Final Exam 264

While assessing an adult male client, the nurse detects pimple-like lesions on the client's glans. The nurse explains the need for a referral to the client. The nurse determines that the client has understood the instructions when the client says he may have

herpes infection.

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

herpes simplex virus infection.

Examination of the skin should be

integrated throughout the head-to-toe examination.

The nurse wants to assess a client's 5th cranial nerve. What approach should be used?

stroke each side of the cheek with a cotton wisp

A 54-year-old man is found to be anemic. Which of the following nursing diagnosis is most likely to be recorded in his plan of care?

Fatigue

The intestines of a 32-year-old male weightlifter are palpable in his scrotum. The hernia originates above the client's inguinal ligament. Which of the following hernias can the nurse rule out first?

Femoral

The nurse selects the diagram shown to use when teaching a female client. What health problem is the nurse reviewing with this client?

Fibroids

Prior to conducting a mental status exam with a client who has a diagnosis of depression, the nurse can obtain that information by observing the client?

grooming affect Posture

You are caring for a 33 year old male who has come to the clinic for a physical examination. He states that he has not had a routine physical in five years. During the examination the physician finds that digital rectal examination (DRE) reveals extensive hardening in the posterior lobe of the prostate gland that is not mobile. The nurse recognizes that the observation typically indicates what

A sign of early prostate cancer

The nurse is performing a genitourinary assessment on a 42-year-old client and has explained to her that the assessment will require rectovaginal palpation. The client winces and asks, "Is that really necessary?" Which of the nurse's responses would provide the best rationale for rectovaginal palpation?

"I know this is probably unpleasant, but it's important for me to determine if your uterus is where it's expected."

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"

The nurse uses deep palpation of the abdomen to assess the client for presence of an abdominal mass. The client grimaces and grips the handrails of the bed. Which response by the nurse is best?

"We can take a break anytime."

The nurse has been asked to perform a stereognosis test on an adult client. Which instructions should the nurse provide to the client before performing the test?

"With your eyes closed, identify the object I place in your hand."

A tender painful swelling of the scrotum should suggest which of the following?

A tender, painful, swelling of the scrotum can be a medical emergency. All of these conditions should be considered as well as acute orchitis.

The corpora spongiosum extends distally to form the acorn-shaped

Glans

A client presents to the health care clinic and reports a 7-day history of vaginal discharge and swelling of the labia. During the examination of the external genitalia, the nurse notices an enlarged Bartholin's gland. The nurse should prepare to culture this client for which condition?

Gonorrhea

You are giving an educational event to a local men's group about prostate cancer. What group should you be sure to tell the attendees of this event should receive information regarding the predisposition of prostate cancer?

African Americans

While examining a client's head the nurse notes that several pieces of needed equipment are missing. Which item should be used to assess aspects of the ears and nose?

Otoscope

During which part of a head-to-toe physical examination should the nurse palpate the epitrochlear lymph nodes?

Arms, hands, and fingers The epitrochlear lymph nodes are found on the inside of the upper arm, just above the elbow.

A client reports the new onset of mucus in the stool. How should the nurse document this in the client's history?

Steatorrhea

An adult female client is about to undergo a physical assessment conducted by a nurse practitioner at the gynecology clinic. The nurse is preparing the room for a complete head-to-toe examination, along with a genitalia and rectal assessment and screening through the Papanicolaou test. What should the nurse do next before proceeding?

Ask for the client's permission to perform the assessment

The nurse suspects a client weighing 161 pounds may be exhibiting signs of sepsis. Which urinary output value indicates acute oliguria?

50 mL in past 2 hours

Which client should the nurse recognize has the highest risk to develop prostate cancer? 35-year-old African American male with a diet high in fat 65-year-old Caucasian male whose father had prostate cancer at age 55 70-year-old Asian male who is not circumcised and eat a low fat diet 60-year-old male who works in a tire and rubber manufacturing plant

65-year-old Caucasian male whose father had prostate cancer at age 55 Age, African American race, and having a brother or father who was diagnosed with prostate cancer before the age of 60 are the greatest risk factors. Therefore, the older male with a first-degree relative has the highest risk.

Which client would the nurse identify as being at highest risk for the development of testicular cancer? A 45-year-old white man with a history of hypertension. A 25-year-old man with a history of cryptorchidism. A 39-year-old African-American man who is HIV-negative. A 75-year-old white man with erectile dysfunction.

A 25-year-old man with a history of cryptorchidism. Testicular cancer is most common in between 15 and 34 years of age and is the leading cause of cancer deaths in men between 25 to 34 years of age. Its incidence is higher in Caucasians and men with a history of cryptorchidism. Other clients at risk are those with a family history of the disease, those who are HIV-positive or have developed AIDS, and those who already have had cancer in one testicle.

A client asks the nurse when a colonoscopy is recommended. Which advise by the nurse provides the most appropriate advice?

A flexible sigmoidoscopy should be done every five years starting at age 50"

A 29-year-old woman with a longstanding diagnosis of genital herpes has presented to the clinic because of a recent "flare-up." What should the nurse expect during inspection of this recurrence of herpes?

A local patch of small, painful lesions on the client's vulva Small, painful ulcers characterize herpes infection. Recurrent infections are usually marked by a local patch of lesions that is less extensive than the initial infection. A firm, round cystic nodule is more likely an epidermoid cyst, while cauliflower-like growths are associated with venereal warts.

Which of the following would lead the nurse to suspect a hydrocele versus other causes of scrotal swelling?

A positive transillumination test Hydrocele contains fluid while scrotal swelling does not

What would be included in a shift assessment? Select all that apply.

Auscultation of lungs on a client with pneumonia Inspection of skin on a client that is not mobile Palpating pulses on a client with PVD

A nurse should use light palpation of the abdomen to obtain objective data about which characteristic of the abdomen?

Abdominal reflex

Francis is a middle-aged man who noted right sided lower abdominal pain after straining with yard work. Which of the following findings would make a hernia a more likely diagnosis?

Absence of symmetry of the inguinal areas with straining Even in the presence of a hernia, absolute symmetry to inspection may be preserved. The actions of straining and increasing intra-abdominal pressure cause the hernia to protrude. Hernias will not necessarily be present on CT scans unless this maneuver is undertaken. Pain with straining and bowel sounds heard in the scrotum further support the diagnosis of indirect hernia.

A client is explaining to the nurse how vaginal dryness has decreased her enjoyment of sexual intercourse. The nurse is aware that which of the following are the glands that produce mucus that lubricates the vagina during intercourse?

Bartholin's glands

When assessing a client during the physical examination of the genitalia, the nurse palpates the scrotal contents. Which finding should the nurse recognize as an indication that an infection or cysts are present?

Beaded or thickened cord

A 60-year-old coach comes to the clinic complaining of difficulty starting to urinate for the last several months. He believes the problem is steadily getting worse. When asked he says he has a very weak stream, and it feels like it takes 10 minutes to empty his bladder. He also has the urge to go to the bathroom more often than he used to. He denies any blood or sediment in his urine and any pain with urination. He has had no fever, weight gain, weight loss, or night sweats. His medical history includes type 2 diabetes and high blood pressure treated with medications. He does not smoke but drinks a six pack of beer weekly. He has been married for 35 years. His mother died of a myocardial infarction in her 70s, and the client's father is currently in his 80s with high blood pressure and arthritis. Examination reveals a mildly obese alert and cooperative man. His blood pressure is 130/70 with a heart rate of 80. He is afebrile, and his cardiac, lung, and abdominal examinations are normal. Visualization of the anus shows no inflammation, masses, or fissures. Digital rectal examination reveals a smooth, enlarged prostate. No discrete masses are felt. There is no blood on the glove. An analysis of the urine shows no red blood cells, white blood cells, or bacteria. What disorder of the anus, rectum, or prostate is most likely?

Benign prostatic hyperplasia (BPH) BPH becomes more prevalent during the fifth decade and is often associated with hesitancy in starting a stream, decreased strength of stream, nocturia, and leaking of urine. On examination an enlarged, symmetrical, firm prostate is palpated. The anterior lobe cannot be felt. These clients may also develop UTIs secondary to their obstruction.

A client visits the clinic and tells the nurse that her stools have been pale for the past 2 days and her skin has been itching. The nurse should refer the client to a physician for possible

Biliary disease Gray or tan stool results from the lack of bile pigment.

The nurse completes the assessment of a client's heart. What should be assessed next?

Breast

The nurse prepares to complete a head-to-toe assessment on a client. For which assessments should the nurse wear gloves? Select all that apply.

Eyes Breasts Skin, hair, nails Thorax and lungs

When palpating the rectal mucosa, how does the nurse rotate the examining hand?

Clockwise, then counterclockwise To palpate the rectal mucosa, the nurse rotates the hand clockwise to palpate the right side of the client's rectal mucosa, then counterclockwise to palpate the surface posteriorly and on the client's left side.

A nurse examining a client's external genitalia notices that his scrotum and testes draw up and he shivers. This phenomenon is known as which of the following?

Cremasteric reflex

When asking a client to bear down as the labia minora is separated, a nurse notices a bulging of the anterior wall of the vaginal musculature. How should this finding be documented by the nurse?

Cystocele Bulging of the anterior vaginal wall may indicate a cystocele. Bulging of the posterior vaginal wall may indicate a rectocele. Uterine prolapse is seen when the cervix or uterus protrudes downward. Decreased uterine tone is assessed by asking the client to squeeze the examiner's finger.

The nurse is assessing the genitalia of a female client and detects a bulging anterior wall in the vagina. The nurse should plan to refer the client to a physician for

Cystocele.

The school nurse is presenting a class on female reproductive health. While discussing prevention the nurse teaches what about a Pap smear?

Detect Cervical cancer The test should be performed when the patient is not menstruating, and douching washes away cellular material. The test detects cervical cancer, and false-negative Pap smear results occur mostly from sampling errors or improper technique. A Pap smear should be done annually.

A nurse is assessing a client who seems to have developed a hearing impairment after working at a construction site for a few months. The nurse is using the Weber test to assess the client's hearing acuity. Weber's test does which of the following?

Determines the equality or disparity of bone-conducted sound.

A nurse is preparing a client for a head-to-toe examination. Which of the following should the nurse do at this time? Select all that apply.

Discuss the purpose and importance of the health history with the client Acquire the client's permission to ask personal questions Explain your respect for the client's privacy and confidentiality Explain that the client will need to change into a gown

A female client tells the nurse that she may be experiencing premenstrual syndrome. An appropriate question for the nurse to ask the client is

Do you experience mood swings or bloating?"

While reviewing the medical record before examining a male clinic patient, 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

Epispadias

A male infant is born with the urethral meatus opening on the underside of the penis. When providing information to the parents, what is the correct terminology to use for this condition?

Hypospadias

Upon observation, the nurse documents that a male child's urethral meatus is located on the underside of his penis. What is the term for this structural abnormality?

Hypospadias

Order the parts of the physical examination of the neck in the correct sequence from first to last.

Inspect the front of the neck for masses, enlarged nodes, or deviation. Inspect the position of the trachea. Inspect the thyroid gland. Test the head and neck for range of motion. Palpate the head, neck, and subclavicular lymph nodes. Palpate the thyroid.

During the assessment of a female client, which physical examination techniques should the nurse use to assess the vagina?

Inspection

The nurse is assessing a client's skin. Which additional action should the nurse take while performing this assessment?

Instruct on preventive measure

The head-to-toe assessment is a very important tool in providing the best possible care to a client. What is the reason for a comprehensive health assessment? Select all that apply.

Integrates all body systems Gives the nurse an overall impression of the client's condition Helps the nurse identify risk factors for potential health problems

A nurse is performing a head-to-toe examination of a client. At which point should the nurse first put on gloves?

Just before the mouth and throat assessment

A nurse is teaching a sex education class at the local university. In a prelecture quiz, the nurse asks what the two small folds that extend from the clitoral hood to the posterior fourchette of the vagina are called. What would be the correct answer?

Labia minora

An older gentleman asks the nurse what the effects of aging on the male reproductive system. What is the best response by the nurse to the client about the effects of aging on the male reproductive system?

Many men experience benign or malignant hypertrophy of the prostate gland.

The nurse identifies during assessment that the client is at risk for the development of pressure ulcers. What findings did the nurse identify? Select all that apply.

Moisture Poor nutrition Altered sensory perception

Inspection of the female external genitalia begins with what?

Mons pubis Inspection begins with the mons pubis. Inspection of the inguinal area, pubic hair, and skin follows inspection of the mons pubis.

A nurse observes a few small, yellow nodules on the cervix of a client during the speculum exam. They are not painful or odorous, and a thin, clear discharge is present. The nurse recognizes that these are most indicative of what type of condition?

Nabothian cysts

The nurse is conducting a head-to-toe assessment on a client. Which body systems are typically integrated throughout the entire assessment? Select all that apply.

Neurologic Musculoskeletal

Which of the following is a sign or symptom of benign prostatic hypertrophy (BPH)?

Nocturia BPH is usually not associated with systemic symptoms such as weight loss or fever. Bone pain is associated with prostate cancer, which often metastasizes to the lower axial skeleton. Nocturia, sensation of incomplete voiding, weak stream, and difficulty initiating urination are also common symptoms.

A nurse practitioner documents as follows: "Client reports pain and tenderness over the area of right ovary and a history of irregular menses." With which of the following diagnoses are these findings consistent?

Ovarian cyst

The nurse will obtain the greatest amount of information about the thyroid gland by using which technique of assessment?

Palpation

During a comprehensive assessment, a female client complains of intense external genital itching. The nurse should carefully assess for which condition that commonly presents with this symptom?

Pediculosis pubis

Which of the following is the most important risk factor for cervical cancer?

Persistent HPV infections High-risk strains of HPV constitute the most significant risk factor for cervical cancer. Immunosuppressive illnesses, poor nutrition, and smoking are not noted risk factors. Failure to seek screening is a risk factor, but of less significance than HPV infection.

During the physical examination of the genitalia for an uncircumcised client, the nurse asks the client to retract the foreskin of the penis. The nurse observes that the foreskin is tight and cannot be retracted. How should the nurse document this condition?

Phimosis

On inspecting a client's external genitalia, a nurse notes that he is uncircumcised. This means that which of the following covers the glans of the penis?

Prepuce

The nurse is documenting current health concerns during the health history of an older adult male client. Identification of what may help most at this time?

Previous

A nurse observes that the mucosa of the rectum and the rectal wall of a female client protrudes out through the anal opening. It appears as a red, doughnut-like mass with radiating folds. How should the nurse document this condition of the rectum?

Prolapse

When inspecting the face for facial symmetry, what would the nurse have the client do? (Select all that apply.)

Raise eyebrows Frown Smile Close eyes

The nurse has reviewed the previous physical assessment notes on a client and sees the following documentation: PERRLA, L 6-4, R 6-4. What is the nurse's best action for follow-up care on this client?

Re-assess as needed

The nurse is reviewing the functions of the ovaries, uterus, clitoris and vagina with a group of nursing students. Based on this information, what would be the best response by a nursing student about the function of the uterus?

Receives the fertilized ovum and provides housing and nourishment for a fetus.

Which finding in a female client's history would alert the nurse to assess for signs of diabetes mellitus?

Recurrent candidiasis infections

A nurse performs the Mini-Mental Status Exam to assess cognitive abilities of a client. What will the nurse assess as a part of the Mini-Mental Status Exam?

Remote memory of the past

A client visits the health care facility with reports of mild hearing loss. The nurse prepares to perform which test to compare bone and air conduction?

Rinne

Students are learning about subjective data collection. What data are collected subjectively? (Mark all that apply.)

Risk factors Common symptoms Family history

The nurse is documenting the description and amount of wound drainage present in a Stage III pressure ulcer. Which term should the nurse use to describe bloody drainage observed when the dressing was removed?

Sanguineous

Upon inspection and palpation of the scrotum, the nurse discovers a mass. The nurse asks the client to lie down, and the bulge remains. On auscultation, the nurse finds bowel sounds. The nurse should document this finding as which type of hernia?

Scrotal

When performing a shift assessment, the nurse identifies the client has on a sequential compression device. What must the nurse then assess?

Skin

While inspecting the genitalia of a male client, the nurse observes a chancre lesion under the foreskin. The nurse has explained this observation to the client. The nurse determines that the client understands the need for a referral when the client says that chancre lesions are associated with

Syphilis.

A nurse is performing a general survey of a patient admitted to the hospital. Which of the following actions is an element of this procedure?

Taking Vital Signs

When collecting subjective data, the nurse gives the client time and encouragement to do what?

Tell about the client's concerns

What symptom(s) found during assessment would cause the nurse to suspect the client may be experiencing sepsis? Select all that apply.

Temperature greater than 102 °F (38.9 °C) Respiratory rate 36 breaths per minute Altered mental state Documented or suspected infection

The nurse is providing a sex education informational session for a group of male clients. Which information should the nurse include?

The hepatitis A vaccine is recommended for men who have sex with men.

After positioning a 34-year-old client for examination of the anal region, the nurse notes a small opening above the gluteal crease that contains a tuft of hair. How should the nurse interpret this assessment finding?

The pilonidal cyst and sinus are usually benign, but can occasionally become infected or develop further sinuses.

When assessing a pregnant female, the nurse documents Gravida 3, Para 2 regarding obstetrical history in the health record. Which situation correctly corresponds to the obstetrical history of the woman?

The woman has been pregnant three times and has delivered two live children. Gravida refers to the number of pregnancies a woman has had, including the present pregnancy. Para refers to the number of births a woman has had after 20 weeks even if the fetus died at birth.

A nurse is performing a part of a physical assessment for a client using palpation. What is the purpose of using this technique?

To check the skin temperature and moisture.

A teenager presents at the ER with severe scrotal and abdominal pain, vomiting, and nausea. He tells the nurse that he participated in a polar bear plunge in his community (jumping into cold water off-season). What conditions would the nurse suspect?

Torsion of the spermatic cord

During a gynecologic examination, the nurse observes that the client has a yellow-green frothy vaginal discharge. The nurse should plan to test the client for possible

Trichomonas vaginalis infection.

During the examination of the external genitalia, the nurse notices drainage from the urethra. The nurse should prepare to assess this client for which condition?

Urethritis

In the female client, the tube of muscular tissue that extends from the vaginal introitus to the uterus is called what?

Vagina

The nurse is preparing to conduct a physical examination of a client who experiences pain when moving positions. Which of the following can the nurse examine while the client is still standing?

Vision Spinal motion Balance

The nurse suspects that a client has an infection of the lower leg. What skin assessment finding caused the nurse to make this clinical determination? Select all that apply.

Warmth Erythema

When should the nurse assess the costovertebral angle for tenderness?

after assessing the posterior thorax

During the general survey a client comments about the extremely cold weather even though the client lives in a major northeastern United States city and the month is July. What action should the nurse take?

assess mental status

A client turns the head to the right after the nurse whispers the direction to do so in the client's left ear. What information should the nurse obtain from the client's response?

cranial nerve VIII is intact Responding appropriately to the "whisper test" assesses cranial nerve VIII.

Acute oliguria

decreased or no urinary output. It is defined as urine output less than 0.5 mL/kg/hr for at least 2 hours. Convert 161 pounds to kg by dividing by 2 = 73 kg. 0.5 X 73 = 36.5 mL. In 2 hours output should be at least 73 mL.

The nurse is conducting a physical examination of a client who has congestive heart failure. The general survey can provide the nurse with which information?

edema of the face and limbs presence of cyanosis respiratory rate

When examining a client's musculoskeletal system, for which assessment should the client be in a seated position?

elbow flexion

In order to assess a client's abdominal reflexes, what should the nurse include in the physical examination?

light stroking inward from all quadrants

In order to conduct an examination of the eye muscles, the nurse should prepare to administer which tests? Select all that apply.

six cardinal directions of gaze convergence near reaction cover-uncover test

A client with congestive heart failure presents to the emergency department with soreness from swelling of the ankles. When conducting the physical examination of this client, the nurse would require a stethoscope for which reason?

to auscultate the lungs