305 Exam 5

During the breast exam, the nurse palpates a series of lymph nodes. Why is this a part of the breast exam? a. To assess shoulder range of motion. b. It's not. It's done because the chest area is exposed. c. To review the integrity of the skin. d. To assess the deep lymph nodes which drain the mammary lobules.

d. To assess the deep lymph nodes which drain the mammary lobules.

A man comes to clinic after falling off bike landing on left side of handlebars. The RN suspects he may have injured his spleen. which of this is true regarding his assessment a. spleen can be enlarged as result of trauma b. spleen is normally felt upon routine palpation c. enlarged spleen is noted the rn should palpate thoroughly to determine size d. enlarged spleen should not be palpated because it can rupture easily

d. enlarged spleen should not be palpated because it can rupture easily

A woman who's 8 weeks pregnant is in clinic for checkup. The RN reads chart her cervix is softened and looks cyanotic. The RN knows that the woman is exhibiting ____ sign and ____ sign a. tanners, hegars b. hegard, goodells c. chadwicks, hegars d. goodells, chadwicks

d. goodells, chadwicks

a 22 yr old woman has been considering oral contraceptives. as part of history RN should ask a. do you have heart murmur b. will you be in monogamous relationship c. have you thought this through carefully d. if you smoke how much do you smoke a day

d. if you smoke how much do you smoke a day

when the RN is performing a genital exam on a male patient, the patient has an erection. The RN's most appropriate response/action is a. ask pt if he would like someone else to exam him b. continue with the exam as if nothing happened c. stop exam leave room while stating exam will resume at later time d. reassure pt this is a normal response and continue with exam

d. reassure pt this is a normal response and continue with exam

rn is preparing to teach women about b s e ,which statement by rn is correct it is more important than ever for you because you have never had any kids it is so important because 1/9 women will develop breast cx. monthly basis will help you feel familiar w/ own breasts

monthly basis will help you feel familiar w/ own breasts

rn is caring for newborn infant. 30 hrs after birth infant passes dark green meconium stool. this is important because stool would indicate anal potency dark green could indicate occult blood in stool meconium stool can be reflective of distress should pass stool in first 12 hrs of birth

stool would indicate anal potency

during health interview pt states she has pain in L breast. RN best response is don't worry about pain, I would like more info about the pain I had pain like that after my son was born breast pain is almost always the result of benign breast dx

I would like more info about the pain

A patient is complaining of sharp pain along costovertebral angles. The RN knows this symptom is most often indicative of a. ovary infection b. liver enlargement c. kidney inflammation d. spleen enlargement

c. kidney inflammation

RN sees abdominal pulsations between xiphoid and umbilicus. RN would suspect these are: a. pulsations of renal arteries b. pulsation of inferior vena cava c. normal abdominal aortic pulsations d. increased peristalsis from bowel obstruction

c. normal abdominal aortic pulsations

A nurse explains to a 30-year-old woman during her annual exam that the American Cancer Society currently recommends that women have an annual mammogram after what age? a. 60 b. 40 c. 50 d. 30

b. 40

when assessing newborn infant genitalia the RN notices genitalia are somewhat engorged. labia major are swollen, clitoris looks large, and the hymen is thigh. vaginal opening is difficult to visualize. the infants mother states she us worried about the labia being swollen. RN should reply this is a normal finding in newborns and should resolve in few weeks indicate an abnormality and may need to be evaluated by the dr we will need to have estrogen levels evaluated to make sure they're in normal limits we will need to keep close watch over for the next few days to see if the genitalia decrease in size

this is a normal finding in newborns and should resolve in few weeks

rn is teaching pregnant woman about breast milk which statement by rn is correct your breast milk is present immediately after delivery breast milk is rich in protein and sugars but has little fat the colostrum which is present right after birth, does not contain same nutrition as breast milk you may notice a thick yellow fluid expressed fro your breasts as early as 4th month of pregnancy

you may notice a thick yellow fluid expressed fro your breasts as early as 4th month of pregnancy

in examining 70 yr old male rn notices he has bilateral gynecomastia. which is rn best action recommend he make appt w/ dr for mammogram ignore it. explain this condition may be result of hormonal changes and recommend he see his dr tell him gynecomastia in men is usually associated w/ prostate enlargement recommended he be screened thoroughly

explain this condition may be result of hormonal changes and recommend he see his dr

while exam 75 y/o woman rn notices skin over her r breast is thick and hair follicles are exaggerated this condition is known as dimpling retraction peau d'orange benign breast dx

peau d'orange

in review of breast cancer statistics which woman greater than 50 years has highest risk asian american indian african american white

white

The nurse obtains a health history from the following clients. To which one should she give priority in teaching about breast cancer prevention? a. Age 57, has taken estrogen replacement therapy for 10 years, 5 feet, 2 inches tall, 210 pounds b. Gravida 4, Para 4, regular menstrual cycle, uses Depo- Provera for birth control c. Menarche at age 13, drinks a glass of wine three times per week, sister with uterine cancer d. Age 45, African-American, lives in federally funded housing

a. Age 57, has taken estrogen replacement therapy for 10 years, 5 feet, 2 inches tall, 210 pounds Women over 50 who have taken estrogen replacement therapy for more than five years and are obese after menopause are at greater risk for breast cancer. The other women do not exhibit risk factors.

During the breast exam, the nurse asks the client to raise her arms over her head. Why did the nurse change the client's position? a. Skin dimpling is accented in this position. b. The nurse couldn't palpate the axillae correctly. c. The client has small breasts. d. The client has large breasts.

a. Skin dimpling is accented in this position.

The clinic is sponsoring a client education session for breast cancer awareness month. Which of the following considerations should be included to support cultural differences about breast health? a. Refer all clients to the American Cancer Society if they have questions. b. Encourage all females to complete monthly breast exams. c. Inform all about the low-cost breast cancer screening program. d. Encourage all females to increase their intake of vitamins A and E.

b. Encourage all females to complete monthly breast exams.

A 43-year-old woman reports symptoms of hot flashes, weight gain, and insomnia. She says: "I can't be going through menopause, something else must be wrong! My mother didn't go through menopause until she was 54 years old!" What is an appropriate response by the nurse? a. "You definitely are going through menopause, even though it is unusual to do so at such a young age." b. "These are not menopausal symptoms, and you need tests to determine what is happening." c. "This is menopause, and you will have to learn to live with it." d. "Menopause usually happens anytime between ages 40 and 55. It sounds like you are upset about this."

d. "Menopause usually happens anytime between ages 40 and 55. It sounds like you are upset about this." Rationale: Menopause usually occurs anytime between ages 40 and 55. The average age is 47. Common symptoms are hot flashes, chilliness, breast flabbiness, weight gain, insomnia, and more frequent headaches. This can be an anxiety-producing time for women, and the nurse can offer support.

just before going home a new mother asks RN about infants umbilical cord. which of these statements is correct? a. it should fall off by 10 to 14 days b. it will soften before it falls. c. it contains two veins and one artery. d. skin will cover the area within 1 week.

a. it should fall off by 10 to 14 days

17. A patient is brought to the emergency department after a bee sting. The family reports a history of severe allergic reaction, and the patient appears to have some oral swelling. Which of the following is the most urgent nursing action? A. Consult a physician. B. Maintain a patent airway. C. Administer epinephrine subcutaneously. D. Administer diphenhydramine (Benadryl) orally.

B. Maintain a patent airway. The patient may be experiencing an anaphylactic reaction. The most urgent action is to maintain an airway, particularly with visible oral swelling, followed by the administration of epinephrine by subcutaneous injection. The physician will see the patient as soon as possible with the above actions underway. Oral diphenhydramine is indicated for mild allergic reactions and is not appropriate for anaphylaxis.

Claudication is caused by: A. venous insufficiency. B. arterial insufficiency. C. varicose veins. D. stasis ulcerations.

B. arterial insufficiency.

11. Emergency department triage is an important nursing function. A nurse working the evening shift is presented with four patients at the same time. Which of the following patients should be assigned the highest priority? A. A patient with low-grade fever, headache, and myalgias for the past 72 hours. B. A patient who is unable to bear weight on the left foot, with swelling and bruising following a running accident. C. A patient with abdominal and chest pain following a large, spicy meal. D. A child with a one-inch bleeding laceration on the chin but otherwise well after falling while jumping on his bed.

C. A patient with abdominal and chest pain following a large, spicy meal. Emergency triage involves quick patient assessment to prioritize the need for further evaluation and care. Patients with trauma, chest pain, respiratory distress, or acute neurological changes are always classified number one priority. Though the patient with chest pain presented in the question recently ate a spicy meal and may be suffering from heartburn, he also may be having an acute myocardial infarction and require urgent attention. The patient with fever, headache and muscle aches (classic flu symptoms) should be classified as non-urgent. The patient with the foot injury may have sustained a sprain or fracture, and the limb should be x-rayed as soon as is practical, but the damage is unlikely to worsen if there is a delay. The child's chin laceration may need to be sutured but is also non-urgent.

A patient arrives at the emergency department complaining of mid-sternal chest pain. Which of the following nursing action should take priority? A. A complete history with emphasis on preceding events. B. An electrocardiogram. C. Careful assessment of vital signs. D. Chest exam with auscultation.

C. Careful assessment of vital signs.

The RN notices a pt has ascites, which indicates the presence of a. fluid b. feces c.flatus d.fibroid tumors

a. fluid

Which movement should the nurse instruct the client to perform to assess range of motion for the knee? a) Flexion b) Circumduction c) Rotation d) Abduction

Correct response: Flexion Explanation: The nurse should instruct the client to perform flexion to assess the range of motion for the client's knee. Circumduction, rotation, and abduction movements are not possible in the knees. Circumduction is the circular motion of the joint. Rotation involves turning the head to the right shoulder then back to midline and then turning the head to the left shoulder then back to midline. Abduction refers to moving away from the midline of the body. The knees are capable of performing only flexion and extension.

while examining client abdomen the client states she had pain in RUQ. The RN moves to LUQ holding her hand at 90 degrees pushes her hand slowly and deeply into abdomen and quickly releases it. This is which test? a. rebound tenderness b. reported tenderness c. repeat tenderness d. resounding tenderness

a. rebound tenderness

The RN is inspecting scrotum and testes. which finding would require follow up a. skin on scrotum is taut b. left testicle hangs lower than right c. scrotal skin has yellow 1cm nodules that are firm and contender d. testes move closer to body in response to cold temp

a. skin on scrotum is taut

RN is reviewing changes that occur with menopause. which is associated with menopause? 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 ...

a. uterine and ovarian atrophy along with thinning vaginal epithelium

rn is preparing for class in early detection of breast cx. which is true about african american women in US? breast cancer is not a threat to african american women african american women have lower incidence of regional or distant breast cx. african american women are more likely to die of breast cancer at any age

african american women are more likely to die of breast cancer at any age

during discussion for mens health group the rn relatives that the group with highest incidence of prostate cancer is asian americans african americans american indians hispanics

african americans

A 54 year old woman who has just completed menopause is in clinic for an annual exam. which statement should RN include in teaching? a. is not at greater risk for heart disease than younger women. b. should be aware she is at increased risk for dyspareunia because of decreased vaginal secretions c. has only stopped menstruating there are no other significant changes which she should be concerned d. is likely to have difficult with sexual pleasure as result of drastic changed in female.

b. should be aware she is at increased risk for dyspareunia because of decreased vaginal secretions

A 52 yr old patient states she sneezes/coughs she wets herself. The RN suspects a. dysuria b. stress incontinence c. hematuria d. urge incontinence

b. stress incontinence

RN is listening to bowel sounds. Which is true about bowel sounds? a. usually loud, high pitched rushing tinkling sounds b. usually high pitched gurgling irregular sounds c. sound like 2 pieces of leather being rubbed together d. they originate from movement of air and fluid through the large intestine

b. usually high pitched gurgling irregular sounds

rn is conducting class about breast self exam. which indicates proper b s e technique best time is in middle of menstrual cycle woman needs to do b s e bimonthly unless she has fibrocystic breast tissue best time to perform b s e is 4-7 days after 1st day of period.

best time to perform b s e is 4-7 days after 1st day of period.

RN is watching a new grad nurse doing auscultation of abdomen which statement shows correct understanding of the reason auscultation precedes percussion and palpation of the abdomen? a. "we need to determine areas of tenderness before using percussion and palpation." b. "it prevents distortion of bowel sounds that might occur after percussion and palpation." c. "It allows pt more time to relax and therefore be more comfortable." d. " Prevents distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation."

b. "it prevents distortion of bowel sounds that might occur after percussion and palpation."

A nurse, performing a health screening on a female client, notes palpable nodes during palpation of the axillae. The nurse recognizes this finding as which of the following? a. Indicative of a normal finding b. Indicative of a possible malignancy c. Indicative of an infection of the head or lungs d. Indicative of an inflammatory process

b. Indicative of a possible malignancy

A client comes into the clinic for a routine breast and axilla exam. Which assessment technique does the nurse use first during this examination? a. Palpation b. Inspection c. Auscultation d. Percussion

b. Inspection

The nurse notices that a client walks with a limp and has long legs. Which of the following aspects of the general survey is this nurse assessing? a. Physical appearance b. Mobility c. Behavior d. Mental status

b. Mobility

A female client tells the nurse, "I know I should examine my breasts but I just don't." What should the nurse do with this information? a. Instruct the client on how to perform the breast exam again. b. Talk with the client about possible fears associated with the breast exam. c. Instruct the client on getting an annual mammogram instead. d. Nothing.

b. Talk with the client about possible fears associated with the breast exam.

A pregnant client is upset and thinks she has breast disease because she has a thick white discharge coming from her left breast. What can the nurse say or do for this client? a. Call the physician. This information is not normal. b. Help the client understand that she might not be able to breastfeed her infant. c. Nothing. This client needs a mammogram as soon as possible. d. A thick yellow discharge from the breasts during pregnancy is normal.

d. A thick yellow discharge from the breasts during pregnancy is normal.

A client postoperative hip replacement is prescribed a pillow between the legs. Which position will this pillow serve for the client? a. Circumduction b. Flexion c. Adduction d. Abduction

d. Abduction

The nurse notes that a client's nails have a slight convex curve with the angle from the skin to nail base about 160 degrees. What condition of the client's nails is this nurse seeing? a. Paronychia of the nails b. Clubbing of the nails c. Spoon nails d. Normal nails

d. Normal nails

A nurse is testing the range of motion of a client's wrist for supination. Which movement will this involve? a) Moving the tips of the fingers away from the forearm b) Turning the palm of the hand downward c) Moving the tips of the fingers toward the forearm d) Turning the palm of the hand upward

Correct response: Turning the palm of the hand upward Explanation: Supination involves turning or facing upward, in this case turning the palm upward. Pronation involves turning or facing downward, in this case turning the palm downward. Flexion involves bending the extremity at the joint and decreasing the angle of the joint, in this case moving the tips of the fingers toward the forearm. Extension involves straightening the extremity at the joint and increasing the angle of the joint, in this case moving the tips of the fingers away from the forearm.

The nurse is planning a focused breast/axilla interview and wants to include a general health question. Which of the following questions would fit this criteria? a. Are you still menstruating? b. Have you had any breast trauma? c. Has your mother or sister had breast cancer? d. Have you ever had a mammogram?

a. Are you still menstruating?

An advanced practice nurse assessing a client's prostate gland notes a 1 cm protrusion with obliteration of the median sulcus. This finding is indicative of which of the following? a. Benign prostatic hypertrophy b. Prostatitis c. Carcinoma d. A normal finding

a. Benign prostatic hypertrophy

An elderly female client wants to know when she can stop doing breast exams. What can the nurse say to this client? a. Breast cancer can still develop when you get older. b. Probably in a month or two. c. You can stop five years after menopause. d. It's not really necessary at your age.

a. Breast cancer can still develop when you get older.

The nurse finds the blood pressure reading for a 75-year-old female to be extremely low. Which of the following should the nurse do first after measuring this blood pressure? a. Ensure the correct cuff size was used to measure this blood pressure. b. Nothing. Extremely low blood pressures are normal in the elderly. d. Call the physician.

a. Ensure the correct cuff size was used to measure this blood pressure.

A nurse is teaching a lecture on menopause at a local community center. Which symptoms should the nurse educate the women that they may experience as part of the psychologic and physiologic changes associated with menopause? (Select all that apply) a. Osteoporosis b. Insomnia c. Night sweats d. Gray pubic hair e. A decrease in high-density lipoprotein

a. Osteoporosis b. Insomnia c. Night sweats d. Gray pubic hair e. A decrease in high-density lipoprotein Rationale: As many as 80-90% of women who are perimenopausal or menopausal experience a vasomotor disturbance commonly known as a hot flash, making it the most commonly reported menopausal symptom (Varney et al., 2004). Hot flashes are typically described as a feeling of heat rising from the chest and spreading to the neck and face. Hot flashes at night are often accompanied by sleep disturbances triggered by profuse sweating (night sweats) in which a woman awakens with drenched night clothes and bedding. Osteoporosis, a decrease in bone strength related to diminished bone density and bone quality, is a major health concern for women. This change is associated with lowered estrogen levels; however, the greatest influencing factor is family history of osteoporosis. Pubic hair thins, turns gray or white, and may ultimately disappear. Estrogen has a protective mechanism that fosters elevated levels of high-density lipoprotein (HDL) and lower low-density lipoprotein (LDL). As estrogen levels fall during menopause, this protective mechanism ceases.

A postmenopausal client has difficulty remembering to complete a monthly breast exam. What can be done to help this client? a. Suggest the client plan to conduct the exam the first day of every month. b. Nothing. This client doesn't need to do self examinations. c. Schedule the client to come into the clinic every month for the exam. d. Schedule the client to receive a monthly phone call from the clinic as a reminder.

a. Suggest the client plan to conduct the exam the first day of every month.

A client describes breast swelling and tenderness. What piece of data would be most important for the nurse to gather? a. Timing of the symptoms b. Birth control method c. Method of breast self-examination d. Diet history

a. Timing of the symptoms The breast undergoes regular cyclical changes in response to hormonal stimulation. The nurse will want to determine when the swelling and tenderness occurs within the menstrual cycle. Birth control method, method of BSE, and diet history may contribute to the database, but do not have priority.

The nurse is preparing to measure the temperature of a client with an endotracheal tube. Which method of temperature measurement should the nurse use for this client? a. Tympanic b. Axillary c. Oral d. Rectal

a. Tympanic Rationale: The tympanic temperature measures a client's core body temperature quickly and accurately. This method is the most comfortable and least invasive for the client.

An African American male, age 42, has a PSA (prostate-specific antigen) level of 1.5 ng/mL. In planning the client's follow up, the nurse recognizes that the criteria recommend the client have a. annual testing. b. no additional testing until age 45. c. further evaluation with a biopsy. d. no additional testing until age 50.

a. annual testing.

a newborn baby boy is about to have circumcision. The RN knows indication for circumcision include a. cultural and religious beliefs b. prevention of testicular cancer c. improving sperm count later in life d. preventing dysuria

a. cultural and religious beliefs

which of these statements is most appropriate when RN is obtaining a GU history from an elderly 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 preform testicular self exam? d. has anyone every touched your genitals when you did not want them to?

a. do you need to get up at night to urinate?

Which of the following is most important when assessing a client's pain? a. The physical location of the pain b. The client's perception of the pain c. The client's vital signs d. The client appears uncomfortable

b. The client's perception of the pain

RN is assessing the patients risk of STI. appropriate question to ask is: a. you know it's important to use condoms for protection right? b. do you use a condom with each episode of sex? c. do you have an sexually transmitted infection? d. you are aware the dangers of unprotected sex?

b. do you use a condom with each episode of sex?

RN is preparing to examine pt who is complaining of RLQ pain. which technique is correct during assessment a. examine tender area 1st b. examine tender area last c. avoid palpating tender area d. palpate tender area 1st then auscultate for bowel sounds

b. examine tender area last

RN is preparing to exam external genitalia of school age girl. which position is most appropriate a. parents lap b. frog leg position on exam table c. in lithotomy position w/ feet in stirrups d. lying flat on exam table

b. frog leg position on exam table

When assessing an infant for pain, the pain management nurse recognizes that: a. a lack of a physiologic or behavioral response means a lack of pain. b. if something causes pain in an adult, it can cause pain in an infant. c. the parent's observations should not be included in the patient's assessment of pain. d. Wong-Baker FACES Scale is an appropriate assessment tool.

b. if something causes pain in an adult, it can cause pain in an infant.

The RN is describing how to perform TSE to a patient. Which statement is most appropriate by the nurse? A. a good time to exam your testicles is just before you shower b. if you notice enlarged testicle or painless lump call your doctor c. testicle is egg shaped and moveable. it feels firm and has lumpy consistency d. perform tse at least once a week

b. if you notice enlarged testicle or painless lump call your doctor

patient is suspected of having inflammation of gallbladder, or cholecystisits. The RN should conduct which technique to assess? a. obturator test b. murphy's sign c. rebound tenderness d. iliopsoas muscle test

b. murphy's sign

A nurse is teaching a group of women about the appropriate method for performing a breast self-exam (BSE). Which of the following statements regarding breast self-exam demonstrates correct comprehension of the material? a. "Breast exams should begin around age 30." b. "Breast exams should be done one week prior to the menstrual cycle." c. "Breast exams should incorporate both feeling and looking at the breasts." d. "Breast exams should be done during the middle of the menstrual cycle."

c. "Breast exams should incorporate both feeling and looking at the breasts." Breast exams should incorporate both feeling and looking at the breasts. Premenstrual swelling and tenderness of the breasts may be present one week prior. Breast self-examination should begin as early as possible, preferably when the individual is an adolescent.

A 45-year-old woman reports to the nurse that she is experiencing slightly irregular menstrual cycles and some hot flashes, insomnia, and vaginal dryness. What should the nurse tell this patient? a. "You are experiencing menopause symptoms, which are normal for your age." b. "You are experiencing a hormonal imbalance that requires medical evaluation and treatment." c. "You are experiencing perimenopause symptoms, which are normal for your age." d. "You are having dysfunctional uterine bleeding and will probably require a D&C."

c. "You are experiencing perimenopause symptoms, which are normal for your age."

A nurse assessing a female client's breasts notes a thickened, dimpled skin with enlarged pores in the areola. The nurse recognizes this finding as which of the following? a. Associated with mastitis b. Indicative of a normal finding c. Associated with malignancy d. Suggestive of benign lesions

c. Associated with malignancy

A client asks the nurse, "Why do I need to examine my armpits when I do my monthly breast exam?" Which of the following would be an appropriate response for the nurse to make to this client? a. Who told you that you have to do that? b. I'm not sure why that is important, but it sounds like it is. c. Breast tissue extends into the axilla. d. This is the hardest area to feel for changes.

c. Breast tissue extends into the axilla.

A 14-year-old female client is upset because her breast development is not equal. What can the nurse say to this client? a. They look equal to me. b. Don't worry about that! c. Breast tissue growth is uneven but will even out as you get older. d. Maybe you should talk with your mother about breast surgery?

c. Breast tissue growth is uneven but will even out as you get older.

The client tells the nurse, "At times I have drainage from my right breast." What should the nurse do with this information? a. Phone for a mammogram for the client immediately. b. Write it in the medical record and say nothing to the client. c. Explain that this could be benign or it could mean something else. It needs to be further investigated. d. Nothing. It doesn't mean a thing.

c. Explain that this could be benign or it could mean something else. It needs to be further investigated.

A 51-year-old male has never had a prostate examination. Which of the following should be done for this client? a. Schedule him for this examination as soon as possible. b. Nothing. c. Instruct him in the need for prostate examinations after the age of 50. d. Encourage him to continue with monthly self-testicular examination.

c. Instruct him in the need for prostate examinations after the age of 50.

The nurse is preparing to assess a client's hip joints. Which of the following should the nurse expect to assess with this client? a. Rotation only b. Slipping and gliding motion c. Movement in all axes and planes d. Flexion and extension only

c. Movement in all axes and planes

During the physical examination of a male client's scrotum, the nurse palpates a mass. What should the nurse do next with this information? a. Nothing. This is a normal finding. b. Document mass palpated, left testicle. c. Perform transillumination to further assess the finding. d. Ask the client how long he's had a tumor in his testicle.

c. Perform transillumination to further assess the finding.

An elderly client with back and leg pain avoids eye contact with the nurse and has vital signs within normal limits. The nurse notices that this same client was in the clinic four weeks earlier with complaints of acute pain. From this information, the nurse could determine: a. The client no longer has pain. b. Nothing. There isn't anything new with this client. c. The client might be experiencing chronic pain. d. The client is in severe acute pain.

c. The client might be experiencing chronic pain.

A client tells the nurse, "My legs are always cold." What significance does this information have to the nurse? a. The client smokes. b. The client has stasis ulcers. c. The client might have arterial insufficiency. d. The client has edema.

c. The client might have arterial insufficiency.

The nurse notes that the fold of epidermal skin around an adolescent client's fingernails is bleeding. Which of the following does this finding indicate about the client? a. The client will have difficulty regulating body temperature. b. The client will have difficulty synthesizing vitamin D. c. The client's nail roots can be at risk for infection. d. The client is at risk for losing viable hair follicles.

c. The client's nail roots can be at risk for infection.

A client with a head injury is demonstrating difficulty swallowing and talking. Which cranial nerve might be adversely affected with this head injury? a. Hypoglossal b. Glossopharyngeal c. Vagus d. Accessory

c. Vagus Rationale: The vagus (CN X) innervates the muscles of the throat and mouth for swallowing and talking.

A client is two weeks postoperative appendectomy and is still experiencing pain. The nurse realizes this client is most likely experiencing: a. Referred pain b. Deep somatic pain c. Visceral pain d. Intractable pain

c. Visceral pain

during exam of aging male, the RN recognizes normal changes to expect would be; a. enlarged scrotal sac b. increased pubic hair c. decreased penis size d. increased rugae over scrotum

c. decreased penis size

A patient is having difficulty swallowing medications and food. The nurse would document that this patient has a. aphasia b. dysphasia c. dysphagia d. anorexia

c. dysphagia

The RN notices a patient has black tarry stool and recalls possible cause would be a. gallbladder disease b. overuse of laxatives c. gi bleed d. localized bleeding around the anus

c. gi bleed

A nurse is volunteering at a health screening sponsored by a local church and community center. The nurse is educating men about benign prostatic hyperplasia (BPH). Which of the following men is at greatest risk of developing BPH? a. A 38 year old Japanese man who is a vegetarian b. A 52 year old Caucasian man who has a family history of BPH c. A 27 year old Hispanic man who has a family history of BPH d. A 56 year old African American man who is a carnivore

d. A 56 year old African American man who is a carnivore

During an admission assessment on a 79-year-old client, the nurse learns the client has been taking three different medications, all for the same health condition. What should the nurse do with this information? a. Nothing. This is typical for clients in this age range. b. Phone the admitting physician to ensure all medications are on the admission orders. c. Document it in the medical record. d. Contact the primary care physician.

d. Contact the primary care physician. Rationale: Older adults often consume several prescription medications. Overmedication may occur because older adults seek care from multiple healthcare providers without collaboration regarding treatment.

A client is admitted to the hospital for acute bleeding related to peptic ulcer disease. The nurse knows that which of the following assessments of the client's stool indicates acute hemorrhage? a. Drainage that is dark red b. Drainage that is the color of coffee grounds c. Stool that is black and tarry d. Drainage that is bright red and contains clots

d. Drainage that is bright red and contains clots Drainage that is dark red, or the color of coffee grounds, is observed when blood has been in the stomach for a period of time. Stool that is black and tarry indicates less acute bleeding. Drainage that is bright red with possible clots, or stool containing red blood and clots indicates acute hemorrhage. The risk of fluid volume deficit, decreased blood volume, and electrolyte disturbances is great with acute bleeding and should be managed aggressively.

A 45-year-old patient reports pain in the foot that moves up along the calf, saying: "My right foot feels like it is on fire." The patient reports that the pain started yesterday and that he or she has no previous history of injuries or falls. Which components of pain assessment has the patient reported? a. Aggravating and alleviating factors b. Exacerbation, and associated signs and symptoms c. Intensity, temporal characteristics, and functional impact d. Location, quality, and onset

d. Location, quality, and onset

A nurse performing a physical assessment on a male client palpates a smooth, firm, mobile, tender disc of breast tissue behind the areola. The nurse suspects which of the following? a. This is a normal finding. b. This is a carcinoma. c. This indicates metastasis. d. This is gynecomastia.

d. This is gynecomastia.

RN is aware that one change that may occur in gi system of an aging adult is a. increased salivation b. increased liver size c. increased esophageal empty d. decreased gastric secretion

d. decreased gastric secretion

The doctor comments that a patient has abdominal borborygmi. The RN knows that this term refers to: a. a loud continous hum. b. a peritoneal friction rub. c. hypoactive bowel sounds d. hyperactive bowel sounds

d. hyperactive bowel sounds

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? a. percuss & palpate lumbar region b. inspect & palpate epigastric region c. auscultate & percuss the inguinal region d. percuss and palpate in the midline area above the suprapubic bone

d. percuss and palpate in the midline area above the suprapubic bone

during health history 22 yr old asks, "can I get that vaccine for HPV? I have genital warts and I'd like them to go away." The nurses best response is a. HPV vaccine is for girls 9-29 so we can start today b. the vaccine is only for girls who have not started having sex c. lets check with dr to see if you're a candiate d. the vaccine cannot protect you if you already have HPV

d. the vaccine cannot protect you if you already have HPV

RN is caring for elderly female who complains of dry mouth. Knowing what you do about changes to the GI system as we age what is the best follow up question for the nurse to make a. what have you had to eat in last 24 hrs b. have you had any n/v in last few days c. how have you been moving your bowels d. what medications are you taking?

d. what medications are you taking?

when testing stool for occult blood rn is aware false positive may result in absent bile pigment increased fat content increase ingestion of iron large amount of red meat in last 3 days

large amount of red meat in last 3 days

pt visiting clinic has abd pain x 2 weeks. describes stool being soft and black for 10 days denies meds. these symptoms are most indicative of excessive fat caused my malabsorption increased iron intake resulting from diet change occult blood resulting in gi bleed absent bile pigment from liver problem

occult blood resulting in gi bleed