Ch 3 - Assessment and Health Promotion

1 Obesity is defined as a BMI of 30 or greater. A BMI of 32 puts the woman into the obese category. Overweight is defined as a BMI of 25 to 29.9.

A body mass index (BMI) of 32 is calculated for a woman. The nurse knows that this index puts the woman into which category of weight? 1 Obesity 2 Appropriate 3 Underweight 4 Overweight

The nurse is assessing a woman's breast self-examination (BSE) technique. Which action indicates that the woman needs additional instruction regarding BSE? 1 Performs every month on the first day of her menstrual period 2 Uses the pads of her fingers when palpating each breast 3 Inspects her breasts while standing before a mirror and changing arm positions 4 Places a folded towel under right shoulder and right hand under head when palpating right breast

1 BSE should be performed once a month after the menstrual period has ended. Using the pads of the fingers when palpating each breast, inspecting the breasts while standing before a mirror, placing a folded towel under the right shoulder and right hand under the head are appropriate actions for BSE.

What does the nurse regularly monitor in a patient with cocaine addiction to prevent its associated complications? 1 Blood pressure 2 Blood glucose levels 3 Blood uric acid levels 4 White blood cell counts

1 Cocaine impairs cardiac functioning and causes cardiovascular disorders, such as tachycardia and hypertension. Therefore, to prevent these complications the nurse should regularly monitor blood pressure and heart rate of the patient. Cocaine does not affect the pancreas and insulin levels, so it is not mandatory to regularly monitor blood glucose levels. Cocaine also does not affect hyperuricemia and leucopenia. Therefore, the nurse need not assess the blood uric acid levels and white blood cell count.

A body mass index (BMI) of 32 is calculated for a woman. The nurse knows that this index puts the woman into which category of weight? 1 Obesity 2 Appropriate 3 Underweight 4 Overweight

1 Obesity is defined as a BMI of 30 or greater. A BMI of 32 puts the woman into the obese category. Overweight is defined as a BMI of 25 to 29.9.

A 42-year-old woman asks the nurse about mammograms, now that she is "getting older." The nurse should tell her that: 1 the American Cancer Society recommends mammograms every 1 to 2 years for women ages 40 to 49. 2 the best time to perform a mammogram is just before a menstrual period. 3 regular mammograms reduce the need to perform breast self-examination (BSE). 4 mammograms can confirm the diagnosis for breast cance

1 The current guidelines indicate that a mammogram should be performed every 1 to 2 years on women between the ages of 40 and 49. Mammograms are best performed beginning at about 1 week after menstruation when the breasts are the least tender. Mammograms are not a substitute for BSE, which should still be performed every month. A biopsy of cells from suspicious lesions is required to confirm a diagnosis of cancer.

At a community health care center, the nurse advises a patient to regularly self-examine the breast for early detection of changes in the breast tissue. What instruction does the nurse give while teaching the procedure to the patient? 1 "Palpate the breast slowly with the tip of your three middle fingers." 2 "Lie down and place your hands straight without bending the shoulders." 3 "Apply light pressure to feel the breast tissue close to the chest and ribs." 4 "Observe for presence of a firm ridge in the lower curve of the breast."

1 The nurse should instruct the patient to palpate the breast with the tips of the three middle fingers. This helps to identify the presence of lumps in the breast. While examining the breast the patient should choose a comfortable position. For instance, lying down and placing the pillow under the shoulder helps examine all the breast tissue, such as near the shoulders from the collarbone to under arms. Due to the presence of bony covering, firm pressure should be applied to assess the tissue near to the chest and rib. Appearance of firm ridge in the lower curve of the breast is a normal finding. Dimpling of skin, changes in the nipple, redness, or swelling in the breast are the signs of breast disorders.

Which statement provides correct information about performing a Papanicolaou (Pap) test? 1 The woman should not douche, use vaginal medications, or have intercourse for at least 24 hours before the test. 2 It should be performed once a year beginning with the onset of puberty. 3 A lubricant such as Vaseline should be used to ease speculum insertion. 4 The specimen for the Pap test should be obtained after specimens are collected for cervical infection.

1 Women should not douche, use vaginal medications, or have sexual intercourse for 24 hours before the examination to not alter the cytology results. Pap tests are performed annually for sexually active women or by age 18, especially if risk factors for cervical cancer or reproductive tract infections are present. Pap tests may be performed every 3 years in low risk women after three negative results on annual examination. Only warm water should be used on the speculum so as not to alter the cytology results. The cytologic specimen should be obtained first.

The nurse prepares to communicate with an abused patient. The nurse finds that the patient has pain due to pelvic fracture. Which points does the nurse keep in mind before communicating with the patient? Select all that apply. 1 To sit with the patient in a closed room. 2 To tell the patient,"You are not alone." 3 To teach pelvic muscle exercises to the patient. 4 To tell the patient that the pelvic pain is progressive. 5 To inform the patient that pelvic fracture may cause amenorrhea.

1, 2 There are certain guidelines that a nurse should follow while communicating with patients who have been abused. The nurse should sit down with the patient in a closed room and reassure the patient that he or she is not alone, as this helps build trust and enhance the patient's self-esteem. The patient is taught pelvic muscle exercises to strengthen the muscles that support the pelvic floor in order to prevent accidental urine loss. These exercises are taught after interacting with the patient and making the patient feel comfortable. Nurses should not make the patient feel anxious by giving wrong information that the pelvic pain is progressive. The nurse should assure the patient that better treatment will be provided for having effective relief from the pain. Dysrhythmias and amenorrhea are caused due to anorexia nervosa. Therefore, the nurse should not give false information that pelvic fracture may cause amenorrhea.

The women's health nurse knows which statements regarding sexual response are accurate? Select all that apply. 1 Women and men are more alike than different in their physiologic response to sexual arousal and orgasm. 2 Vasocongestion is the congestion of blood vessels. 3 The orgasmic phase is the final state of the sexual response cycle. 4 Facial grimaces and spasms of hands and feet are often part of arousal. 5 Sexual difficulties should be disregarded in the postpartum period.

1, 2, 4 Men and women are more alike than different in regards to the physiologic response to sexual arousal and orgasm. Vasocongestion causes vaginal lubrication and engorgement of the genitals. The final state of the sexual response cycle is the resolution phase after orgasm. Arousal is characterized by increased muscular tension (myotonia). Sexual difficulties should be addressed during the postpartum period.

The primary health care provider (PHP) suggests acupuncture for a pregnant patient. Which symptoms in the patient made the PHP suggest acupuncture? Select all that apply. 1 Seizures 2 Agitation 3 Tachycardia 4 Hallucinations 5 Mild euphoria

1, 3 Acupuncture is the best treatment for cocaine abuse in pregnancy. Seizures and tachycardia are the effects of cocaine abuse. Agitation is produced by phencyclidine (PCP) and lysergic acid diethylamide (LSD) (Delsyd). PCP causes hallucinations and other dissociative symptoms. Mild euphoria is produced by marijuana.

Which symptoms are noted by the nurse while assessing a patient with stress? Select all that apply. 1 Grinding of teeth. 2 Accentuated alertness. 3 The patient cries for no reason. 4 Sweaty hands. 5 The patient has low blood pressure.

1, 3, 4 During stress the patient becomes nervous and has anxiety. Therefore, while assessing a patient with stress the nurse should make a note of the symptoms, such as grinding teeth, crying for no reason, and having sweaty hands. During stress the patient has reduced attention and impaired decision-making abilities. The blood pressure increases during stress due to elevated levels of norepinephrine. Therefore, being on extreme alert and having low blood pressure are not indicative of stress.

The nurse records the body mass index (BMI) of a patient and finds that the patient is overweight. What would be the approximate BMI of the patient? 1 17.5 2 28.3 3 32.6 4 22.9

2 A BMI of 25.0 to 29.9 is an indication of being overweight. In this case, the patient's BMI would be 28.3. If BMI is 17.5 or below 18.5, then the patient is said to be underweight. The BMI of 18.5 to 24.9 indicates normal weight, and a range of 30.0 to 34.5 indicates obesity. Hence, the patient's BMI may not be 32.6 or 22.9.

The primary health care provider observes fetal hyperactivity in a pregnant patient. What is a possible reason for fetal hyperactivity? 1 Pregnant woman had acupuncture treatment. 2 Methadone maintenance treatment during pregnancy. 3 Inadequate maternal intake of calcium supplements. 4 Inadequate maternal intake of folic acid supplements.

2 Fetal hyperactivity is a withdrawal symptom of methadone consumption in pregnant patients, which is used to treat opiate abuse. As methadone is more rapidly metabolized in the pregnant patient, the treatment should be closely monitored. Acupuncture is used to treat cocaine abuse in pregnancy. Cocaine abuse causes an increased incidence of miscarriage, preterm labor, small-for-gestational age babies, abruption of placenta, and stillbirth and anomalies. Inadequate intake of calcium supplements leads to osteoporosis in the pregnant patient. Folic acid insufficiency in the pregnant patient increases the risk of neural tube defects, such as spina bifida and anencephaly.

Which exercises should the nurse teach a patient to strengthen the muscles of the pelvic floor? 1 Squat exercises 2 Kegel exercises 3 Plank exercises 4 Aerobic exercises

2 Kegel exercises are pelvic muscle exercises that involve the tightening and relaxing of the muscles that support the bladder and urethra. Squat exercises are for buttocks and thighs to strengthen the legs. Plank exercises are used for the abdomen, shoulders, and chest muscles. Aerobic exercise increases the metabolism and helps with weight loss. Aerobic exercise does not help to strengthen the pelvic floor muscles.

The nurse is caring for a pregnant patient with injuries and burns. When interacting with the patient, the nurse understands that the patient is being physically abused by the intimate partner. What will be the immediate action of the nurse? 1 Tell the patient, "It is your mistake to tolerate your partner's misbehavior." 2 Tell the patient, "It is a crime, and you deserve to be treated with respect." 3 Ask the patient, "Why you are silent and not revolting against your partner?" 4 Talk to the patient's partner and advise to stop abusing the patient during pregnancy.

2 Many patients who have been physically abused have low self-esteem and depression. The nurse should effectively communicate with the patients to increase their self-esteem. The nurse should give moral support to the patient by saying, "It is a crime, and you deserve to be treated with respect." Such a statement provides comfort to the patient, as it shows that the nurse is understanding and perceptive. Making the patient feel to blame could cause the patient to become more depressed, which would lead to withdrawal. Additionally, making negative remarks like, "It is your mistake to tolerate," may make the patient defensive, and, in turn, cause the patient to stop interacting with the nurse. The nurse should avoid asking the patient why she remains silent, because this may come across as if the nurse is blaming her for being abused. The nurse should not talk to the patient's partner, as it may put the patient in further danger.

A pregnant patient is admitted to the emergency department. The laboratory reports show that there is increased carbon dioxide level in the blood and improper oxygen supply to the fetus. On evaluating the medical history of the patient, the nurse finds that the patient is addicted to drugs. Which drug did the patient use? 1 Cocaine 2 Marijuana 3 Phencyclidine 4 Methamphetamine

2 Marijuana is a substance derived from the cannabis plant, which causes an altered state of awareness. In a pregnant patient marijuana readily crosses the placenta and increases carbon dioxide levels in the mother's blood, which leads to a reduced oxygen supply to the fetus. Cocaine is a powerful nervous system stimulant that causes high pleasure, but, in pregnant patients, can lead to miscarriage, stillbirth, or preterm labor. Phencyclidine (PCP) is a synthetic drug. It causes dissociative symptoms, such as hallucination and disordered thinking. Methamphetamine is a highly addictive stimulant that makes the user feel hypersexual and uninhibited. In the pregnant patient, the use of methamphetamine leads to preterm birth and intrauterine growth restriction.

The nurse-midwife is teaching a group of pregnant women about Kegel exercises. Which statement by a participant indicates a correct understanding of the instruction? 1 "I will only see results if I perform 100 Kegel exercises each day." 2 "I should hold the Kegel exercise contraction for 10 seconds and rest for 10 seconds between exercises." 3 "I should only perform Kegel exercises in the sitting position." 4 "I will perform daily Kegel exercises during the last trimester of my pregnancy to achieve the best results."

2 The correct technique for Kegel exercises is to hold the contraction for at least 10 seconds and rest for 10 seconds in between so the muscles can have time to recover and each contraction can be as strong as the woman can make it. Guidelines suggest that women perform between 30 and 80 Kegel exercises. Kegel exercises are best performed in a supine position with the knees bent. Kegel exercises should be performed throughout the pregnancy to achieve the best results.

The nurse is preparing to conduct a pelvic exam in a patient with trichomoniasis. The nurse finds that the patient has visual impairment and is physically disabled. Which action does the nurse employ while conducting the test? 1 The nurse conducts the test in the presence of the patient's family member. 2 The nurse informs about each step to the patient before performing the test. 3 The nurse asks the patient to lie in lithotomy position during the pelvic exam. 4 The nurse takes the permission of the patient's family members for conducting the test.

2 While assessing and examining a patient with visual impairment and physical disability, the nurse should make the patient feel comfortable to reduce the patient's anxiety. The nurse should explain the examination and inform the patient before touching him or her. The nurse should conduct the pelvic examination in a private and comfortable setting. The patient may not be comfortable with the presence of the family members during the examination. Lithotomy position may not be comfortable to physically disabled patients. Hence, the nurse should explain different positions to the patient and ask which position may be most comfortable for him or her. The nurse should take the permission of the patient before conducting the test, as it helps to establish trust and reduce anxiety.

What should the clinic nurse include in the instructions for a woman scheduling a pelvic examination? Select all that apply. 1 You can use a douche the day before the examination. 2 You should avoid intercourse for 24-48 hours before the examination. 3 Be sure to apply any vaginal medication you are taking before the examination. 4 If you start your menstrual cycle on the day of the examination, we will need to reschedule. 5 Arrive at the clinic with a full bladder.

2, 4 The complete gynecologic assessment includes a pelvic examination. The woman should schedule the examination between menstrual periods and should not douche or have sexual intercourse for 24-48 hours before the examination. She also is advised not to use vaginal medications, sprays, or deodorants that might interfere with interpretation of specimens that are collected. A full bladder is not necessary for a pelvic examination and could be uncomfortable for the client.

What is the purpose of recommending a Papanicolaou (Pap) test for women over 20 years of age? To detect if the patient has: 1 An infection. 2 Conceived. 3 Cervical cancer. 4 Been sexually abused.

3 A Pap test is commonly recommended for women between 20 to 65 years of age to detect the presence of carcinogenic conditions, such as cervical cancers. Urinary tract infection can be assessed by doing a urine culture. Pregnancy can be determined by assessing the human chorionic gonadotropin levels in the urine or blood. The smear from the vagina is examined for presence of sperm to find out if the woman has been sexually abused.

A patient is suffering from a sleep disorder. What advice does the nurse give to the patient to improve sleep? 1 Do aerobics for 2 hours before sleeping. 2 Consume energy drinks before sleeping. 3 Avoid consuming alcohol before sleeping. 4 Try to sleep at all possible times for few weeks.

3 Difficulty staying asleep or initiating sleep is correlated to physical and mental health. Alcohol should be avoided to improve sleep as it causes a hazy mind and proper rest is not provided. Physical strain or vigorous activity, like aerobics, should be avoided before sleep. Instead the patient must be advised to partake in soothing activities, such as guided imagery and listening to soft music. Energy drinks contains high amounts of caffeine, which affect the central nervous system and can lead to sleep deprivation. Hence, the nurse should advise the patient to avoid consuming energy drinks before going to bed. To prevent sleep disorders the patient must be encouraged to follow a regular sleep pattern. This promotes a proper sleep-wake cycle. Therefore, the nurse should advise the patient to not sleep unnecessarily, and the patient should sleep only at night.

The nurse is teaching a woman of childbearing age about the purpose of a pelvic examination. Which statement made by the woman indicates further teaching is needed? 1 "I know the pelvic exam is done to take samples for the Pap test." 2 "I know the health care provider will be palpating my uterus during the pelvic exam." 3 "I know they will be able to feel my fallopian tubes and check them during the pelvic exam." 4 "I know they can collect a sample during the pelvic exam to rule out if I have chlamydia."

3 Feeling the fallopian tubes usually is not possible during a pelvic examination, so the woman needs further teaching if a statement is made that the fallopian tubes will be checked. The pelvic examination is done to take a Pap sample, a chlamydia sample, and the uterus is palpated during the pelvic examination.

While assessing a patient using the SCOFF questionnaire, the nurse finds that the patient has gradually lost weight over several months. What factor responsible for weight loss does the nurse suspect in the patient? 1 Obesity 2 Stress 3 Anorexia nervosa 4 Lack of physical activity

3 SCOFF is a questionnaire used to assess whether the patient has anorexia nervosa—an eating disorder. Obesity results in an increase of weight rather than a decrease of weight. Stress results in hormonal imbalance, muscle tenseness, and a weakened immune system. Exercise helps to strengthen and support muscles, lowers stress, and helps prevent diseases. A drastic decrease in weight is not due to lack of physical exercise.

The nurse is providing instruction to an adolescent regarding the normal menstrual cycle. To assess understanding, the nurse asks the young woman to repeat back to her the appropriate phase of the cycle for implantation of the fertilized ovum to occur. The correct phase is: 1 Menstrual 2 Proliferative 3 Secretory

3 The menstrual phase is marked by the shedding of the lining of the uterus. This phase lasts 3 to 5 days and is known as the woman's period. The proliferative phase beings at the end of menses and is one of restoration and repair. Under the influence of estrogen the uterine lining proliferates and becomes more vascular. During the secretory phase the secretion of progesterone by the corpus luteum results in the thickening of the uterine lining, creating the perfect environment for the fertilized ovum.

The nurse should include questions regarding sexuality when gathering data for a reproductive health history of a female patient. Which principle should guide the nurse when interviewing the patient? 1 An in-depth exploration of specific sexual practices should be included for every patient. 2 Sexual histories are optional if the patient is not currently sexually active. 3 Misconceptions and inaccurate information expressed by the patient should be corrected promptly. 4 Questions regarding the patient's sexual relationship are unnecessary if she is monogamous.

3 To obtain the most accurate reproductive health history, the nurse needs to correct misconceptions and inaccurate information. More in-depth assessments are required if the patient is sexually active or if problems or concerns are raised during general questions. Sexuality should be included on every reproductive health history whether or not the patient is sexually active. The relationship and sexual partner should be discussed even if the patient is monogamous.

What risk factors does the nurse assess in a patient during preconception care? Select all that apply. 1 Gingivitis 2 Sleep disorder 3 Exposure to toxic chemicals 4 Down syndrome and cystic fibrosis 5 Hypertension, diabetes, and anemia

3, 4, 5 The nurse should assess patients for risk factors, such as toxic chemicals exposure, Down syndrome, cystic fibrosis, hypertension, diabetes, and anemia, during preconception care to minimize fetal malformations and miscarriage. Sleep disorders and gingivitis do not cause fetal malformation and miscarriage. However, advising the patient to avoid consuming coffee and to listen to soft music can treat sleep disorders. Gingivitis can be prevented by advising the patient to maintain proper oral hygiene and to take vitamin C supplements. These do not cause major risks to the fetus and patient.

The nurse observes that a patient weighs 166 lb and is 160 cm tall. What is the approximate body mass index (BMI) of the patient? Record your answer using a whole number. ___________

30 The weight of the patient is 166 lb. 1 kg= 2.2 lb. Therefore, 166 lb = 75.4 kg. The patient's height = 160 cm. If 1 m= 100 cm, then 160 cm = 1.6 m. BMI is defined as a measure of a person's weight (kilograms) divided byte square of the height (meters). Hence, the BMI of the patient = 75.4/1.62 = 75.4/2.56=29.45. It is approximately equal to 30.

During the assessment of a pregnant patient the nurse suspects that the patient may have dysrhythmias, cardiomyopathy, and heart failure. To prevent these complications the nurse suggests the patient maintain a healthy diet and stop rigorous exercise. What is the most likely reason for anticipating these complications in the patient? 1 Maternal obesity. 2 Maternal presentation of bulimia nervosa. 3 Patient is a cigarette smoker. 4 Maternal presentation of anorexia nervosa

4 Anorexia nervosa is a chronic eating disorder in which a patient perceives himself or herself to be too heavy. As such, patients with anorexia nervosa undertake severe diets and rigorous exercise. As a result, the patient may have dysrhythmias and cardiomyopathy. To prevent these complications the nurse advises the patient to maintain a healthy diet and stop rigorous exercise. Patients who are very obese are at increased risk for hypertension, diabetes, gallbladder disease, postterm pregnancy, and musculoskeletal problems. Bulimia nervosa is a chronic eating disorder in which the patient practices secret, uncontrolled binge eating habits that alternate with methods to prevent weight gain. If the patient had bulimia, the nurse would anticipate that the patient may have dehydration and electrolyte imbalance, gastrointestinal abnormalities, and cardiac dysrhythmias. Cigarette smoking causes early menopause, osteoporosis, and chronic lung disorders.

After assessing a patient, the nurse understands that the patient may have early menopause and is also at risk for osteoporosis. What could be the reason for this condition? The patient is: 1 Diabetic. 2 Morbidly obese. 3 Severely anemic. 4 A cigarette smoker.

4 Cigarette smoking may reduce the age for menopause and increase the risk for osteoporosis after menopause. Diabetes is caused by an increase in blood glucose levels due to reduced insulin production. This condition does not result in menopause. Obesity is caused due to accumulation of excess fat in the body. It can cause premature death, diabetes, heart disease, and osteoporosis. It does not cause early menopause. Anemia is caused by reduced red blood cell count and does not usually result in menopause and osteoporosis.

The laboratory report of a pregnant patient indicates high blood plasma levels of methamphetamine. What are the possible complications that nurse suspects to find in the neonate? 1 Hearing impairment 2 Microcephaly 3 Absence of upper limbs 4 Reduced head circumference

4 Methamphetamine is a central nervous system stimulant that is cheap and easily available. Like other illicit drugs, amphetamine decreases the intrauterine growth and causes major birth defects in the neonate if the mother takes it during pregnancy. It leads to growth retardation and decreases the head circumference of the neonate. Hearing impairment is caused by amino glycosides antibiotics, and not by methamphetamine. Microcephaly is caused by alcohol consumption. Absence of upper limbs or reduced development of limbs is called phocomelia and is caused by thalidomide (Thalomid). However, its use is banned all over the world.

A pregnant patient is unable to curtail alcohol abuse. What does the health care provider prescribe for the patient to prevent fetal abnormalities? 1 Iron supplements 2 Calcium supplements 3 Folic acid supplements 4 Multivitamin supplements

4 Multivitamin supplements are provided to pregnant patients who are unable to curtail alcohol abuse. Multivitamin supplements help reduce the effect of prenatal alcohol exposure in children. Iron supplements are used to treat anemia or iron deficiency, but not alcohol abuse. Calcium supplements are prescribed for bone ailments. Folic acid is prescribed during pregnancy to prevent miscarriage or birth defect, but is not taken for alcohol abuse.

The nurse is preparing to examine a patient with cervical cancer. Which is the most suitable site of examination for the patient? 1 Clitoris 2 Fallopian tube 3 Bartholin glands 4 Transformation zone

4 The nurse should examine the transformation zone: the junction of squamous and columnar epithelial layers, for any neoplastic changes. The clitoris is a small structure composed of erectile tissue with numerous sensory nerve endings and is located underneath the prepuce. Its size increases during sexual arousal. The fallopian tubes provide a passage between the ovaries and the uterus for the movement of the ovum. Bartholin glands are located posteriorly on the sides of the vaginal opening. They secrete clear mucus to lubricate the vagina during sexual arousal.