternate pathway that bypasses the external and middle ear is called what? A) Air conduction B) Sensory conduction C) Neuro conduction D) Bone conduction

D) Bone conduction Rationale: An alternate pathway, known as bone conduction, bypasses the external and middle ear and is used for testing purposes.

What lines the cheeks? A) Alveolar mucosa B) Labial mucosa C) Lingual mucosa D) Buccal mucosa

D) Buccal mucosa

The nurse is presenting client education on STDs to a high school health class. What infection would the nurse tell the students can be transmitted by oral-penile transmission? A) Urethritis B) Prostatitis C) Cervical cancer D) Chlamydia

D) Chlamydia Rationale: Infections from oral-penile transmission include gonorrhea, chlamydia, syphilis, and herpes.

What activity is known to aggravate a tension headache? A) Prolonged sleep B) Listening to music C) Exercise D) Driving

D) Driving Rationale: Factors that aggravate or provoke: sustained muscle tension, as in driving or typing.

A client presents to the clinic with "sores around the mouth." The nurse notes vesicular lesions on the upper lip and right corner of the lips. The client describes these as painful. The nurse suspects what condition? A) Syphilis B) Actinic cheilitis D) Herpes simplex E) Angioedema

D) Herpes simplex

What is a lay term for the spontaneous loss of pregnancy? A) Missed pregnancy B) Missed abortion C) Abortion D) Miscarriage

D) Miscarriage

The nursing instructor is discussing assessment of the head and neck with the class. What identifying characteristic would the instructor use for the thyroid cartilage? A) Its relation to the cricoid cartilage B) The curve on its inferior edge C) Its position just below the mandible D) The notch on its superior edge

D) The notch on its superior edge Rationale: The thyroid cartilage is readily identified by the notch on its superior edge.

The nurse is performing a physical examination and notes an enlarged left supraclavicular lymph node. The nurse understands that this could be indicative of A) tonsillitis B) nasopharyngitis C) a goiter D) a metastasis

D) a metastasis

The nurse is using the ophthalmoscope to examine the client's eyes. The nurse holds the scope A) in the left hand for both eyes B) in the left hand for the right eye and in the right hand for the left eye C) in the right hand for both eyes D) in the right hand for the right eye and in the left hand for the left eye

D) in the right hand for the right eye and in the left hand for the left eye

A client complains of feeling like he is slowly losing his central vision. The nurse knows this symptom could represent A) open-angle glaucoma B) retinal detachment C) hemianopsia D) macular degeneration

D) macular degeneration Rationale: Macular degeneration causes deterioration in the center of the retina, which leads to a gradual loss of central vision.

The frontal sinuses are the only ones readily accessible to clinical examination. FALSE TRUE

FALSE

The scrotum of a male client appears inflamed. The nurse should assess the femoral nodes. FALSE TRUE

FALSE

The nurse explains to a client that primary dysmenorrhea is a result of increased prostaglandin production. FALSE TRUE

TRUE

The thyroid gland is usually larger in women than in men. FALSE TRUE

TRUE