Client Assessment Exam 3

A woman who has undergone a total hysterectomy asks a nurse about follow-up Pap smears. What statement by the nurse is correct?

"Cervical screening is not necessary once a total hysterectomy is performed."

A 17-year-old client has expressed concern over having a vaginal discharge just before her menses begins. What response should the nurse provide the client to best address her concerns?

"If there are no other signs or symptoms, it is likely a result of normal ovulation."

A 52-year-old client with myopia calls the ophthalmology clinic very upset. She tells the nurse, "I keep seeing semi-clear spots floating across my vision. What is wrong with me?" What would be the most appropriate response by the nurse?

"It is not an uncommon finding in people older than 40 years for this to happen. They are called 'floaters'.

Which statement by a client in regards to her ability to conceive should prompt a nurse to ask additional questions about infertility?

"My husband and I have had unprotected intercourse for over a year"

Which vision acuity reading indicates blindness?

20/200

Upon examination of the head and neck of a client, a nurse notes that the submandibular nodes are tender and enlarged. The nurse should assess the client for further findings related to what condition?

Acute infection

A nurse is assessing the mouth of a client and finds that she has a smooth, red, shiny tongue without papillae. The nurse should recognize this as indicative of a loss of which vitamin?

B12

The nurse is examining a child with severe cerebral palsy. On sudden movement of the child's foot dorsally, a sustained "beating" of the foot against the nurse's hand ensues. What does this represent?

Clonus

A client presents to the health care clinic for a routine pelvic examination. The client tells the nurse that she has experienced several yeast infections over the past year. The nurse should ask the client about the presence of which disease process?

Diabetes mellitus

What recommendations would a nurse advocate during infancy and childhood to help reduce potential adult complications such as orchitis?

Ensure immunizations against infectious diseases such as mumps.

The nurses assesses the thyroid gland of a client with recent weight loss. On auscultation, a low, soft, rushing sound is heard over the lateral lobes. What condition is most likely?

Hyperthyroidsim

A client diagnosed with goiter has undergone a thyroidectomy. Which statement from the client indicates understanding of post-operative care teaching?

I must take thyroid hormone replacement medication for the rest of my life.

The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should proceed to examine the

Maxillary sinuses

When performing an assessment of the nervous system, it is most appropriate for a nurse to complete it in which sequence?

Mental, status, cranial nerves, motor/cerebellar, sensory reflexes

The nursing instructor is discussing the administration of nasal spray with the nursing students. What information is most important to include in this discussion?

Overuse of nasal spray may cause rebound congestion

On palpation of a client's prostate, a nurse detects hard, fixed, and irregular nodules on the prostate. Which condition should the nurse most suspect in this client?

Prostate cancer

A 12-year-old presents to the clinic with his father for evaluation of a painful lump in the left eye. It started this morning. The client denies any trauma or injury. There is no visual disturbance. Upon physical examination, there is a red raised area at the margin of the eyelid that is tender to palpation; no tearing occurs with palpation of the lesion. Based on this description, what is the most likely diagnosis?

Stye

When the female client reports a frothy yellow-green or brown vaginal discharge, the nurse suspects the client has a vaginal infection caused by what?

Trichomonas vaginalis

Which of the following assessment techniques should the nurse use to determine a client's stereognosis?

With the client's eyes closed, place a coin or key in hand and ask him or her to identify the object.

The functional reflex that allows the eyes to focus on near objects is termed

accommodation

The nurse notes a white curd-like discharge when inspecting a female client's labia. What should the nurse suspect this client is experiencing?

candida vaginitis

The husband of a 65-year-old female tells the nurse, "My wife is having trouble navigating the steps in our home and needs my help to step down off a curb." What part of the nervous system should the nurse assess for a potential source of the problem?

cerebellum

The client has experienced a stroke and has dysphagia. The nurse knows this is what?

difficulty swallowing

The outer layer of the vaginal wall is under the direct influence of

estrogen

The rectum is lined with folds of mucosa, and each fold contains a network of arteries, veins, and visceral nerves. When these veins undergo chronic pressure, the result may be

hemorrhoids.

What information should nurse include in the teaching plan for a client considering a vasectomy?

offers permanent birth control

A client visits the clinic and tells the nurse that he is depressed because of a recent job loss. He complains of dull, aching, tight, and diffuse headaches that have lasted for several days. The nurse should recognize that these are symptoms of

tension headaches.

The nurse understands that malocclusion may be related to what?

tooth loss

When the nurse is obtaining the health history of the nose and sinuses, a client reports symptoms of rhinorrhea. Which question should the nurse ask to determine associated manifestations of this symptom?

"Have you had a sore throat?"

A nurse is assessing a client for abnormalities of gait due to a concern that the client is at increased risk for a fall. Which instruction should the nurse give the client first?

"Walk across the room and back"

When assessing muscle tone and strength, the nurse would document expected findings as

"upper and lower extremity muscle strength is 5/5 bilaterally"

A male client is assessed for suspected benign prostatic hypertrophy (BPH). The nurse expects the client to suffer from what symptoms?

- Inability to empty the bladder - Weak urinary stream - Dribbling after urination - Frequent urination during the night

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 left temporal hemianopsia

The nurse lightly strokes the sides of a client's abdomen, above and below the umbilicus. For which reflex is the nurse testing?

Abdominal

A nurse examines the external genitalia of a client and observes that the scrotum is underdeveloped and the testis cannot be palpated. How should the nurse document this condition?

Cryptorchidism

When performing the cover test, a nurse notices that the client's left eye turns outward. How should the nurse document this finding in the client's record?

Exotropia

A nurse examines the anal area of a client and observes the presence of a varicose vein. How should the nurse document this finding?

External hemorrhoid

The nurse instructs the client to raise his arm out to the side and overhead. The nurse is asking the client to adduct his arm. (t/f)

False

Upon inspection and palpation of the front of the client's thigh, the nurse discovers a bulge that appears when the client coughs. The nurse should document this finding as what type of hernia

Femoral

A female client has been diagnosed with menorrhagia. What information should the nurse provide the client concerning menses flow?

Flow may include clots.

A client visits a community clinic reporting severe allergies causing a "crackling sensation" in the ear. The physician diagnoses serous otitis media. What is a characteristic of this condition?

Fluid collects in the middle ear causing an obstruction of the auditory tube

A client reports the appearance of rings around lights. A nurse should perform further assessment to confirm the onset of what disorder?

Glaucoma

A nurse is providing client teaching to the parents of a preschooler who experiences chronic epistaxis. What would the nurse identify as the area where most nosebleeds originate?

Kiesselbach's plexus

A client presents to the health care clinic with reports of clay-colored stool. The nurse recognizes that this finding is most likely a result of which of the following?

Lack of bile pigment

The nurse is caring for an adult client who suffers from a spinal cord hemisection due to a tumor. The client is unable to feel pain or temperature changes below the level of the tumor. What other symptoms should the nurse teach the family to expect the client to experience?

Loss of position sense, vibration, and motor function on the same side of the body

A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headaches that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a

Migraine headache

A client comes to the Emergency Department complaining of sudden sharp testicular pain. Further examination reveals torsion of the spermatic cord. Which of the following would the nurse expect to do next?

Prepare the client for surgery.

The nurse observes a middle-aged colleague fully extending her arm to read the label on a vial of medication. What age-related changes is the nurse likely to have observed?

Presbyopia

What characteristic feature of the tympanic membrane should a nurse anticipate finding in a client with acute otitis media?

Red, bulging, with an absent light reflex

When examining the uterus, a nurse finds that the cervix and the body of the uterus are tilted backward. How should the nurse document this uterine finding?

Retroverted

A client presents to the health care clinic and reports pain in the eyes when working on the computer for long periods of time. The client states that he almost ran into a parked car yesterday because he misjudged the distance from the bumper of his own car. He works for a computer software company and has noticed he is experiencing difficulty reading the manuals that accompany the software he installs for companies. What nursing diagnosis can the nurse confirm based on this data?

Risk for Injury

An adult male client comes to the clinic complaining of awakening at night to void and voiding more than once in a 2-hour time period. The client has a history of bladder irritation. What would be an appropriate nursing diagnosis for this client?

Risk for urge incontinence

Palpation of a 15-year-old boy's submandibular lymph nodes reveals them to be enlarged and tender. What is the nurse's most reasonable interpretation of this assessment finding?

There is an infection in the area that these nodes drain.

The nurse plans to test which cranial nerve when testing an elderly client's hearing status?

VIII

The nurse assessing for unilateral hearing loss by using a tuning fork. What test is the nurse performing?

Weber's test

An adult client tells the nurse that he has been experiencing gradual vision loss. The nurse should

check the client's blood pressure

While performing a gynecologic examination, the nurse observes small, painful, ulcer-like lesions with red bases on the client's labia. The nurse should refer the client to a physician for possible

herpes simplex virus infection.

A client notices that the newspaper print is not as clear to read as it used to be. What health problem should the nurse consider is occurring with this client?

hyperopia

A client reports using pain medication and sitting in a dark room on the onset of a migraine headache. In what part of the subjective section of the physical examination should the nurse document this information?

relieving factors

A 22-year-old unemployed roofer presents to the clinic with pain in his testicle and penis. He states the pain began last night and has steadily worsened. He states it hurts when he urinates; he has not attempted intercourse since the pain began. He has tried acetaminophen and ibuprofen without improvement. He denies any fever or night sweats. His past medical history is unremarkable. He has had four previous sexual partners and has had a new partner for the last month. She uses oral contraceptives so he has not used condoms. His parents are both in good health. Examination shows a young man lying on his side. He appears mildly ill. His temperature is 38.2°C, and his blood pressure, respirations, and pulse are normal. On visualization of the penis he is circumcised with no lesions or discharge from the meatus. Visualization of the scrotal skin appears unremarkable. Palpation of the testes shows severe tenderness at the superior pole of the normal-sized left testicle. He also has tenderness when palpating the structures superior to the testicle through the scrotal wall. The right testicle is unremarkable. An examining finger is placed through each inguinal ring without bulges being noted with bearing down. His prostate examination is unremarkable. Urine analysis shows white blood cells and bacteria. What diagnosis of the male genitalia is most likely in this case?

Acute epididymitis

A 24-year-old travel agent comes to your clinic complaining of pain and swelling in her vulvar area. She states that 2 days before she could feel a small tender spot on the left side of her vagina but now it is larger and extremely tender. Her last period was 1 year ago; she is sexually active. She uses the Depo-Provera shot for contraception. She denies any nausea, vomiting, constipation, diarrhea, pain with urination, or fever. Her past medical history is significant for ankle surgery. Her mother is healthy, and her father has type 2 diabetes. On examination she appears her stated age and is standing up. She states she cannot sit down without excruciating pain. Her blood pressure, temperature, and pulse are unremarkable. On visualization of her perineum a large, red, tense swelling is seen to the left of her introitus. Palpation of the mass causes a great deal of pain. What disorder of the vulva is most likely causing her problems?

Bartholin's gland infection

What should nurses teach all men, especially those who have had cryptorchidism?

How to perform a testicular self-examination