FINAL FINAL FINAL

Lakukan tugas rumah & ujian kamu dengan baik sekarang menggunakan Quizwiz!

The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding?

C) Plantar reflex present

Mr. Turner is a 43-year-old patient who presents for a yearly physical examination. On exam you note balanitis associated with phimosis. Which individual is this most likely to occur in? A. Newborn male infants B. Diabetic men C. Uncircumcised men D. Men exposed to radiation

C. Uncircumcised men

Acute inflammation of the testes is: A. herpes progenitalis. B. priapism. C. orchitis. D. paraphimosis.

C. orchitis.

Testing the deep tendon reflexes gives the examiner information regarding the intactness of the: A. corticospinal tract. B. medulla. C. reflex arc at specific levels in the spinal cord. D. upper motor and lower motor neuron synaptic junction.

C. reflex arc at specific levels in the spinal cord.

People who have Parkinson disease usually have which of the following characteristic styles of speech? A. a garbled manner B. loud, urgent C. slow, monotonous D. word confusion

C. slow, monotonous

Tenderness during abdominal palpation is expected when palpating: A. the liver edge B. the spleen C. the sigmoid colon D. the kidneys

C. the sigmoid colon

The sudden twisting of the spermatic cord causes a surgical emergency called: A. prepuce. B. spermatocele. C. torsion. D. progenitalis.

C. torsion.

Erosion

Erosion is caused by loss of the surface of a skin lesion; it is a shallow moist or crusted lesion.

When the nurse is testing the triceps reflex, what is the expected response?

Extension of the forearm

Viral risk factor for cervical cancer?

HPV.

Mons Pubis?

Hair-covered fat pad overlying the symphysis pubis.

Obtaining Vaginal Specimens

Pap Smear: Rotate 5X and obtain sample before any other test samples Then any swabs for infection

Tinel's Sign

Tap on the Median Nerve

Of the 33 vertebrae in the spinal column, there are: A) 5 lumbar. B) 5 thoracic. C) 7 sacral. D) 12 cervical.

The ankle joint is the articulation of the tibia, the fibula, and the: A) talus. B) cuboid. C) calcaneus. D) cuneiform bones.

atrial gallop ta lub dub, abnormal finding; "a stiff wall"; could be myocardial infarction, coronary artery disease, hypertension, aortic stenosis, hyperthyroidism

glasgow coma scale best motor response to pain 4

flexion withdrawl

esotropia

inward turing of eye

Protuberant Contour

pregnant

5L underneath the jawbone

submandibular

tendon reflex grading 4+

very brisk hyperactive with clonus indicative of disease

At what age do you start cervical cancer screening?

Guidelines of Cervical cancer screening after 21?

21-29: PAP every 3 years. 30-65: PAP and HPV every 3 years unless have 3 negatives with no other risk factors, then every 5. After hysterectomy-discontinue if no other risks. >=65: Discontinue if 3 or ore negatives and no abnormals in past 20 years.

A nurse is teaching a client about nutrition. The client is on an 1800-calorie diet. How many grams of carbohydrates are recommended for this client each day?

247.5 to 270 grams The nurse must remember that the recommended percentage for carbohydrates is between 55% and 60% and that 1 gram of carbohydrate equals 4 calories. Therefore, 1800 calories × 0.55 = 990/4 calories/gram = 247.5 grams and 1800 calories × 0.60 = 1080/4 calories/gram = 270 grams.

A patient is complaining of a sharp pain along the costovertebral angles. The nurse knows that this symptom is most often indicative of?

C) Kidney inflammation

36. During report, the student nurse hears that a patient has "hepatomegaly" and recognizes that this term refers to:

A) an enlarged liver.

During report, the student nurse hears that a patient has "hepatomegaly" and recognizes that this term refers to?

A) An enlarged liver

A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement?

A) Flexion.

The ankle joint is the articulation of the tibia, the fibula, and the:

A) Talus.

Of the 33 vertebrae in the spinal column, there are:

ANS: 5 lumbar. There are 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 3 to 4 coccygeal vertebrae.

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which assessment finding?

Clubbing of the nails

pulmonic stenosis

calcification at the entrance to the pulmonary artery, causing reduced arterial flow to lungs

8L turn the head to the side diagonal pattern down the neck

deep cervical chain

The primary muscles of respiration include the:

diaphragm and intercostals.

positive babinski

extension of the great toe and fanning of the toes dorsiflexion in adults and plantar flexion in infants

glasgow coma scale best motor response to pain 3

flexion- abnormal (decorticate rigidity)

"If you smoke, how many cigarettes do you smoke a day?"

A 22 year-old woman has been considering using oral contraceptives. As part of her history, the nurse should ask:

Dysphagia

A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has:

Scars

no scars should be present, note color, lenght, location, and cause for each

friction rub

sounds like leather rubbing on leather; distinguish between respiratory and cardiac types by having patient hold breath

advantitous sounds

sounds that are not normally heard in the lungs such as crackles or wheezing

Glasgow coma scale Eye opening response 4

spontaneously

10L have the person shrug their shoulders and feel superior to clavical

supraclavicular

two point discrimination

test persons ability to distinguish separation between two simultaneous pin points on the skin

extraoccular movement

test to determine alignment and coordination for 6 cardinal gazes, observe for strabismus, nystagmus

whisper test

tests Auditory Nerve: Whisper in patients ear and ask them to repeat what you said

percussion

the diagram indicates location for ____ of the four abdominal quadrants

The nurse is examining a patient who tells the nurse, "I sure sweat a lot, especially on my face and feet but it doesn't have an odor." The nurse knows that this could be related to:

the eccrine glands

Globus pharyngis

the feeling of having a lump in the throat

borborygmi

the sounds of gas moving through the intestines; the sounds of stomach rumbling

1. The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply.

B) Test for Blumberg's sign. D) Perform iliopsoas muscle test.

28. A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition?

B) Test for Murphy's sign

The functional unit of the skeletal system is the: A. bursa. B. articulation. C. joint. D. epiphysis.

C. joint.

During an assessment of the spine, the patient would be asked to: A. adduct and extend B. supinate, evert, and retract C. extend, adduct, invert and rotate D. flex, extend, abduct, and rotate

D. flex, extend, abduct, and rotate

A congenital defect in which the urethra opens on the ventral side of the penis is known as: A. phimosis. B. urethritis. C. priapism. D. hypospadias.

D. hypospadias.

A dull percussion note forward of the left midaxillary line is: A. normal, an expected finding during splenic percussion B. expected between the 8th and 12th ribs C. found if the examination follows a large meal D. indicative of splenic enlargement

D. indicative of splenic enlargement

Viscera is the term given to: A. bowel obstruction. B. the midline longitudinal ridge in the abdomen. C. a proximal part of the large intestine. D. internal organs.

D. internal organs.

Gynecomastia occurs with: A. Addison disease B. hypothyroidism C. calcium channel blockers D. liver cirrhosis

D. liver cirrhosis

An elderly woman is brought to the emergency department after being found lying on the kitchen floor 2 days, and she is extremely dehydrated. What would the nurse expect to see upon examination?

Dry mucous membranes and cracked lips

Cervix

During a speculum inspection of the vagina, the nurse would expect to see what at the end of the vaginal canal?

The preoperative nurse comforts the anxious patient awaiting surgery. You overhear the nurse tell the patient, "Don't worry. Everything will turn out fine. You're in good hands." This exemplifies which nontherapeutic interviewing technique?

Offering false reassurance

What decreases risk of ovarian cancer?

Oral contraceptive use, pregnancy, and a history of breastfeeding.

How do you examine a nipple that is having spontaneous discharge?

Press around the areola with index finger and try to express fluid. Note the color, consistency, and quantity of discharge and the exact location where it appeared.

Labia minora?

Thinner pinkish-red folds that extend anteriorly to form the prepuce and the clitoris.

fasciculi

bundles of muscle fibers

When listening to heart sounds, the nurse knows that S1:

coincides with the carotid artery pulse

earlobe crease

condition of the ear associated with arterial disease

leukocoria

condition of the white pupil; could be indicative of tumors in the eye

A man who has had gout for several years comes to the clinic with a problem with his toe. On examination, the nurse notices the presence of hard, painless nodules over the great toe; one has burst open with a chalky discharge. This finding is known as: A) a callus. B) a plantar wart. C) a bunion. D) tophi.

ptosis

drooping eyelid

hyperemesis

excessive vomiting

hyperemesis

excessive vomiting in pregnancy that may last well into the second trimester and beyond

broca's area

frontal lobe mediates motor speech expressive aphasia

culture is learned through

language acquisition and socialization

decreased fetal movement

may be indicative of fetal distress or impending fetal death

probable signs

signs detected by the examiner such as an enlarged uterus

The nurse has completed the musculoskeletal examination of a patient's knee and has found a positive bulge sign. The nurse interprets this finding to indicate:

swelling from fluid in the suprapatellar pouch

When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale?

Self Breast Exam Instructions

5-7 days after period for women still menstruating or can choose a time of month if menopausal.

The pancreas is: A. a soft, lobulated gland behind the stomach. B. a soft mass of lymphatic tissue on the postlateral wall. C. a bean-shaped, retroperitoneal gland. D. None of the above

A. a soft, lobulated gland behind the stomach.

The epididymis is: A. a sperm storage site. B. folds of thin skin on the scrotal wall. C. the joining of the vas deferens with the seminal vesicle. D. the muscle that controls the size of the scrotum.

A. a sperm storage site.

Auscultation of the abdomen may reveal bruits of the _____ arteries. A. aortic, renal, iliac, and femoral B. jugular, aortic, carotid, and femoral C. pulmonic, aortic, and portal D. renal, iliac, internal jugular, and basilic

A. aortic, renal, iliac, and femoral

When teaching the breast self-examination, you would inform the woman that the best time to conduct breast self-examination is: A. at the onset of the menstrual period B. on the 14th day of the menstrual cycle C. on the 4th to 7th day of the cycle D. just before the menstrual period

C. on the 4th to 7th day of the cycle

Gynecomastia?

Found in men due to an imbalance of estrogens and androgens.

Breast cancer mass palpable characteristics

Irregular, firm, may be mobile or fixed to surrounding tissue.

Why is increased breast density on mammogram a risk factor?

It can mask the development of breast cancer. An increase in radiologic breast density in 60-75% of breast tissue increases the risk of breast cancer by 4-6 fold.

Murphy's Sign

Pt. supine position stand on right sign. Palpate below the liver margin at the lateral border of the rectus muscle, deep breath, no pain should be elicted. Pain is present the pt. may stop inhaling to guard against the pain. Murphy's sign is positive in inflammatory processes of the gallbladder, such as cholecystitis.

The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds?

Wheezes

mitral

at this landmark, S1>S2

glasgow coma scale best motor response to pain 2

extension-abnormal (decerebrate rigidity)

A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual?

hyporeflexia

Best place to observe an older adult?

in their own environment?

A man has come in to the clinic for a skin assessment because he is afraid he might have skin cancer. During the skin assessment the nurse notices several areas of pigmentation that look greasy, dark, and "stuck on" his skin. Which is the best prediction? He probably has:

seborrheic keratoses, which do not become cancerous.

The nurse is testing the function of cranial nerve XI. Which of these best describes the response the nurse should expect if the nerve is intact? The patient:

shrug shoulders against resistance with equal strength

The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ____ comparison.

side-to-side

The nurse knows that normal splitting of the second heart sound is associated with:

inspiration

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would:

listen with the bell of the stethoscope to assess for bruits.

During an assessment of an 80 year old patient, the nurse notices the following: inability to identify vibrations at the ankle and to identify position of the big toe, slower and more deliberate gait, and slightly impaired tactile sensation. All other neurological findings are normal. The nurse should interpret that these findings indicate:

normal changes due to aging.

Hypoactive Bowel sounds

or diminished indicate decreased mobility of the bowel and can occur with peritonitis and nonmechanical obstruction. Other causes include inflamation, gangrene, electrolyte imblances, and intraoperative manipulation of the bowel.

glasgow coma scale best verbal response 5

oriented x3

why do we auscultate first?

percussion and palpation can increase peristalsis which would give a false interpretation of bowel sounds

abdominal muscle guarding

perform light palpation of the rectus muscles during expiration. Muscle guarding, or tensing of the abdominal musculature, is absent during expiration. The abdomen is soft. Normally during expiration the pt. cannot exercise voluntary muscle tensing.

The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect?

peripheral neuropathy

McBurney's Point

the name given to the point over the right side of the abdomen that is one-third of the distance from the anterior superior iliac spine to the navel. A sign of acute appendicitis. People will point this out if it hurts. Do not touch it if it hurts.

S2 is

the result of pressure changes from the closure of the aortic and pulmonic valves

A 35-year-old recent immigrant is being seen in the clinic for complaints of a cough that is associated with rust-colored sputum, low-grade afternoon fevers, and night sweats for the past 2 months. The nurse's preliminary analysis, based on this history, is that this patient may be suffering from:

tuberculosis

decorticate rigidity

upper extremities flexion of arm, wrist and fingers lower extremities extension, internal rotation

decerebrate rigidity

upper extremities stiffly extended adducted internal ration palms pronated

S3 sound is heard where

at the beginning of diastole

Vascular sounds (Auscultation)

complete over abdominal aorta, renal arteries, iliac arteries, and femoral arteries. Listen for bruits. None should be heard.

McMurray Test

Pt supine with knee flexed, one hand medial knee and the other medial ankle. Extend the leg and laterally rotate, watching for clicking

Drawer Sign

Pt supine with knee flexed, your thumbs at the medial/lateral joint line and fingers wrapped around. Then sharply push/pull, watching for laxity

During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition?

Pulmonary consolidation

A patient is being assessed for range of joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called:

adduction.

B) Your acromion process."

During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects: A) tactile fremitus. B) crepitus. C) friction rub. D) adventitious sounds.

B) crepitus.

An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because:

B) of the shortening of the vertebral column.

What is the Bethesea system?

Classification system of pap smear cytology.

Cutaneous Hypersensitivity

Life a fold of skin away from the underlying muscle poke with pin. No reaction should be noted. Cutaneous hypersensitivity indicates a zone of peritoneal irritation. Localized pain is all or part of the RLQ may accompany appendicitis. Midepigastrium pain could signal a peptic ulcer.

2L behind the middle of the ear

Postauricular

non-synovial joints

bones united by a fibrous tissue

Grade 4

distinctly loud, thrill palpable

when you percuss over an organ what should the sound be?

dull

triglycerides

higher ____ cause lowered amounts of HDL

During an assessment of a 22-year-old woman who has a head injury from a car accident 4 hours ago, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to light. What does finding this suggest?

increased intracranial pressure

hyperlipidemia

indicated by the presence of ascus senilus in those younger than 60-65

tenderness along the costal vertebral angles would indicate what?

inflammation of the kidney or paranephric area

abnormal findings obesity

inspection- uniformly round, umbilicus sunken auscultation- normal bowel sounds percussion- tympany scattered dullness over adipose palpation- normal

A patient is complaining of a sharp pain along the costovertebral angles. The nurse knows that this symptom is most often indicative of:

kidney inflammation

umbo

knob of the malleus that shows through the tympanic membrane

ectropion

lower lid turned away from eye, excessive tearing, feels like dry painful eyes; caused by Bell's Palsy or aging

bronchovesicular

lung sounds heard over major bronchus area and upper right posterior lung field, between scapula and next to sternum, medium pitch and intensity, inspiration = expiration

vesicular

lung sounds heard over peripheral lung field, low pitched and soft, longer inspiratory

tracheal

lung sounds heard over the trachea; harsh high pitched, longer during inspiratory phase

pulse amplitude

measured as 4+ (bounding), 3+ (increased), 2+ (normal), 1+ (weak); document its location and scale used

A professional tennis player comes into the clinic complaining of a sore elbow. The nurse will assess for tenderness at the:

medial and lateral epicondyle

List 3 good sources of Calcium What is the recommendation for calcium intake in the elderly or those with osteoporosis?

milk cheese sardines salmon green vegetables 1200-1500

Who are Graves specula better for?

multips with vaginal prolapse. Rounded edges to keep vaginal walls open for exam.

Respiratory movement

normal rises with inspiration and falls with expiration. Abnormal may be due to appendicitis with local peritonitis, pancreatitis, biliary colic, or a perforated ulcer

aorta pulsations in abdomen

normal to see pulsations from the aorta in the epigastric area

Rounded contour

normal,

The most reliable indicators of true hypertension are:

numerous measurements taken over a period of time

male genitals (internal)

penis and scrotum

9L behind deep cervical chain lymph nodes

posterior cervical

What can BV cause?

premature births, PID, increased risk for HIV from openings in the vaginal mucosa.

Illipsoas Muscle Test

present with acute abdominal pain, an inflamed or perforated appendix. Place hand over the right thigh and push down as they raise the leg flexing at the hip. No pain should be present. Pain in RLQ indicates inflamed appendix

leukonychia

refers to white spots or discoloration of the nail

consensual response

response which occurs when the light striking one pupil causes a the iris of the unaffected pupil to contract

barrel chest

ribs more horizontal, spine slightly curved, seen in emphysema/COPD due to air trapped in lung causing hyperinflation

what changes are associated with menopause?

sacral ligaments relax uterus drops, vagina atrophies, vaginal PH becomes more alkaline, breast tissue changes

Symmetry

should be symmetrical bilaterally. Asymmetry may be caused by a tumor, cysts, bowel obstruction, enlargement of abd. organs, or scoliosis. Bulging at the umbilicus can indicate a hernia.

4L underneath the chin

submental

accommodation

the automatic adjustment in focal length of the lens of the eye

bronchial sounds

trachea and larynx

Grade 6

very loud, audible w/o stethoscope on chest, thrill palpable and visible

(second heart sound) occurs with closure of pulmonary and aortic semilunar

When should we start screening women for breast cancer risks?

20 years old. Looking for a pattern of familial history of breast and ovarian cancer especially before age 50. (BRCA 1 or 2).

Amanda has been sick a lot, and advised by her health care provider to get 15% of her daily calories from protein. If she consumes a 2,000 calorie diet, how many calories of it should be protein?

300 2,000 cal x 15% = 300

The nurse is preparing for a class on risk factors for hypertension, and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world?

African-Americans

The American Cancer Society and the AMA recommend annual mammography beginning at what age?

40-74

"Normal" muscle strength is documented as grade _____

Bartholin's Glands

5 and 7

Explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.

A 62 year-old man states that his doctor told him that he has an "inguinal hernia." He asks the nurse to explain what a hernia is. The nurse should:

Of the 33 vertebrae in the spinal column, there are:

A) 5 Lumbar

The nurse is reviewing statistics for lactose intolerance. In the USA, the incidence of lactose intolerance is higher in adults of which ethnic group?

A) African-Americans

To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate?

A) Ask child to hop on one foot.

The nurse should use which test to check for large amounts of fluid around the patella?

A) Ballottement

1. The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear?

A) Dullness

Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites?

A) Dullness across the abdomen

A nurse notices that a patient has ascites, which indicates the presence of?

A) Fluid

A woman who is 8 months pregnant comments that she has noticed a change in posture and is having lower back pain. The nurse tells her that during pregnancy women have a posture shift to compensate for the enlarging fetus. This shift in posture is known as:

A) Lordosis.

During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be manifested by?

A) Projectile vomiting

The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate nurse shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

B) "It prevents distortion of the bowel sounds that might occur after percussion and palpation."

The nurse is assessing the muscle strength of a client. The client had complete range of motion against gravity with full resistance. What would the nurse record using a 0-5 scale in this situation? A. 4/5 B. 2/5 C. 5/5 D. 3/5

C. 5/5

During a breast examination, you detect a mass. Identify the description that is most consistent with cancer rather than benign breast disease. A. round, firm, well demarcated B. irregular, poorly defined, fixed C. rubbery, mobile, tender D. lobular, clear margins, negative skin retraction

B. irregular, poorly defined, fixed

The rugae: A. is a corpus spongiosum cone of erectile tissue. B. is folds of thin skin of the scrotal wall. C. controls the size of the scrotum. D. is an acute inflammation of the testes.

B. is folds of thin skin of the scrotal wall.

The organ in the right upper quadrant of the abdomen is the: A. spleen. B. liver. C. cecum. D. sigmoid colon.

B. liver.

Retinal Structures

Macula/Fovea Optic Disc Red Reflex Vessels

Positive Phalen test and Tinel sign are seen in a patient with: A. a torn meniscus B. hallux valgus C. carpal tunnel syndrome D. tennis elbow

C. carpal tunnel syndrome

The nurse is performing an assessment on an adult. The adult's vital signs are normal and capillary refill time is 5 seconds. What should the nurse do next?

Consider this a delayed capillary refill time and investigate further.

Why should women always get their mammograms at the same facility?

Consistency and easier to find changes when there are other films for comparisons.

Which structure is located in the lower left quadrant of the abdomen?

D) Sigmoid colon

Inflammation of the urinary bladder is called: A. hypospadias. B. orchitis. C. urethritis. D. cystitis

D. cystitis

Bowel sounds are: A. high pitched. B. air and fluid moving through the small intestine. C. irregular. D. All of the above.

D. All of the above.

During the assessment of a two-month-old, the nurse flexes the infant's knees and compares the height of the knees. What does this maneuver assess? A. Tibial torsion B. Genu valgum C. Genu varum D. Allis' sign

D. Allis' sign

What can Acanthosis Nigricans off the axillary indicate?

Diabetes, endocrine issue, adenocarcinoma of the GI tract. Can be hereditary.

Facial (Motor)controls muscles used in facial expression (puff out teeth, smile, frown) also controls (sensory) taste anterior 2/3 of tongue

Risk factors for ovarian cancer?

Family history, BRCA1 or BRCA2, risk is tripled with first degree relative with breast or ovarian cancer. 90% of ovarian cancers are random.

Borborygmi

Hyperactive bowel sounds that are lound, audible, gurgling may be due to hyperperistalsis (stomach growling) or the sound of flatus in the intestine

What could cervical motion tenderness and/or adnexal tenderness indicate on the bimanual exam?

PID, ectopic pregnancy, and appendicitis.

McBurney's Point

Pain in the RLQ indicates appendicitis

Rovsing's Sign

Pressure on LLQ causes referred pain in RLQ

Urethral caruncle?

Red, small, benign tumor at the posterior part of the urethral meatus.

pectoriloquy

a striking transmission of voice sounds through the pulmonary structures, so that they are clearly audible through the stethoscope; commonly occurs from lung consolidation

Which of the following is accurate regarding the third and fourth heart sounds?

a, b S2 is loudest over aortic and pulmonic areas at the 2nd ICS.

Flat Contour

normal,

what is the order of examination

auscultate, percussion, palpate (light then deep)

A 32-year-old woman tells the nurse that she has noticed "very sudden, jerky movements" mainly in her hands and arms. She says, "They seem to come and go, primarily when I am trying to do something. I haven't noticed them when I'm sleeping." This description suggests:

chorea

The nurse notices that a woman in an exercise class is unable to jump rope. The nurse knows that to jump rope, one's shoulder has to be capable of:

circumduction

When assessing a patient's lungs, the nurse recalls that the left lung:

consists of two lobes

glasgow coma scale best verbal response 4

conversation confused

Humans have the ability to perform very skilled movements such as writing. This ability is controlled by the

corticospinal tract

kyphotic

curvature of the spine associated with barrel chest

Glasgow coma scale Best motor response to pain 6

obeys verbal response

get up and go test

observe patient rise from a chair walk 10 feet turn walk back to the chair and sit down

3L closer to the back of the head

occipital

of sharp pain that increases with movement

Your patient has denied any abuse when answering the Abuse Assessment Screen, but you have noticed some other conditions that are associated with intimate partner violence. Such conditions include:

depression.

pica

desire to eat non-nutritive substances

tendon reflex grading 1+

diminished low normal or occurs only with reinforcement

The nurse is doing an assessment on a 29-year-old woman who visits the clinic complaining of "always dropping things and falling down." While testing rapid alternating movements, the nurse notices that the woman is unable to pat both her knees. Her response is very slow and she misses frequently. What should the nurse suspect?

dysfunction of the cerebellum

A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has:

dysphagia

what is the first sign of esophageal cancer

dysphagia

syncopy

fainting

true or false benign breast disease makes you more at risk for cancer

false

hyperopia

farsightedness

first trimester

period is missed breast tingling and tissue changes increased progesterone fatigue in 7TH gestational week BP with drop until midpregnancy increased HCG

flatus

gas in the digestive tract or expelled through the anus

when would hyperresonance occur?

gaseous distention

osteoporosis

gradual loss of bone density

groin

inguinal nodes

groin area, drain most of the lymph of the lower extremity, the external genitalia, and the anterior abdominal wall

uvula

hangs from center of soft palate

nipple

glasgow coma scale best motor response to pain 1

no response

glasgow coma scale best verbal response 1

no response

glasgow coma scale eye opening response 1

no response

tendon reflex grading 0

no response

A patient has been diagnosed with osteoporosis and asks the nurse, "What is osteoporosis?" The nurse explains to the patient that osteoporosis is defined as:

loss of bone density

Risk factors for cervical cancer are both?

viral and behavioral.

voice sounds

vocal sounds which when clear on auscultation are abnormal

female genitals (external)

vulva, mons pubis, labia majora/minora, frenulum, clitoris, hymen, urethral meatus, vestibule, para urethral glands, vaginal orifice, vestibular glands

direct observation

watching the person directly in their own environment, its the best way to assess nutrition patterns.

when assessing sensorineural loss what should you ask?

what meds the patient is taking

Whispered pectoriloquy

whisper "ninety-nine" or "one-two-three" and if louder, clearer whispered sounds, then whispered pectoriloquy

leukoplakia

thickened, white, leathery-looking spots on the inside of the mouth that can develop into oral cancer

T10

umbilicus

Normal size of aorta

under 3 cm

Light palpation

use one hand and press 1cm - think kneading dough

Deep palpation

use two hands and press 2-3cm

when unsure about your findings what should you do?

validate your data by asking a co-worker

During the history, a patient tells the nurse that it feels like the room is spinning. The nurse knows this is:

vertigo

During your examination, your patient tells you that she sometimes it feels as if objects are spinning around her. You would note that she occasionally experiences:

vertigo.

Dullness

Is normally heard over orgasns such as liver, or a distended bladder. Dull sounds are high-pitched and moderate duration. May occur by masses, tumors, pregnancy, ascites, or a full intestine

Torus Palatinus

Midline bony growth in hard palate that is fairly common in adults. Size and lobulation vary. Harmless

In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or stimulation. The mother reports that in the last week he has been sleeping all the time, and when he is awake all he does is cry. The nurse hears that the infant's cries are very high pitched and shrill. What should be the nurse's appropriate response to these findings?

A) Refer the infant for further testing.

While obtaining a history of a 3-month-old infant from the mother, the nurse asks about the infant's ability to suck and grasp the mother's finger. What is the nurse assessing?

A) Reflexes

A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes?

A) Reflexes will be normal.

33. When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved?

A) Spleen

The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal women. Which of these actions is the best way to prevent or delay bone loss in this group?

A) Taking calcium and vitamin D supplements.

The nurse is assessing the abdomen of a pregnant woman who is complaining of having "acid indigestion" all the time. The nurse knows that esophageal reflux during pregnancy can cause?

B) Pyrosis

A patient is able to flex his right arm forward without difficulty or pain but is unable to abduct his arm because of pain and muscle spasms; the nurse should suspect:

B) Rotator cuff lesions.

The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply. A) Test for Murphy's sign. B) Test for Blumberg's sign. C) Test for shifting dullness. D) Perform iliopsoas muscle test. E) Test for fluid wave.

B) Test for Blumberg's sign. E) Test for fluid wave.

The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply:

B) Test for Blumberg's sign. D) Perform iliopsoas muscle test.

An older adult's (eighth to ninth decades) lactiferous ducts are more palpable and feel firm and stringy because of fibrosis and calcification. The number of lobes within the breast ranges between: A. 10 to 20. B. 15 to 20. C. 20 to 25. D. 20 to 40.

B. 15 to 20

Oculomotor eye movement/pupil construction motor and sensory

5 Lumbar

Of the 33 vertebrae in the spinal column, there are:

What is a the orange peel appearance of a breast called?

Peau d'orange appearance (concerning for underlying edema or cancer)

3rd Step

Percussion: General, liver span, liver descent, speen, stomach, kidneys, liver, bladder.

Thrush on the palate

Yeast infection. Thick, white plaques are somewhat adherent to underlying mucosa. Predisposing factors: prolonged Tx with antibiotics or corticosteroids and AIDS

Signs and testing for Candida?

Yeast overgrowth (can happen after antibiotic use), white and curdy vaginal discharge, not malodorous, pruritis, painful urination, dyspareunia, vulva inflamed and swollen, may be bloody. PH <4.5. Can see on KOH prep.

ascites

fluid in the peritoneal cavity occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer

Dullness on respiratory percussion

fluid or solid tissue replaces air containing lung or occupies the pleural space beneath your fingers

Describe a cervical polyp?

red and protrudes into the endocervical canal. usually benign but can cause spotting between menstrual cycles.

what environmental change should the examiner make during the interview

reduce noise by turning off televisions and radios

Bronchial Sounds

louder, harsher, and higher in pitch, with a short silence between inspiratory and expiratory sounds. Expiratory sounds last longer than inspiratory sounds..

low frequency heard best at the apex, use bell and lay on the left side. Ventricular gallop - means that ventricular compliance is low. Heard at the beginning of diastole. Blood flowing into overfilled non-compliant left ventricle rapidly decelerates. Sound of it "popping" open quickly. Ken-tuc-ky

low frequency, heart best at the apex, use bell and lay on left side. Atrial gallop, pericardial friction rub. Heard at the end of diastole. Atrial contraction trying to push blood to the ventricle, but it is stiff. Ten-ness-ee.

entropion

lower lid turned in toward eye; eyelashes cause corneal/conjunctival irritation; caused by spasms or aging, foreign body feeling

arcus senilus

ring of lipids around iris; normal in those older than 60-65; in younger may indicate hyperlipidemia

asthma

lung condition indicated by use of accessory muscles, tachypnea, dyspnea, audible wheezing, prolonged expiration

the presence of a benign breast disease...

makes it more difficult to examine the breasts

24 hour diet recall

patient or family member completes a questionnaire or is interviewed and asked to recall everything eaten in the last 25 hours

Diaphragmatic excursion

percuss after breathing in and holding it, then same for breathing out and holding it - then look at the distance between the two. Normal is 3-5.5cm

When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as a(n):

positive Romberg sign

Cafe au lait spots

Irregular patches of tan skin pigmentation may be attributed to von Recklinghausen's disease a familial condition associated with the formation of neurofibromas.

What is Birads?

Is how mammography results are graded. 1-incomplete exam, 2-normal exam, 3-essentially normal with a benign finding, recommend annual screening, 4-indeterinate finding, biopsy recommended, 5-high suspicion of cancer, biopsy recommended.

Pigmentation and Color

Jaundice suggest liver dysfunction (average level for visible jaundice is 2mg/dL) accumulation of bilirubin in the blood. Blue tint at the umbilicus suggests free blood in the peritoneal cavity can be caused by rupture of fallopian tube or hemorrhagic pancreatisis (Cullen sign). Irregular patches of tan skin may be attributaed to von Recklinghausen's disease. Engorged veins associated with circulatory obstruction of the superior or inferior vena cava. Dilated veins can occur with hypertension, cirrhosis, and vena cava obstruction secondary to increased venous pressure.

A patient states, "I can hear a crunching or grating sound when I kneel." She also states that "it is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problem?

A) Crepitation

Which of these tests would the nurse use to check the motor coordination of an 11-month-old infant?

A) Denver II

The nurse is percussing the right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear?

A) Dullness

30. Which of these percussion findings would the nurse expect to find in a patient with a large amount of ascites?

A) Dullness across the abdomen

When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be:

A) Proximal to distal.

To assess the head control of a 4-month-old infant, the nurse lifts the infant up in a prone position while supporting his chest. The nurse looks for what normal response?

A) Raises head and arches back

A) These are normal findings resulting from aging.

19. A nurse notices that a patient has ascites, which indicates the presence of:

A) fluid.

Mr. Jeffries is a 48-year-old patient who comes to the clinic for a follow-up after an emergency room visit. On examination, you note a soft mass of lymphatic tissue immediately under the diaphragm, which is the: A. gallbladder. B. liver. C. cecum. D. spleen.

D. spleen.

The shape of the spinal column and the resilient intervertebral disks facilitate: A. greater mobility of the spinal column. B. the ability to coordinate movement between the upper extremities and lower extremities. C. ease and coordination of head and neck movement. D. the ability to absorb a great deal of shock.

D. the ability to absorb a great deal of shock.

The control of body temperature is located in: A. Wernicke's area B. the thalamus C. the cerebellum D. the hypothalamus

D. the hypothalamus

psoas sign

increased abdominal pain with psoas stretching maneuvers (1. place your hand above the patient's right knee and ask the patient to raise that thigh against your hand's resistance OR 2. Ask the patient to lie on the left side. Extend the patient's right leg at the hip.) Pain with either of these maneuvers implies irritation of the psoas muscle by an inflamed overlying appendix.

thrombophlebitis

inflammation of a vein that may or may not be a result of a clot. May see this around an IV site. Subjective symptoms include pain and redness over affected site Objective symptoms include erythema and tenderness over the affected site

What do you tell a patient who is complaining of constipation

medications on, fiber diet, water consumption, mobility to get to toilet, decreased activity

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include the presence of:

muffled voice sounds and symmetrical tactile fremitus

expected assessment findings in normal adult lungs

muffled voice sounds and symmetrical tactile fremitus

A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. Based on these findings, the nurse recalls that:

nonpitting, hard edema occurs with lymphatic obstruction

While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are:

normal abdominal aortic pulsations

venous hum

occurs rarely. heard in pariumbilical region , originates from inferior vena cava, occurs with portal hypertension and cirhotic liver

rest tremor

occurs when muscles are quiet and supported against gravity course and slow disappears with voluntary movement

An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because:

of the shortening of the vertebral column.

strabismus

one eye constantly deviated

what physical changes are associated with menopause?

pubic hair decreases, skin is thinner, fate deposits decrease

aniscoria

unequal pupil size

A 60-year-old male patient has been treated for pneumonia for the past 6 weeks. He is seen today in the clinic for an "unexplained" weight loss of 10 pounds over the last 6 weeks. The nurse knows that:

unexplained weight loss often accompanies short-term illnesses.

Signs and testing for trichomonas?

yellowish, green or grey frothy discharge, possibly malodorous, pruritis, pain with urination, dyspareunia, reddened mucosa. Not always transmitted sexually. Can see on a wet mount.

When should the HPV vaccine be given?

Before first sexual contact. Usually between 11 and 12 years old but as young as 9.

umbilicus

Belly Button; may be inverted or everted

Phalen's Test

Bend wrists at 90 degrees and put back of hands against each other for 1 minute and see if there is numbness/tingling

Discharge from both breast is usually?

Benign

fibroid

Benign uterine tumors composed of muscle and fibrous tissue

Clear, serous, green, black, or non-bloody discharges that are multi-ductal are usually?

Benign.

When is sojourning time most rapid for women?

Between the ages of 40-49. Breast cancer grows in 2 to 2.5 years.

Postmenopausal bleeding?

Bleeding that occurs 6 months or more after cessation of menses.

What is chadwick's sign?

Blueish cervix-indicates pregnancy.

acrocyanosis

Bluish discoloration of the hands and feet in the newborn in response to temperature changes; peripheral cyanosis. Should not persist beyond 24 hours after birth

Which measurement does the nurse use as the most reliable and valid for identifying adults at risk of morbidity and mortality due to overweight or obesity?

Body mass index

Do you listen for carotid Bruits with the bell or the diaphragm?

Both

What does asymmetry of which direction the nipples point concerning for?

Breast cancer

Type 5

Bristol stool grade characterized by soft blobs with clear-cut edges

melasma

Brownish pigmentation of the face during pregnancy

What is cystocele?

Bulging in the anterior wall of the vagina caused the prolapse of the bladder into the vagina.

What is a rectocele?

Bulging of the posterior vaginal wall from the rectum protruding into the vagina.

A mother asks when her newborn infant's eyesight will be developed. The nurse should reply: A) "Vision is not totally developed until 2 years of age." B) "Infants develop the ability to focus on an object at around 8 months." C) "By about 3 months, infants develop more coordinated eye movements and can fixate on an object." D) "Most infants have uncoordinated eye movements for the first year of life."

C) "By about 3 months, infants develop more coordinated eye movements and can fixate on an object."

When taking the history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information?

C) "Do you have any warning sign before your seizure starts?"

A 14-year-old boy who has been diagnosed with Osgood-Schlatter disease reports painful swelling just below the knee for the past 5 months. Which response by the nurse is appropriate?

C) "Your disease is due to repeated stress on the patellar tendon. It is usually selflimited, and your symptoms should resolve with rest."

The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm?

C) A pulsating mass is usually present

26. The nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm?

C) A pulsating mass is usually present.

A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination because he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurse's finger, then his own nose, then the nurse's finger again (which has been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger. The nurse should suspect which of the following?

C) Acute alcohol intoxication

A patient is being assessed for range of joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called:

C) Adduction.

22. During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures?

C) Appendix

During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures?

C) Appendix

When the nurse is testing the triceps reflex, what is the expected response?

C) Extension of the forearm

The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be?

C) GI bleeding

While examining the patient, the nurse observes abdominal pulsations between the xiphoid and the umbilicus. The nurse would suspect that these are?

C) Normal abdominal aortic pulsations

During an assessment of an 80-year-old patient, the nurse notices the following: inability to identify vibrations at the ankle and to identify position of big toe, slower and more deliberate gait, and slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate:

C) Normal changes due to aging.

During a neonatal examination, the nurse notices that the newborn infant has six toes. This finding is documented as:

C) Polydactyly

A patient is complaining of pain in his joints that is worse in the morning, is better after he has moved around for awhile, and then gets worse again if he sits for long periods of time. The nurse should assess for other signs of what problem?

C) Rheumatoid arthritis

C) Suspect that the infant may have weakness of the shoulder muscles

A patient who has had rheumatoid arthritis for years comes to the clinic to ask about changes in her fingers. The nurse will assess for signs of what problems?

C) Swan neck deformities

The articulation of the mandible and the temporal bone is known as the:

C) Temporomandibular joint

A patient has a severed spinal nerve as a result of trauma. Which of these statements is true in this situation?

C) The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve.

A patient is not able to perform rapid alternating movements such as patting her knees rapidly. The nurse should document this as:

C) The presence of dysdiadochokinesia.

During the assessment of an 18-month-old, the mother expresses concern about the infant's inability to toilet train. What would be your best response?

"The nerves that will allow your baby to have control over the passing of stools are not developed until at least 18 to 24 months of age."

The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal? A) An increase in body weight from younger years B) Additional deposits of fat on the thighs and lower legs C) The presence of kyphosis and flexion in the knees and hips D) A change in overall body proportion, a longer trunk, and shorter extremities

C) The presence of kyphosis and flexion in the knees and hips

thrills

"cat purrs" in the chest related to turbulent blood flow

While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of arms and legs; fanning of fingers, and curling of index and thumb in a C position followed by infant bringing in arms and legs to body. What does the nurse know about this response?

C) This reflex should have disappeared between 1 and 4 months of age.

The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include?

C) Tympani, hyperressonance, and dullness

3. A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has:

C) dysphagia.

Diptheria

-Acute infection caused by Corynebacterium diptheriae; rare -Throat is dull red and grey exudate is present on uvula, pharynx, and tongue. Airway may become obstructed.

Perforated ear drum

-Central perforation: don't extend to the margin of the drum -Marginal perforations: involve the margin -Reddened internal ear, might have drainage, no cone of light

Acute otitis media with purulent effusion-ear

-Commonly caused by bacterial infection with S. penumoniae and H. influenza -s/s: earache, fever, hearing loss. Eardrum reddens, loses its landmarks, and bulges laterally toward the examiner -hearing loss is conductive

What 6 risk factors are included in the Gail model for breast cancer?

1. Age 2. Age of menarche 3. Age of first live birth 4. Number of 1st degree relatives with breast cancer 5. Number of previous breast biopsies 6. One biopsy with atypical hyperplasia (recently updated to include breast density).

How do you describe a nodule (7 descriptors)?

1. Location-cm. distance from the nipple and then place on breast according to time on clock 2. Size 3. Shape 4. Consistency-soft, firm, hard 5. Delimitation-well-circumscribed or not 6. Tenderness 7. Mobility

Tips for successful pelvic exam?

1. No sex for 2 days prior to exam 2. Don't schedule during menses 3. no douches, foams, contraceptive creams 48 hours before 4. Empty bladder before exam 5. supine with head and shoulders elevated to reduce tightening of abdominal muscles.

Cranial Nerves

1. Olfactory: Sensory 2. Optic: Sensory 3. Occulomotor: Motor 4. Trochlear: Motor 5. Trigeminal: Both 6. Abducens: Motor 7. Facial: Both 8. Acoustic: Sensory 9. Glossopharyngeal: Both 10. Vagus: Both 11. Spinal Accessory: Motor 12. Hypoglossal: Motor

8 Risk factors for breast cancer?

1. Previous breast cancer 2. An affected mother or sister 3. biopsy showing hyperplasia 4. increasing age 5. early menarche (<12 years) 6. Late menopause (>55 years) 7. Late or no pregnancies (>30 years) 8. Previous radiation to the chest.

C) normal changes due to aging.

Mammography reduces the risk of breast cancer by?

1/3.

When does breast development start in teens? Include tanner stages of breast development.

10-13 years old. (Tanner stage 2-breast buds change, stage 3-enlargement of breast and areola, stage 4-swelling of breast underneath the areola (young teens to young 20's), stage 5-fully mature breast).

16. The nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include:

C) tympany, hyperresonance, and dullness.

What is a women's lifetime risk of breast cancer?

12% or 1 in 8 women with 95% of new cases occurring after the age of 40.

Describe a 1st, 2nd,and 3rd degree prolapse of the uterus?

1st-cervix is inside the vagina, 2nd- cervix is at the introitus, 3rd- cervix and vagina are outside of the introitus.

During the assessment of deep tendon reflexes, the nurse finds that a patient's responses are normal bilaterally. What number is used to indicate "normal" deep tendon reflexes when the documenting this finding. _____+ ANS:

The absence of bowel sounds is established after listening for: A. 1 full minute B. 3 full minutes C. 5 full minutes D. none of the above

C. 5 full minutes

A nurse notices that a client's meal contains 25 grams of carbohydrates, 15 grams of protein, and 8 grams of fat, and calculates that the meal contains how many calories?

232 calories The number of calories in a meal is calculated by multiplying the number of grams of carbohydrates and of protein by 4 kilocalories and the number of grams of fat by 9 kilocalories and adding. Therefore, 25 grams of carbohydrates × 4 kilocalories + 15 grams of protein × 4 kilocalories + 8 grams of fat × 9 kilocalories = 232.

expected date of delivery

280 days from the first day of the last menstrual period

An example of objective information obtained during the physical assessment

2X5 cm scar present on the R lower forearm

A first-time mother asks the nurse when she can expect her 2 month old to begin creeping or crawling. The most appropriate response would be:

9 months

What is the PH of normal vaginal secretions?

< 4.5

What would the vaginal PH be with BV, Trich, and atrophic vaginitis?

>4.5

Describe nodes that would suggest malignancy?

>= 1cm, firm or hard, matted together or fixed to skin or underlying tissues.

Protuberant

A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as:

If you have to use lube on speculum where should you put it?

A small amount on the lower blade.

In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect to see?

A) Hyperreflexia

A postoperative hip replacement client is prescribed a pillow between the legs. Which position will this pillow serve for the client? A. Abduction B. Flexion C. Pronation D. Adduction

A. Abduction

In which of the following ethnic groups would you expect to see the lowest incidence of osteoporosis? A. Blacks B. Whites C. Asians D. Native Americans

A. Blacks

Bundles of muscle fibers that compose skeletal muscle are identified as: A. fasciculi. B. fasciculations. C. ligaments. D. tendons.

A. fasciculi.

A soft, lobulated gland located behind the stomach is the: A. pancreas. B. liver. C. gallbladder. D. spleen.

A. pancreas.

The ejaculatory duct is: A. the joining of the vas deferens and the seminal vesicle. B. a muscular duct continuous with the epididymis. C. a narrow tunnel inferior to the inguinal ligament. D. a narrow tunnel superior to the inguinal ligament.

A. the joining of the vas deferens and the seminal vesicle.

A pinpoint, constricted opening at the meatus or inside along the urethra is: A. urethral stricture. B. urethritis. C. acuminate. D. progenitalis.

A. urethral stricture.

ANS: Asymmetric joint involvement Pain with motion of affected joints Affected joints are swollen with hard, bony protuberances In osteoarthritis, asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. Affected joints have stiffness, swelling with hard bony protuberances, pain with motion, and limitation of motion. The other options reflect signs of rheumatoid arthritis.

51. The nurse knows that testing kinesthesia is a test of a person's: a. Fine touch. b. Position sense. c. Motor coordination. d. Perception of vibration.

ANS: B Kinesthesia, or position sense, is the person's ability to perceive passive movements of the extremities. The other options are incorrect.

20. During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs? a. Motor component of CN IV b. Motor component of CN VII c. Motor and sensory components of CN XI d. Motor component of CN X and sensory component of CN VII

ANS: B The findings listed reflect a dysfunction of the motor component of the facial nerve (CN VII).

The nurse has just completed an inspection of a nulliparous woman's external genitalia. Which of these would be a description of a finding within normal limits? A) Redness of the labia majora B) Multiple nontender sebaceous cysts C) Discharge that is sticky and yellow-green D) Gaping and slightly shriveled labia majora

ANS: B There should be no lesions, except for occasional sebaceous cysts. These are yellowish 1-cm nodules that are firm, nontender, and often multiple. The labia majora are dark pink, moist, and symmetrical; redness indicates inflammation or lesions. Discharge that is sticky and yellow-green may indicate infection. In the nulliparous woman, the labia majora meet in the midline, are symmetric and plump.

During a bimanual examination, the nurse detects a solid tumor on the ovary that is heavy and fixed, with a poorly defined mass. This finding is suggestive of: A) an ovarian cyst. B) endometriosis. C) ovarian cancer. D) an ectopic pregnancy.

ANS: C Ovarian tumors that are solid, heavy, and fixed, with poorly defined mass are suggestive of malignancy. Benign masses may feel mobile and solid. An ovarian cyst may feel smooth, round, fluctuant, mobile, and nontender. With an ectopic pregnancy, the examiner may feel a palpable, tender pelvic mass that is solid, mobile, and unilateral. Endometriosis may have masses (in various locations in the pelvic area) that are small, firm, nodular and tender to palpation, with enlarged ovaries.

4. The area of the nervous system that is responsible for mediating reflexes is the: a. Medulla. b. Cerebellum. c. Spinal cord. d. Cerebral cortex.

ANS: C The spinal cord is the main highway for ascending and descending fiber tracts that connect the brain to the spinal nerves; it is responsible for mediating reflexes.

19. A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination? a. Glasgow Coma Scale b. Neurologic recheck examination c. Screening neurologic examination d. Complete neurologic examination

ANS: D The nurse should perform a complete neurologic examination on an individual who has neurologic concerns (e.g., headache, weakness, loss of coordination) or who is showing signs of neurologic dysfunction. The Glasgow Coma Scale is used to define a person's level of consciousness. The neurologic recheck examination is appropriate for those who are demonstrating neurologic deficits. The screening neurologic examination is performed on seemingly well individuals who have no significant subjective findings from the health history.

45. A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing? a. Scissors gait b. Cerebellar ataxia c. Parkinsonian gait d. Spastic hemiparesis

ANS: D With spastic hemiparesis, the arm is immobile against the body. Flexion of the shoulder, elbow, wrist, and fingers occurs, and adduction of the shoulder, which does not swing freely, is observed. The leg is stiff and extended and circumducts with each step. Causes of this type of gait include cerebrovascular accident. (See Table 23-6 for more information and for the descriptions of the other abnormal gaits.)

The nurse is examining a 2-month-old infant and notices asymmetry of the infant's gluteal folds. The nurse should assess for other signs of what disorder?

ANS: Hip dislocation Unequal gluteal folds may accompany hip dislocation after 2 to 3 months of age, but some asymmetry may occur in healthy children. Further assessment is needed. The other responses are not correct.

ANS: Rheumatoid arthritis Rheumatoid arthritis is worse in the morning when arising. Movement increases most joint pain, except in rheumatoid arthritis, in which movement decreases pain. The other options are not correct.

What is the most important risk factor for breast cancer?

Age

What Abdominal locations do you listen for bruits with the Bell of the stethoscope?

Aoritc, Illiac, Femoral

Explain cancer chances with different grades of pap smear?

Atypical squamous cells-rarely become cancer. Low-grade has an increased risk of progressing to higher grade or to invasive cancer over 24 months and higher grade has a much higher chance of becoming invasive over 24 months.

2nd Step

Auscultation: Bowel sounds, Vascular sounds, venous Hum, Friction rubs.

B) "Does the tremor change when you drink the alcohol?"

The ability that humans have to perform very skilled movements such as writing is controlled by the:

B) Corticospinal tract.

An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to?

B) Decreased gastric acid secretion

A patient has hypo-active bowel sounds. The nurse knows that a potential cause of hypo-active bowel sounds is?

B) Peritonitis

The spinous processes that are prominent at the base of the neck are: A. T7 and T8. B. C7 and T1. C. T12 and L1. D. L3 and L4.

B. C7 and T1.

Mrs. Landers is a 53-year-old patient with rheumatoid arthritis. On examination, which of the following would you expect to find due to this type of arthritis? A. Dislocation B. Painful motion C. Increased ROM D. Muscle spasms

B. Painful motion

Mr. Sanchez is a 48-year-old patient who presents for a routine health assessment, and you examine his abdomen. The left lower quadrant contains which of the following organs? A. Pancreas B. Sigmoid colon C. Kidney D. Gallbladder

B. Sigmoid colon

A red, round, superficial ulcer with serous discharge, which is a possible sign of syphilis, is called: A. cystitis. B. a chancre. C. hypospadias. D. phimosis.

B. a chancre.

A medical emergency due to a retracted and fixed foreskin behind the glans is called: A. Peyronie disease. B. paraphimosis. C. phimosis. D. cryptorchidism.

B. paraphimosis.

Cerebellar function is tested by: A. muscle strength assessment. B. performance of rapid alternating movements. C. the Phalen maneuver. D. superficial pain and touch assessment.

B. performance of rapid alternating movements.

The name for the hood or flap of skin over the glans is: A. varicocele. B. prepuce. C. genitalis. D. progenitalis.

B. prepuce.

Pronation and supination of the hand and forearm are the result of the articulation of the: A. scapula and clavicle B. radius and ulna C. patella and condole of fibula D. femur and acetabulum

B. radius and ulna

During a neurologic examination, the tendon reflex fails to appear. Before striking the tendon again, the examiner might use the technique of: A. two-point discrimination B. reinforcement C. vibration D. graphesthesia

B. reinforcement

Senile tremors may resemble parkinsonism, except that senile tremors do not include: A. nodding the head as if responding yes or no B. rigidity and weakness of voluntary movement C. tremor of the hands D. tongue protrusion

B. rigidity and weakness of voluntary movement

Clonus that may be seen when testing deep tendon reflexes is characterized by a(n): A. additional contraction of the muscle that is of greater intensity than the first. B. set of rapid, rhythmic contractions of the same muscle. C. parallel response in the opposite extremity. D. contraction of the muscle that appears after the tendon is hit the second time.

B. set of rapid, rhythmic contractions of the same muscle.

A retention cyst in the epididymis filled with milky fluid containing sperm is called a: A. varicocele. B. spermatocele. C. Peyronie's disease. D. prepuce.

B. spermatocele.

To elicit a Babinski reflex: A. gently tap the Achilles tendon B. stroke the lateral aspect of the sole of the foot from heel to the ball C. present a noxious odor to the person D. observe the person walking heel to toe

B. stroke the lateral aspect of the sole of the foot from heel to the ball

Mrs. Painter is a 62-year-old patient who comes to the clinic for a follow-up health assessment for complaints of joint tenderness. On examination you note a joint that has a boggy, soft feel to palpation. This is generally indicative of: A. rheumatoid arthritis. B. synovial thickening. C. synovial subluxation. D. crepitation.

B. synovial thickening.

Signs and testing for Bacterial vaginosis?

Bacterial overgrowth (prob.anaerobic). Can be transmitted sexually. Small amt of thin grey or white vaginal discharge that coats the walls of the vagina. Unpleasant fishy smell. Vulva normal. Can see clue cells on wet mount. +sniff test when adding KOH to slide.

The nurse should use which test to check for large amounts of fluid around the patella?

Ballottement

Rinne Test

Base of the tuning fork is placed on the mastoid bone, count how long they hear it. Then move it in front of the ear and count how long they hear that. Normally the sound is heard longer through air than through bone. In conductive hearing loss, sound is heard through bone as long as or longer than it is through air (BC>AC). In sensorineural hearing loss, sound is heard longer through air (AC>BC).

Fluid within the bursa that results in synovial thickening is also described by which of the following terms? A. Subluxation B. Ankylosis C. Effusion D. Effleurage

C. Effusion

Mrs. Bauer comes to your office with her 12-year-old daughter with a complaint of a lump in her groin. On examination you detect a hernia. Which of the following types of hernias is more common in females? A. Direct hernia B. Indirect hernia C. Femoral hernia D. Sliding hernia

C. Femoral hernia

Which of the following is a normal breast variation? A. Polymastia B. Supernumerary breast C. Supernumerary nipple D. None of the above

C. Supernumerary nipple

The breasts of a neonate may be large and very visible, secreting clear or white fluid. What is the basis of this finding? A. It may be due to birth trauma B. The fluid is colostrum, which is typically seen as a precursor to milk C. The cause is maternal estrogen, which crossed the placenta D. This often occurs with premature thelarche

C. The cause is maternal estrogen, which crossed the placenta

Which of the following may be noted through inspection of the abdomen? A. fluid waves and abdominal contour B. umbilical eversion and Murphy sign C. venous pattern, peristaltic waves, and abdominal contour D. peritoneal irritation, general tympany, and peristaltic waves

C. venous pattern, peristaltic waves, and abdominal contour

The four layers of large, flat abdominal muscles form the: A. linea alba. B. rectus abdominus. C. ventral abdominal wall. D. viscera.

C. ventral abdominal wall.

Causes of post-coital vaginal bleeding?

Cervical polyps, cancer, or atrophic vaginitis in older women, use of HRTs.

If there is a history of or appearance of labial swelling, check for what?

Check the Bartholin's gland for swelling or abscess.

Most common organisms for urethritis?

Chlamydia and Gonorrhea.

Striae, which occur when the elastic fibers in the reticular layer of the skin are broken after rapid or prolonged stretching, have a distinct color when of long duration. This color is: A. pink B. blue C. purple-blue D. silvery white

D. silvery white

The left upper quadrant (LUQ) contains the: A. liver B. appendix C. left overt D. spleen

D. spleen

Motor Component of VII

During an assessment of the cranial nerves, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging go the lower eyelids, and escape of air when the nurse presses against right puffed cheek. This would be dysfunction of which of the cranial nerves?

Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time.

During the history of a 78 year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion. "He can't even remember how to button his shirt." In doing the assessment of his sensory system, which action by the nurse is most appropriate?

eupnea

Easy or normal breathing; 12-20/min

What two specimens are obtained with the pap smear?

Endocervical and ectocervical.

What are causes of secondary dysmenorrhea?

Endometriosis, adenomyosis, PID, endometrial polyps.

What could cause lateral displacement of the cervix?

Endometriosis, involving the uterosacral ligaments.

50-60% of girls or women with chronic pelvic pain are diagnosed with?

Endometriosis.

What Abdominal locations do you listen for bruits with the diaphragm of the stethoscope?

Epigastric and Renal

Menorrhagia?

Excessive bleeding.

During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?

Fifth left intercostal space at the midclavicular line

What would a uterus feel like with cancer?

Firm and fixed.

What could a uterus feel like in a client with endometriosis?

Fixed and tender.

Kernig

Flex patient's leg at hip and knee, then straighten the knee. Discomfort behind the knee during full extension should not cause pain.

Obturator Sign

Flex pt's right thigh at the hip, with knee bent, and rotate the leg internally at the hip. It stretches the internal obturator muscle. Right hypogastric pain = positive sign

The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)?

Flexion and extension

Which is a gerontological variation that occurs to the gastrointestinal system?

Gastric acid secretion decreases.

The nurse is providing patient education for a man who has been diagnosed with a rotator cuff injury. The nurse knows that a rotator cuff injury involves the:

Glenohumeral joint.

Glossopharyngeal pharynx phonation and swallowing (motor) taste posterior one third of tongue and gag reflex (sensory)

30-75

HDL should be between ____ mg/dl

Astereognosis:

Inability to recognize objects placed in the hand

Bruits

Indicates turbulence of blood flow and suggests a partial obstruction. Bruits can also occur with abdominal aortic aneurysm, renal stenosis, and femoral stenosis. Never palpate over areas where bruits are ausculatated because it may cause a rupture.

Pain with movig a cervix is a sign of ?

Infection

Oligomenorrhea?

Infrequent bleeding.

How do you check for urethritis?

Insert the index finger into the vagina and milk the urethra from the inside outward. Culture any discharge.

Bulge Sign

Knee extended, hand on knee above the patella and milk downward. Apply medial pressure and tap laterally. Watch for a fluid wave

Puddle Sign

Knee to chest position for several minutes, percuss the umbilical area it should remain tympanic. If dull the ascitic fluids pool because of gravity

Axillary Lymph Nodes

Lateral Pectoral (Anterior) Subscapular (Posterior) Supraclavicular Infraclavicular

scoliosis

Lateral curvature of the thoracic and lumbar segments

Annular Lesions

Lesions grouped in a circle

Accommodation

Look far away and then close up, pupils will constric

Stages of HTN

Normal: under 120/80 Prehypertension: 120-139/80-89 Stage 1: 140-159/90-99 Stage 2: over 160/100 If diabetes or renal disease: goal is under 130/80

Olfactory smell sensory

Mittelschmerz

Pain from ovulation at mid-cycle.

Rebound Tenderness

Pain in RLQ increases when pressure is released quickly

Dysmenorrhea

Pain with menses, often with bearing down. Aching in lower abdomen or pelvis.

Dyspareunia

Painful intercourse.

What color is the cervix after menopause?

Pale

Percussion

Percuss all four quadrants start in RLQ, RUQ, LUQ, LLQ listen for tympany and dullness

Weber Test

Place base of tuning fork on top of the head and see if the patient hears it equally in both ears. If not, this is considered conductive hearing loss and they will hear the sound in the impaired ear.

Psoas Sign

Place hand just above right knee and ask pt to raise that thigh against your hand and turn onto the left side. then extend the right leg at the hip.Flexion of th leg at the hip makes the psoas muscle contract; extension stretches it. Increased abd pain with either maneuver constitutes a positive sign

Finkelstein Test

Pt grabs thumb with hand and you pull down to see if there is tendon tenderness - if positive, might mean tendonitis

Describe inflammatory carcinoma?

Rare. Peau d'orange appearance of the skin. Areola retraction. Lymph nodes are blocked.

A 21 year old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes?

Reflexes will be normal

if there is no reaction when you are doing deep tender reflexes what should you do?

Reinforcement, lock fingers and pull

Endometriosis?

Retrograde flow of menstrual flow and extension of the uterine lining outside of the uterus.

The direction of blood flow through the heart is best described by which of these?

Right atrium right ventricle pulmonary artery lungs pulmonary vein left atrium left ventricle

direction of blood flow through the heard

Right atrium?right ventricle?pulmonary artery?lungs?pulmonary vein?left atrium? left ventricle

Peristalsis

Ripples of peristalsis may be observed in this patients. Peristalsis movement slowly traverses the abdomen in a slanting, downward direction. May indicate obstruction

Waist Circumference

Risk if over 35in for women Risk if over 40in for men

Labia majora?

Rounded folds of adipose tissue.

Liver Encephalopathy

S/S slowed mentation or mental confusion, Asterixis (liver flap), uncoordinated muscle movement, Elevated BUN, ammonia, liver enzymes, and osmolarity. Increased values reflect systemic effects of liver dysfunction.

Click on the area where S1 would sound the loudest.

S1, the beginning of systole, would sound the loudest at the tricuspid and mitral areas. These valves must close to allow the ventricles to pump the blood out and protect the atria.

The electrical stimulus of the cardiac cycle follows which sequence?

SA node AV node bundle of His bundle branches

Spleen (Palpatation)

Same as liver. Should not be palpable, only palpable when enlarged to three times its normal size and usually very tender. Enlargment d/t inflamation, CFH, cancer, cirrhosis, or mononucleosis.

The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in which of these conditions?

Severe dehydration

Shifting Dullness

Shifting Dullness: Indicates ascites - fluid shifts dependently when the patient lies supine vs laying on the side. Percuss to determine or look for fluid wave

Abdominis Muscles

Should be symmetrical bilaterally. Abnormality is known as diastasis recti abdominis and is attributed to marked obsesity or past pregnancy caused by increased intra-abdominal pressure and is not considered to be harmful or ominous.

Pronator Drift

Stand with arms out, eyes closed, and hands supine -- watch for hands pronating.

Romberg Test

Stand with hands to the sides and eyes closed, observe swaying

Bowel Sounds

Start at RLQ listen for frequency and character. Listen for 5 minutes before stating absent. move to RUQ, LUQ, LLQ. B/S are usually intermittent gurling high pitched 5-30 per minute. Result from movement of air in the GI tract. Always present in RLQ (ileocecal valve area)

While palpating a patient's abdominal LUQ, you visualize the underlying organs that include:

Stomach, body of pancreas, splenic flexure of colon

As a mandatory reporter of elder abuse, which of the following must be present before you notify the authorities?

Suspicion of elder abuse and/or neglect.

Weber test

Test for lateralization done by placing the stem of a vibrating tuning fork on the midline of the head and having the patient indicate if the sound is clearer in one ear

A 46-year-old woman is in the clinic for her annual gynecological examination. She voices a concern about cervical cancer because her mother and sister died of it. Which of the following is correct regarding cervical cancer?

The Pap smear detects the presence of cervical cancer.

A patient has a severed spinal nerve as a result of a trauma. Which of these statements is true in this situation?

The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve.

The nurse is reviewing anatomy and physiology of the heart. Which statement best describes what is meant by atrial kick?

The atria contract toward the end of diastole and push the remaining blood into the ventricles.

Inframammory ridge?

The boundary of the breast below the breast.

Percuss and palpate the midline area above the suprapubic bone

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?

Cullen Sign

The observation of a blue tint at the umbilicus suggests free blood in the peritoneal cavity

External Os of the cervix?

The opening of the endocervical canal.

An 18 year-old patient is brought to the Emergency Room. His vital signs are as follows: T 97.6 F, P 56, R 8, BP 98/62. What conclusion do you make about this patient's respiratory status?

The patient is experiencing bradypnea.

Which action would alert the nurse to the possibility that a patient may become hostile?

The patient is speaking in a loud voice with clenched fists

A patient with lack of oxygen to his heart will have pain in his chest and possibly the shoulder, arms, or jaw. The nurse knows that the statement that best explains why this occurs is which of these?

The sensory cortex does not have the ability to localize pain in the heart, so the pain is felt elsewhere.

A patient with lack of oxygen to his heart will have chest pain, and possibly pain in the shoulders, arms or jaw. Why?

The sensory cortex does not have the ability to localize pain to the heart, so pain is felt elsewhere.

These are normal findings resulting from aging.

What changes in nipple suggest cancer besides inversion?

Thickening and loss of elasticity

Trigeminal muscles for chewing(motor) and feeling (sensory) the face

Loss of urethral support leads to?

Urinary incontinence.

Venous Hum (Auscultation)

Use bell of stethoscope listen for hum, normally not present in adults. Can be caused by obstructed portal cisculation, portal hypertension caused by cirrhosis of the liver impedes portal circulation.

Cysts

Usually soft to firm, round, mobile, tender bilaterally in women ages 25-50. Increase in pain and size with menstrual cycle and decrease after period ends.

How do you interpret a Snellen Chart?

Vision of 20/200 means that at 20 ft the pt can read print that a person with normal vision could read at 200ft. The larger the second number, the worse the vision.

A client who kept his fat consumption at 10% of his total calorie intake would be at risk for deficiency of which nutrient(s)?

Vitamins A, D, and K Vitamins A, D, and K are fat soluble vitamins. If the client does not have enough fat intake, adequate amounts of these vitamins cannot be absorbed.

emesis

Vomit

What is the proper way to lubricate a speculum?

Warm water. Lube interferes with cultures and cytology.

When and how do you inspect the vagina for abnormalities?

When removing the speculum slowly, keeping it in the open position.

What age of women is the Gail model most effective for?

Women over the age of 50.

KOH slide (slide 2) only detects what?

Yeast.

auscultation

____ of the spleen or liver below the rib cage indicates abscess or metastatic tumor

decreased

_____ (decreased/increased) fremitus is a result of a soft voice, obesity, emphysema, COPD, fibrosis, tumor, exacerbation of asthma, pleural effusion

increased

_____ (decreased/increased) fremitus occurs in the presence of fluids or solid masses in the lungs

A patient has been diagnosed with a ganglion cyst over the dorsum of his left wrist. He asks the nurse, "What is this thing?" The nurse's best answer would be, "It is: A) a common benign tumor." B) a tumor that will have to be watched because it may turn malignant." C) caused by chronic repetitive motion injury." D) a skin infection that will need to be drained."

The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal woman. A participant shows that she needs more instruction when she states, "I will: A) start swimming to increase my weight-bearing exercise." B) try to stop smoking as soon as possible." C) check with my doctor about taking calcium supplements." D) get a bone-density test soon."

The nurse should use which test to check for large amounts of fluid around the patella? A) Ballottement B) Tinel sign C) Phalen's test D) McMurray's test

When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be: A) proximal to distal. B) distal to proximal. C) posterior to anterior. D) anterior to posterior.

retinoblastoma

a cancer that affects the retina of young children, indicated by loss of red eye reflex

dermatone

a circumscribed skin area that is supplied mainly from one spinal chord segment through a particular spinal nerve

rhonchi

a continous adventitious sound; deep rumbling heard during expiration; indicative of asthma, bronchitis, airway edema, foreign body obstruction;

multigravida

a pregnant woman who has previously carried a fetus to the point of viability

bifid

a uvula split into two parts is called ____

During a cardiovascular assessment, the nurse knows that a "thrill" is

a vibration that is palpable

primigravida

a women who is pregnant for the first time

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.

peritonitis

abdominal pain, edema, and tenderness Inflammation of the peritoneum

preclampsia

abnormal condition associated with pregnancy, marked by high blood pressure, proteinuria, edema, and headache

paresthesia

abnormal sensation

AADL

activities that an older adult preforms as a family member, member of society and community

primipara

after a woman delivers her first child

multipara

after a woman who has delivered more than one child

rhynophyma

also known as bulbous nose, usually occurs in older men.

protuberant

an abdomen that bulges outward is characterized as this

dullness

an abnormal finding when percussing the chest

what do you do when auscultating an adult?

anterior chest from apices (top) to supraclavicular down to 6th rib, progress from side to side as you move down

temperalmandibular joint is located where

anterior to the tragus

When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are:

aortic and pulmonic

caput medusae

appearance of engorged or dilated veins around the umbilicus. Asscoutated with circulatory obstruction of the superior of the inferior ven cave. May be related to obstruction of the portal vein or to emaciation.

mongolian spots

areas of deep bluish-gray pigmentation most commonly on the sacral aspect of a newborn

femoral

arteries indicated in the diaga

iliac

arteries indicated in the diagram

renal

arteries indicated in the diagram

carotid

arteries indicated in the diagram; do not cut off circulation to BOTH at the same time;

aortic

artery indicated in the diagram

food diaries

ask individual or family member to write down everything consumed within a certain time period

The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles and quadriceps, the nurse is unable to elicit a reflex. The nurse's next response should be to:

ask the patient to lock her fingers and "pull"

ask the patient to lock her fingers and "pull."

The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding?

astereognosis

S4 sound is heard where

at the end of diastole

tricuspid

at this landmark, S1>S2

erbs

at this landmark, S2=S1

aortic

at this landmark, S2>S1

pulmonary

at this landmark, S2>S1

tendon reflex grading 2+

average normal

A 40-year-old man has come into the clinic with complaints of "extreme tenderness in my toes." The nurse notices that his toes are slightly swollen, reddened, and warm to the touch. His complaints would suggest: A) osteoporosis. B) acute gout. C) ankylosing spondylitis. D) degenerative joint disease.

A patient is able to flex his right arm forward without difficulty or pain but is unable to abduct his arm because of pain and muscle spasms; the nurse should suspect: A) crepitation. B) rotator cuff lesions. C) dislocated shoulder. D) rheumatoid arthritis.

A patient tells the nurse that "all my life I've been called 'knock knees.'" The nurse knows that another term for "knock knees" is: A) genu varum. B) genu valgum. C) pes planus. D) metatarsus adductus.

A patient's annual physical examination reveals a lateral curvature of the thoracic and lumbar segments of his spine; however, this curvature disappears with forward bending. The nurse knows that this abnormality of the spine is called: A) structural scoliosis. B) functional scoliosis. C) herniated nucleus pulposus. D) dislocated hip.

A woman who has had rheumatoid arthritis for years is starting to notice that her fingers are drifting to the side. The nurse knows that this condition is commonly referred to as: A) radial drift. B) ulnar deviation. C) swan neck deformity. D) Dupuytren's contracture.

An 80-year-old woman is visiting the clinic for a checkup. She states, "I can't walk as much as I used to." The nurse is observing for motor dysfunction in her hip and should have her: A) internally rotate her hip while she is sitting. B) abduct her hip while she is lying on her back. C) adduct her hip while she is lying on her back. D) externally rotate her hip while she is standing.

An imaginary line connecting the highest point on each iliac crest would cross the _____ vertebra. A) first sacral B) fourth lumbar C) seventh cervical D) twelfth thoracic

During an interview the patient states, "I can feel this bump on the top of both of my shoulders—it doesn't hurt but I am curious about what it might be." The nurse should tell the patient, "That is: A) your subacromial bursa." B) your acromion process." C) your glenohumeral joint." D) the greater tubercle of your humerus."

The nurse is assessing a patient's ischial tuberosity. To palpate the ischial tuberosity, the nurse knows that it is best to have the patient: A) stand. B) flex the hip. C) flex the knee. D) in the supine position.

The nurse is examining the hip area of a patient and palpates a flat depression on the upper, lateral side of the thigh when the patient is standing. The nurse interprets this finding as the: A) ischial tuberosity. B) greater trochanter. C) iliac crest. D) gluteus maximus muscle.

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. Nothing. This client needs a mammogram as soon as possible. b. A thick yellow discharge from the breasts during pregnancy is normal. c. Call the physician. This information is not normal. d. Help the client understand that she might not be able to breastfeed her infant.

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

Grade 1

barely audible heart murmur in quiet room with stethoscope

Your patient is 5 years old. You would expect him to:

be able to sit on the examination table.

where do you start auscultation and why?

begin the in the right lower quadrant because bowel sounds are normally always present here

geographic tongue

benign, migratory glossitis; autoimmune issue causes missing patches of papillae of tongue

occlusion

blockage or obstruction

third trimester

blood volume peaks pulse rises 15-20 bears per min edema of the lower extremities lordosis possible hemorrhoids 2 weeks before labor fetal head moves into pelvis

tendon reflex grading 3+

brisker than average may indicate disease probably normal

ecchymosis

bruising

Cullen Sign

bruising around the umbilicus- could be significant internal bleeding

When auscultating over a patient's femoral arteries the nurse notices the presence of a bruit on the left side. The nurse knows that:

bruits occur with turbulent blood flow, indicating partial occlusion

A 14-year-old boy who has been diagnosed with Osgood-Schlatter disease reports painful swelling just below the knee for the past 5 months. Which response by the nurse is appropriate? A) "If these symptoms persist, you may need arthroscopic surgery." B) "You are experiencing degeneration of your knee, which may not resolve." C) "Your disease is due to repeated stress on the patellar tendon. It is usually self-limited, and your symptoms should resolve with rest." D) "Increasing your activity and performing knee-strengthening exercises will help to decrease the inflammation and maintain mobility in the knee."

A 68-year-old woman has come in for an assessment of her rheumatoid arthritis, and the nurse notices raised, firm, nontender nodules at the olecranon bursa and along the ulna. These nodules are most commonly diagnosed as: A) epicondylitis. B) gouty arthritis. C) olecranon bursitis. D) subcutaneous nodules.

A patient is visiting the clinic for an evaluation of a swollen, painful knuckle. The nurse notices that the knuckle above his ring on the left hand is swollen and that he is unable to remove his wedding ring. This joint is called the _____ joint. A) interphalangeal B) tarsometatarsal C) metacarpophalangeal D) tibiotalar

A patient who has had rheumatoid arthritis for years comes to the clinic to ask about changes in her fingers. The nurse will assess for signs of what problems? A) Heberden's nodes B) Bouchard's nodules C) Swan neck deformities D) Dupuytren's contractures

A teenage girl has arrived complaining of pain in her left wrist. She was playing basketball when she fell and landed on her left hand. The nurse examines her hand and would expect a fracture if the girl complains: A) of a dull ache. B) that the pain in her wrist is deep. C) of sharp pain that increases with movement. D) of dull throbbing pain that increases with rest.

During a neonatal examination, the nurse notices that the newborn infant has six toes. This finding is documented as: A) unidactyly. B) syndactyly. C) polydactyly. D) multidactyly.

During an examination, the nurse asks a patient to bend forward from the waist and notices that the patient has lateral tilting. When his leg is raised straight up, he complains of a pain going down his buttock into his leg. The nurse suspects: A) scoliosis. B) meniscus tear. C) herniated nucleus pulposus. D) spasm of paravertebral muscles.

The articulation of the mandible and the temporal bone is known as the: A) intervertebral foramen. B) condyle of the mandible. C) temporomandibular joint. D) zygomatic arch of the temporal bone.

The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen's test. To perform this test, the nurse should instruct the patient to: A) dorsiflex the foot. B) plantarflex the foot. C) hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. D) hyperextend the wrists with the palmar surface of both hands touching and wait for 60 seconds.

To palpate the temporomandibular joint, the nurse's fingers should be placed in the depression _____ of the ear. A) distal to the helix B) proximal to the helix C) anterior to the tragus D) posterior to the tragus

Many females do not perform the breast exam even after receiving instruction. This type of behavior may be related to anxiety and fear of cancer or surgery. During the assessment, the nurse needs to encourage the client to share her fears and concerns. 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. Has your mother or sister had breast cancer? b. Have you ever had a mammogram? c. Are you still menstruating? d. Have you had any breast trauma?

c. Are you still menstruating?

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

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

Gout

caused by an increase of uric acid crystals in the joint

A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is:

caused by the complete absence of melanin pigment.

the two parts of the nervous system are

central and peripheral

A 30 year old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain would the nurse be concerned about with these findings?

cerebellum

The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which of these structures?

cerebrum

Each of the following is a good source of Vitamin C (ascorbic acid) EXCEPT?

chicken

Which food would be highest in protein?

chicken

flaccid quadriplegia

complete loss of muscle tone in all four extremities, indicates completely nonfunctional brainstem

patency

condition of being opened and unblocked

A professional tennis player comes into the clinic complaining of a sore elbow. The nurse will assess for tenderness at the: A) olecranon bursa. B) annular ligament. C) base of the radius. D) medial and lateral epicondyle.

A young swimmer comes to the sports clinic complaining of a very sore shoulder. He was running at the pool, slipped on some wet concrete, and tried to catch himself with his outstretched hand. He landed on his outstretched hand and has not been able to move his shoulder since then. The nurse suspects: A) joint effusion. B) tear of rotator cuff. C) adhesive capsulitis. D) dislocated shoulder.

Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called: A) bursa. B) tendons. C) cartilage. D) ligaments.

The nurse has completed the musculoskeletal examination of a patient's knee and has found a positive bulge sign. The nurse interprets this finding to indicate: A) irregular bony margins. B) soft tissue swelling in the joint. C) swelling from fluid in the epicondyle. D) swelling from fluid in the suprapatellar pouch.

The nurse is examining a 2-month-old infant and notices asymmetry of the infant's gluteal folds. The nurse should assess for other signs of what disorder? A) Fractured clavicle B) Down syndrome C) Spina bifida D) Hip dislocation

The nurse is examining a 3-month-old infant. While holding the thumbs on the infant's inner mid thighs and the fingers outside on the hips, touching the greater trochanter, the nurse adducts the legs until the nurse's thumbs touch and then abducts the legs until the infant's knees touch the table. The nurse does not notice any "clunking" sounds and is confident to record a: A) positive Allis test. B) negative Allis test. C) positive Ortolani's sign. D) negative Ortolani's sign.

The nurse notices that a woman in an exercise class is unable to jump rope. The nurse knows that to jump rope, one's shoulder has to be capable of: A) inversion. B) supination. C) protraction. D) circumduction.

When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale? A) 2 B) 3 C) 4 D) 5

When reviewing the musculoskeletal system, the nurse recalls that hematopoiesis takes place in the: A) liver. B) spleen. C) kidneys. D) bone marrow.

dysarthria

difficult timing words

When you percuss over the ribs what should the sound be?

flat

Body Mass Index

for ___ ___ ___ less than 18.5 is underweight, 18.5 to 24.9 is normal, 25-29.9 is overweight, above 30 is obese

synovial joints

freely movable bones are separated from each other and are enclosed in a joint cavity

Insepct Countour

from costal margin to the symphysis pubis should be flat or rounded

In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect to see?

hyperreflexia

otitus

inflammation of the middle ear

Tympany

is the predominant sound heard because air is present in the stomach and in the intestines. It is high-pitched sound of long duration.

knee

Friction Rub (Auscultation)

listen over the right and left costal margins, liver, and the spleen. No friction rub should be present. They are high pitched sounds (like 2-peices of sandpaper) and increases with inspiration. Occur when tumors, inflamation, or infarct cause the visceral layer of the peritoneum to rub together over the liver and spleen

Sarcopenia

loss of lean body mass and strength with aging

mild, even resistance to movement

Barrett's Esophagitis

more advanced stage of acid reflux in the distal esophagus

Jugular vein distension

most associated with right-sided heart failure and the backing up of the superior vena cava and slowing drainage of the jugular veins.

where are most breast tumors located

most common in upper outer quadrant

A yellowish discharge on the endocervical swab could indicate what?

mucopurulent cervicitis (chlamydia), gonorrhea,or herpes.

myopia

nearsightedness

acanthosis nigricans

neck appears "dirty"; often indicative of Type 2 Diabetes Mellitus

normal lymph node objective findings

nonpalpable, discreet, moveable

mild abdominal pulsations between the xiphiod and umbilicus are...

normal abdominal aortic pulsations

exotropia

outward turning of eye

when would dullness occur

over a distended bladder, adipose tissue, fluid or mass

vesicular

over peripheral lung fields

gravidarum

pregnancy

confluent leisons

run together

glasgow coma scale best verbal response 2

sounds incomprehensible

7L along the superior portion of the neck but not on jaw bone

superficial cervical

the hypothalamus controls ________ and regulates _____.

temperature; sleep

male genitals (external)

testis, epididynis and vas deferens

Lid Lag

the eyelid should follow the eye if it moves down, almost always covering a little bit of the iris.

wheezes

these types of adventitious sounds occur in narrow airways; heard during inspiration and expiration; louder during expiration; indicative of asthma, acute bronchitis, or COPD; unilateral indicates local obstruction or foreign body

ventricular gallop, lub dub da; low pitched; listen with bell, normal in children, young adults, pregnant women; heart failure in adult; "slosh ing in"

The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment?

C) Level of consciousness, motor function, pupillary response, and vital signs

The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment? A) Cranial nerves, motor function, and sensory function B) Deep tendon reflexes, vital signs, and coordinated movements C) Level of consciousness, motor function, pupillary response, and vital signs D) Mental status, deep tendon reflexes, sensory function, and pupillary response

C) Level of consciousness, motor function, pupillary response, and vital signs

C) Limited range of motion during the Moro's reflex.

C) Metacarpophalangeal

D) 5

Which of these statements about the peripheral nervous system is correct?

D) The peripheral nerves carry input to the central nervous system by afferent fibers and away by efferent fibers.

During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate and his lower extremities extend with plantar flexion. Which of these statements about these findings is accurate?

D) This is a very ominous sign and may indicate brainstem injury.

D) Tophi.

38. During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with:

D) ascites.

8. The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a _____ profile.

D) concave

32. A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of about 10 cm. The nurse should:

D) consider this a normal finding and proceed with the examination.

5. The nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is:

D) decreased gastric acid secretion.

While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of: A) a great sense of humor. B) uncooperative behavior. C) inability to understand questions. D) decreased level of consciousness.

D) decreased level of consciousness.

13. The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to:

D) hyperactive bowel sounds.

The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to: A) a loud continuous hum. B) a peritoneal friction rub. C) hypoactive bowel sounds. D) hyperactive bowel sounds.

D) hyperactive bowel sounds.

An ophthalmic examination reveals papilledema. The nurse is aware that this finding indicates: A) retinal detachment. B) diabetic retinopathy. C) acute-angle glaucoma. D) increased intracranial pressure.

D) increased intracranial pressure.

abnormal findings pregnancy

inspection- single curve, umbilicus protruding, breasts engorged auscultation- fetal heart tones bowel sounds diminished percussion- tympany over intestines. dull over enlarging uterus palpation- fetal parts fetal movements

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least: A) 1 minute. B) 5 minutes. C) 10 minutes. D) 2 minutes in each quadrant.

B) 5 minutes.

The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient's toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as:

B) A positive Babinski's sign, which is abnormal for adults.

14. During an abdominal assessment, the nurse would consider which of these findings as normal?

B) A tympanic percussion note in the umbilical region

During an abdominal assessment, he nurse would consider which of these findings as normal?

B) A tympanic percussion note in the umbilical region

During an abdominal assessment, the nurse would consider which of these findings as normal? A) The presence of a bruit in the femoral area B) A tympanic percussion note in the umbilical region C) A palpable spleen between the ninth and eleventh ribs in the left midaxillary line D) A dull percussion note in the left upper quadrant at the midclavicular line

B) A tympanic percussion note in the umbilical region

An 80-year-old woman is visiting the clinic for a checkup. She states, "I can't walk as much as I used to." The nurse is observing for motor dysfunction in her hip and should have her:

B) Abduct her hip while she is lying on her back.

B) Acute gout.

The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding?

B) Astereognosis

B) Asymmetric joint involvement C) Pain with motion of affected joints D) Affected joints are swollen with hard, bony protuberances

The nurse is assessing the joints of a woman who has stated, "I have a long family history of arthritis, and my joints hurt." The nurse suspects that she has osteoarthritis. Which of these are symptoms of osteoarthritis? Select all that apply. A) Symmetric joint involvement B) Asymmetric joint involvement C) Pain with motion of affected joints D) Affected joints are swollen with hard, bony protuberances E) Affected joints may have heat, redness, and swelling

B) Asymmetric joint involvement C) Pain with motion of affected joints D) Affected joints are swollen with hard, bony protuberances

The nurse is examining an infant and prepares to elicit the Moro reflex at which time during the examination? A) When the infant is sleeping B) At the end of the examination C) Before auscultation of the thorax D) Halfway through the examination

B) At the end of the examination

A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: A) diarrhea. B) peritonitis. C) laxative use. D) gastroenteritis.

B) peritonitis

15. The nurse is assessing the abdomen of a pregnant woman who is complaining of having "acid indigestion" all the time. The nurse knows that esophageal reflux during pregnancy can cause:

B) pyrosis.

edema

swelling

The bell of the stethoscope is used to assess what characteristic?

Low-pitched sounds

Where is a normal fundus on palpation?

at the pubis level.

Which of the following statements make by a 72-year-old patient would indicate a normal process of aging?

"Food does not taste the same as it used to."

Using the Glasgow Coma Scale, which number indicates that a patient is in a coma.

6 Fully alert: 15 coma: 3-7

Acoustic hearing and equilibrium (sensory)

Do you listen for aortic, illiac, and femoral bruits?

Bell

Convergence

Eye converge symmetrically at the nose

What technique should be used to evaluate the mental status of a patient with head trauma?

Glasgow Coma Scale

Presbycusis

Hearing loss associated with age

Unless a problem is suspected, which cranial nerve is not routinely tested?

Frontal lobe of the cerebral cortex mediates the following function

Intellectual functions and personality

clonus

Involuntary, rhythmic, muscle contractions

130

LDL cholesterol should be less than ____ mg/dl

Allen Test

Occlude radial and ulnar arteries and then release one and visualize blood return

Optic nerve vision sensory

1L medial to the middle of ear

Preauricular

Nummular Lesions

Round (coin-shaped) lesions. Also known as discoid.

Submaxillary- Wharton's duct

Under the tongue

Is the outlet for the gastrointestinal tract.

Which of these statements about the anal canal is true? The anal canal:

axilla

ptyalism

excessive secretion of saliva

Grade 3

moderately loud, no thrill

straie

stretch marks

Rebound Tenderness

Abnormal finding frequently associated with peritoneal inflammation or appendicitis.

keloid

Abnormal growth of scar tissue that is thick and irregular

Lordosis

Abnormal increase in the forward curvature of the lumbar spine

adventitious sounds

Abnormal lung sounds heard with auscultation.

paresthesia

Abnormal sensation described as numbness, tingling, or pins and needles

The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

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

Bristol Stool Chart

1-7 (hard lumps- liquid); 3-5 is normal

Gyrate Rash

A rash that appears to be whirling in a circle.

Functional Assessment Includes what?

ADLs, IADLs, and mobility

Menarche?

Age at onset of menses.

Murphey's Sign

Assessing gallbladder, pt will stop breathing d/t pain when pushing up on the liver if positive.

The nurse knows that testing kinesthesia is a test of a person's:

B) Position sense.

Which of these statements concerning areas of the brain is true?

B) The hypothalamus controls temperature and regulates sleep.

Most common STI in USA and women?

Chlamydia Trachomatis, causes PID and infertility.

To successfully assess clients, a nurse:

Collects subjective and objective data and analyzes the findings.

Heart conditions that accompany systolic murmurs

•Aortic Stenosis: pressure or gradient that the blood has to flow through due to a smaller valve. Increased pumping pressure of Left ventricle •Pulmonary Stenosis: same as above, heard with diaphragm at 2nd and 3rd intercostal space, medium or rough quality, radiates to left shoulder and neck •Tricuspid Insufficiency: supposed to be closed during systole, so causes a backward flow of blood. Diaphragm at 5th intercostal space at the sternal border, radiates to left anterior sternal line •Mitral Insufficiency: loudest at the apex, 5th intercostal space, high pitched and blowing quality

The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which of these structures?

A) Cerebrum

The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal woman. A participant shows that she needs more instruction when she states, "I will:

A) Start swimming to increase my weight-bearing exercise."

Type 2

Bristol stool grade characterized by lumpy sausage shapes

erythema

redness

crepitus

A crinkly sensation palpated on the chest surface caused by air escaping into the subcutaneous tissues.

What is the most common form of cancer in women?

Breast. Also is the second leading cause of cancer death in women.

aspiration

Breathing fluid, food, vomitus, or an object into the lungs

Type 6

Bristol stool grade characterized by fluffy pieces with ragged edges of mushy stool

dominant percussion sound?

tympany

A 45-year-old man is in the clinic for a routine physical. During the history the patient states he's been having difficulty sleeping. "I'll be sleeping great and then I wake up and feel like I can't get my breath." The nurse's best response to this would be:

"Do you have any history of problems with your heart?"

A 60-year-old man has just been told he has benign prostatic hypertrophy. He has a friend who just died from cancer of the prostate and is concerned this will happen to him. How would you respond?

"The enlargement of your prostate is caused by hormone changes and not cancer."

The mother of a 10-year-old boy asks you to discuss the recognition of puberty. You reply

"The first sign of puberty is enlargement of the testes."

Despite repeated instruction over a period of 3 years, the mother of three young children has still not had them immunized. Which of the following questions would help the health care provider understand this situation?

"What are your beliefs about immunization?"

Egophony

"ee" sounds like "A". This sound is present with consolidation/pneumonia

Bronchophony

"ninety-Nine" - if louder than normal

ascites

Abnormal accumulation of fluid in the abdomen.

Gravida?

Total # of pregnancies.

hematemesis

Vomiting of blood.

The nurse is developing a community program to help prevent deaths from stroke. According to Healthy People 2020, which of the following actions should the nurse include in the program to prevent deaths from stroke? Select all that apply. A. Education related to prevention B. Education of the public about emergency response to symptoms C. Screening for hypertension D. Counseling about maintaining prescribed treatment for hypertension E. Stroke treatment programs

A. Education related to prevention B. Education of the public about emergency response to symptoms C. Screening for hypertension D. Counseling about maintaining prescribed treatment for hypertension E. Stroke treatment programs

Heberden's and Bouchard's nodes are hard and nontender and are associated with: A. osteoarthritis. B. rheumatoid arthritis. C. Dupuytren's contracture. D. metacarpophalangeal bursitis.

A. osteoarthritis.

The shock absorber of the vertebral disks in the spine is which of the following? A. Nucleus pulposus B. Costal facet C. Vertebral bursae D. Nucleus fasciculi

A. Nucleus pulposus

Mr. Peyser is a 38-year-old patient who presents to your office for a yearly physical examination. On exam you note that the foreskin of the penis is very tight, preventing it from retracting over the glans. Which of the following conditions best describes this clinical finding? A. Phimosis B. Paraphimosis C. Spermatocele D. Epispadias

A. Phimosis

The left upper quadrant of the abdomen contains which of the following organs? A. Stomach B. Gallbladder C. Ureter D. Ovary

A. Stomach

Which of the following groups of axillary lymph nodes drains the other three? A. Anterior B. Central C. Lateral D. Posterior

B. Central

Mrs. Baker comes to your office with her 2-year-old son. On examination you note that the urinary meatus appears on the upper surface of the penis. Which of the following conditions best describes these clinical findings? A. Varicocele B. Epispadias C. Hydrocele D. Balanitis

B. Epispadias

During the interview, the nurse notes several problems that Mr. Phelps has experienced, leading to Parkinson's syndrome, that have affected his musculoskeletal system. Which of the following nursing diagnoses would be the most important when the client complains of shuffling gait, falls easily, and has poor posture with forward flexion? A. Pain, chronic related to disease process B. Falls, risk for C. Skin integrity, impaired D. Mobility, wheelchair impaired

B. Falls, risk for

Because Mr. Phelps has difficulty with his gait, the nurse should encourage using throw rugs around the house to help cover electrical cords and extension cords to prevent injury. A. True B. False

B. False

The nurse should encourage Mrs. Barber to spend the next several weeks enjoying a sedentary lifestyle because this lifestyle has been found to help clients with arthritis. A. True B. False

B. False

When the nurse is explaining Parkinson's disease with the client, she explains that Parkinson's disease is a chronic disease with increasing weakness of voluntary muscles with activity and some abatement of symptoms A. True B. False

B. False

Assessing an older adult patient's ability to engage in activities of daily living is a part of which assessment? A. Developmental B. Functional C. Cultural D. Screening

B. Functional

Which of the following would you expect to see in an individual who demonstrates genu valgum? A. Bowleg B. Knock-knee C. Pigeon-toed D. Clubfoot

B. Knock-knee

Mr. Bowers is a 39-year-old patient who presents to the clinic, and you examine the abdomen. The right upper quadrant of the abdomen contains which of the following organs? A. Spleen B. Liver C. Cecum D. Left ureter

B. Liver

Which of the following complaints are the most common musculoskeletal concerns that prompt an individual to seek health care? A. Joint pain and myalgia B. Loss of function and joint pain C. Neuralgia and loss of function D. Neuralgia and myalgia

B. Loss of function and joint pain

Which of the following conditions would best utilize the assessment technique of transilluminatation? A. Palpating for inguinal hernia B. Observing for hydrocele C. Observing for phimosis D. Palpating for tender testes

B. Observing for hydrocele

Which of the following muscles may be congenitally absent in certain individuals? A. Palmaris shortus B. Palmaris longus C. Peroneus secondus D. Synovius membraneous

B. Palmaris longus

The nurse asks a client to stand with feet together and arms at the side with eyes closed. The client immediately starts to sway and moves his feet farther apart. The nurse would document this as a: A. Negative Romberg's sign B. Positive Romberg's sign C. Cerebellar dysfunction D. Vestibular dysfunction

B. Positive Romberg's sign

During the assessment of a client's shoulder joints, the client shrugs his shoulders and then complains of pain with abduction. What does this finding suggest to the nurse? A. Osteoarthritis of the joint B. Possible rotator cuff tear C. Olecranon bursitis D. A dislocated shoulder

B. Possible rotator cuff tear

The spleen is: A. a soft, lobulated gland behind the stomach. B. a soft mass of lymphatic tissue on the posterolateral wall. C. a bean-shaped, retroperitoneal gland. D. None of the above.

B. a soft mass of lymphatic tissue on the posterolateral wall.

The ______ reflex is an example of a _________ reflex. A. plantar; deep tendon B. abdominal; superficial C. quadriceps; pathologic D. corneal light; visceral

B. abdominal; superficial

Splenomegaly is defined as a(n): A. outflow obstruction of the stomach. B. abnormal enlargement of the spleen. C. enlargement of the liver. D. sunken abdominal wall.

B. abnormal enlargement of the spleen.

Phimosis is: A. undescended testes. B. an advanced and fixed foreskin too tight to retract over the glans. C. hard, subcutaneous plaques associated with painful bending of the erect penis. D. a prolonged, painful erection of the penis without sexual desire.

B. an advanced and fixed foreskin too tight to retract over the glans.

Fluid in the knee may be confirmed by performing: A. Tinel's sign. B. bulge sign. C. ROM. D. McMurray's test.

B. bulge sign.

An increase in fluid within a bursa is manifested by which of the following characteristics? A. A decrease in the expected ROM of the joint B. Crepitus heard when putting the joint through ROM C. A bulge that appears on the opposite side of the joint after pushing on the other side D. Subluxation of the joint after flexing and extending the joint

C. A bulge that appears on the opposite side of the joint after pushing on the other side

An individual with functional scoliosis will demonstrate which of the following? A. A lateral spinal curvature that remains visible in the standing and bending position B. A lateral spinal curvature that remains at less than 20 degrees C. A lateral spinal curvature that is visible in the standing position but disappears when the individual bends over D. A lateral spinal curvature that affects either the thoracic area or the lumbar area but not both

C. A lateral spinal curvature that is visible in the standing position but disappears when the individual bends over

What term is used to describe involuntary muscle movements? A. Ataxia B. Flaccidity C. Athetosis D. Vestibular function

C. Athetosis

A herniated nucleus pulposus will produce which of the following results when an individual performs a straight leg-raising test? A. Numbness and tingling in the foot and ankle B. Limited ROM of the hip C. Back and leg pain D. Clicking sound when the knee is extended and externally rotated

C. Back and leg pain

A client is newly diagnosed with osteoarthritis of the spine. The nurse knows that this client has a disease process within the: A. Synovial joints B. Fibrous joints C. Cartilaginous joints D. Cervical bursae

C. Cartilaginous joints

An elderly client is experiencing an alteration in his equilibrium and coordinated muscle movements. The nurse realizes that these functions are controlled by which area of the nervous system? A. Cerebrum B. Hypothalamus C. Cerebellum D. Brainstem

C. Cerebellum

During the musculoskeletal assessment of a female client, the nurse documents that the client has pain in the muscles and soft tissues around the head, neck, shoulders, and hips. Which of the following disorders do these findings suggest in the client? A. Systemic lupus erythematosus B. Gout C. Fibromyalgia D. Osteoarthritis

C. Fibromyalgia

During the assessment of sensory function of a client, the nurse learns that the client has decreased pain sensation. Which of the following should the nurse document about this finding? A. Anesthesia B. Analgesia C. Hypalgesia D. Hypoesthesia

C. Hypalgesia

Mr. Tucker is a 28-year-old patient who presents to your office with a concern that during an erection his penis is bent and painful. This clinical finding is caused by nontender, hard plaques on the surface of the penis known as: A. paraphimosis. B. phimosis. C. Peyronie disease. D. spermatocele.

C. Peyronie disease.

During an assessment of an adult client's plantar reflex, the nurse notes a normal response. Which of the following would be considered normal for this client? A. Babinski response B. Dorsiflexion of the foot C. Plantar flexion of the foot D. Fanning of the toes

C. Plantar flexion of the foot

Pyloric stenosis is a(n): A. abnormal enlargement of the pyloric sphincter. B. inflammation of the pyloric sphincter. C. congenital narrowing of the pyloric sphincter. D. abnormal opening in the pyloric sphincter.

C. congenital narrowing of the pyloric sphincter.

Pyloric stenosis is defined as a(n): A. abnormal enlargement of the pyloric sphincter. B. inflammation of the pyloric sphincter. C. congenital narrowing of the pyloric sphincter. D. None of the above.

C. congenital narrowing of the pyloric sphincter.

Mrs. Moyer comes to the ambulatory health center for a routine assessment. After her examination, you suspect rheumatoid arthritis. Which of the following characteristics differentiates rheumatoid arthritis from other MS conditions? A. Stiffness associated with RA occurs mostly at night. B. Pain associated with RA is worse at night. C. RA involves symmetric joints. D. Activity increases pain in the RA-affected joint.

C. RA involves symmetric joints.

Cerebellar function is assessed by which of the following tests: A. muscle size and strength B. cranial nerve examination C. coordination-hop on one foot D. spinothalamic test

C. coordination-hop on one foot

During the examination of an infant, use a cotton-tipped applicator to stimulate the anal sphincter. The absence of a response suggests a lesion of: A. L2 B. T12 C. S2 D. C5

C. S2

A client, seen previously for herpes zoster, comes into the clinic with ongoing neurologic changes, pain, and sensory/motor function changes. The nurse realizes that this client might be experiencing: A. Myasthenia gravis B. Lyme disease C. Meningitis D. Myelitis

D. Myelitis

When the nurse assesses Mrs. Barber and finds out that she has had erythematous, hot, swollen, tender fingers and pain with movement, which of the following goals would be the most realistic? A. The most important goal for Mrs. Barber is to be able to participate in a fast-paced aerobic exercise regimen several times a week. B. The most important goal for Mrs. Barber is that she will not require any further medication for pain or discomfort associated with her symptoms. C. The most important goal for Mrs. Barber would be to have an understanding of her disease process and have increased awareness of symptoms associated with arthritis. D. The most important goal for Mrs. Barber would be to be free of any pain.

C. The most important goal for Mrs. Barber would be to have an understanding of her disease process and have increased awareness of symptoms associated with arthritis.

A client has a history of anosmia over the past three months. The nurse knows that this condition is: A. Related to swallowing difficulty B. Associated with ataxia C. Difficulty with tongue movements D. Loss of ability to smell or detect odors

D. Loss of ability to smell or detect odors

The liver is: A. a soft, lobulated gland behind the stomach. B. a soft mass of lymphatic tissue on the postlateral wall. C. a bean-shaped, retroperitoneal gland. D. None of the above.

D. None of the above.

Mr. Harrison is a 28-year-old patient who presents to your office urgently with a concern of a penile erection that has not subsided. Which of the following is a prolonged penile erection that is often painful (most cases are idiopathic)? A. Paraphimosis B. Phimosis C. Spermatocele D. Priapism

D. Priapism

During the neurologic assessment, the nurse finds that a client is unable to calculate mathematical problems; however, the remainder of the assessment is normal. Which of the following does this finding suggest to the nurse? A. The client may have an altered cognitive status. B. The client could be depressed. C. The client may have dementia. D. The client may be nervous.

D. The client may be nervous.

Near the conclusion of the neurologic examination, the nurse notices a rapid muscle contraction of the client's left quadriceps muscle. Which of the following could describe this assessment finding? A. This is a fasciculation. B. This is a tic. C. This is a tremor. D. This is myoclonus.

D. This is myoclonus.

cafe au lait

Large round/oval patch of light brown pigmentation; could be a sign of neurofibromyosis

The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment?

LoC, motor function, pupillary response, and vital signs

Why is redness of breast skin concerning for?

Local infection (mastitis) or inflammatory carcinoma

Skene's Glands

Near urethra- can milk to see if there is discharge.

What straie would be concerning for breast cancer?

Newly developed straie for no reason (like pregnancy). New ones would be red.

Kidney (Percussion)

Sitting position, strike costalvertebral angle with a closed fist, no tenderness should be elicted

What is Paget's disease mistaken for?

Skin irritation or eczema. It is a slow-growing cancer of the nipple. (1% of all breast cancers).

xanthelasma

Slightly raised, yellowish, well-circumscribed plaques that appear along the nasal portions of one or both eyelids. May accompany lipid disorders.

Cervical cancer is _____ growing?

Slow.

Fibroadenoma

Smooth, rubbery, round, mobile, non-tender breast lesion usually unilateral in women age 15-25. Don't change with menstrual cycle.

Hypertrophy

Some component of the skin such as a scar is enlarged or has grown excessively. The opposite is atrophy or thinned skin.

Hymen?

Sometimes the introitus can be hidden by this tissue in virgins.

Spinal accessory movement of the trapezius and sternomastoid muscles (motor)

A 6-month-old infant is brought to the clinic for immunizations. While examining the baby, the examiner notes that the anterior fontanel has not closed. What is the significance of this finding?

This is a normal finding.

This is a very ominous sign and may indicate brainstem injury.

The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this?

This is most likely the result of the summation effect.

During an examination, the nurse notices nystagmus in both eyes of a patient. Which of these conclusions by the nurse is correct?

This may indicate disease of the cerebellum or brainstem.

What area is examined by the rectovaginal exam?

The cul-de-sac between the uterus and the rectum called the rectouterine pouch or pouch of Douglas.

When measuring a patient's body temperature, the nurse keeps in mind that body temperature is influenced by:

The diurnal cycle.

Scrotum

The external male genital structures include the:

Joints

The functional units of the musculoskeletal system are the:

Graphesthesia

The inability to recognize numbers written on the hand. Suggests a lesion in the sensory cortex.

The nurse is assessing the lungs of an older adult. Which of these describes normal changes in the respiratory system of the older adult?

The lungs are less elastic and distensible, which decreases their ability to collapse and recoil.

Which of these statements about the peripheral nervous system is correct?

The peripheral nerves carry input to the central nervous system by afferent and away by efferent fibers.

Hyperactive bowel sounds

The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to:

The nurse is assessing an 80-year-old male patient. Which assessment findings would be considered normal?

The presence of kyphosis and flexion in the knees and hips

When inspecting the anterior chest of an adult, the nurse should include which assessment?

The shape and configuration of the chest wall.

Central and peripheral

The two parts of the nervous system are the:

Amenorrhea followed by heavy bleeding could signify what?

Threatened abortion or dysfunctional uterine bleeding related to lack of ovulation.

What is sojourning time in breast cancer growth?

Time of quick breast cancer growth

Perineum?

Tissue between the introitus and the anus.

Anterior to the tragus

To palpate the temporomandibular joint, the nurse's fingers should be placed in the depression________of the ear.

After examining the tonsils of a 10-year-old child, you record your findings as "tonsils are 3+," which means that:

Tonsils are nearly touching the uvula.

Para?

Total number of births. F-full-term, P-premature, A-abortion, L-living child

BMI Classifications

Underweight: <18.5 Normal: 18.5-24.9 Overweight: 25.0-29.9 Obesity class • I: 30.0-34.9 • II: 35.0-39.9 • III: at or over 40

Most breast masses tend to occur in which quadrant?

Upper outer quadrant

Bladder (Palpatation)

Use deep palpation, and palpate the abd at the midline, starting at the symphysis pubis and progessing upward to the umbilicus. An empty bladder is not susally palpable. A moderately full bladder is smooth and round, and it is palpable above the symphysis pubis. A full bladder is palpated about the symphysis pubis and it may be close to the umbilicus

How do you insert the speculum?

Use downward pressure when inserting and go 45 degrees to visualize the cervix.

resonance

a normal finding when percussing the chest

The brainstem controls blood pressure, respiratory rate, swallowing, and coughing. A client with a head injury is demonstrating dysphagia and dysphasia. Which cranial nerve(s) might be involved with this symptom? Select all that apply. A. Glossopharyngeal (CN IX) B. Vagus (CN X) C. Accessory (CN XI) D. Facial (CN VII) E. Trigeminal (CN V)

A. Glossopharyngeal (CN IX) B. Vagus (CN X)

During the neurologic assessment of a client the nurse would like to include questions to assess the client's ability to make health care decisions. Which tool can the nurse use to do this assessment? A. Hopkins Competency Assessment B. General Health Questionnaire C. Mini-mental State Examination D. Cornell Scale for Depression in Dementia

A. Hopkins Competency Assessment

Which of the following statements is true? A. The majority of lymph drains into ipsilateral axillary nodes. B. Rotter's nodes are accessible to examination. C. The subscapular nodes are also known as the lateral axillary nodes. D. Palpable substernal nodes are diagnostic of Paget's disease.

A. The majority of lymph drains into ipsilateral axillary nodes.

A client tells the nurse about upper thigh and hip pain when standing too long. Which of the following does this information suggest to the nurse? A. The client may have some degenerative disease process within the hip. B. The client may have lumbosacral nerve root irritation. C. The client may have referred pain from another body region. D. The client is experiencing paraesthesia.

A. The client may have some degenerative disease process within the hip.

Borborygmi is/are: A. a midline longitudinal ridge in the abdomen. B. normal hyperperistaltic bowel sounds. C. an inflammation of the peritoneum. D. obesity.

B. normal hyperperistaltic bowel sounds.

The musculoskeletal system provides which of the following functions to the human body? A. Protection and storage B. Movement and elimination C. Storage and control D. Propulsion and preservation

A. Protection and storage

When assessing an individual for the presence of a herniated nucleus pulposus, which of the following maneuvers would you ask the individual to perform? A. Raise the legs straight while keeping the knee extended B. Have the individual bend over and attempt to touch the ground while keeping the legs straight C. Have the individual do a knee bend D. Have the individual abduct and adduct the legs while keeping the knee extended

A. Raise the legs straight while keeping the knee extended

When you assess an individual for the presence of a herniated nucleus pulposus, which of the following maneuvers should you ask the individual to perform? A. Raise the legs straight while keeping the knee extended. B. Bend over and attempt to touch the ground while keeping the legs straight. C. Do a knee bend. D. Abduct and adduct the legs while keeping the knee extended.

A. Raise the legs straight while keeping the knee extended.

Mr. Frank, a 32-year-old patient, presents to your office with a complaint of urinary frequency. On examination you note a painless lesion with a clear base and indurated borders that is located on the glans penis. Which of the following best describes this clinical finding? A. Syphilitic chancre B. Lymphogranuloma C. Genital warts D. Herpes simplex

A. Syphilitic chancre

During the focused musculoskeletal interview, the nurse learns that a client developed osteomyelitis after hip replacement surgery. What does this information suggest to the nurse? A. The client is at risk for future episodes of bone infections. B. The client may be more prone to develop osteomalacia. C. The client is at risk for the development of fractures. D. The client is more likely to develop osteoarthritis.

A. The client is at risk for future episodes of bone infections.

The two parts of the nervous system are the:

B) Central and peripheral.

When testing for muscle strength, the examiner does which of the following? A. Observes muscles for the degree of contraction when the individual lifts a heavy object B. Applies an opposing force when the individual puts a joint in flexion or extension C. Measures the degree of force that it takes to overcome joint flexion or extension D. Measures the degree of flexion and extension with a goniometer

B. Applies an opposing force when the individual puts a joint in flexion or extension

Mrs. Jones is a 32-year-old patient who is pregnant and comes to the clinic for a routine health assessment. As part of your patient education, you tell Mrs. Jones that she may feel some discomfort during the third trimester of her pregnancy. What kind of discomfort do you tell her to expect? A. Stiffer joints B. Back pain C. Osteoporosis D. Kyphosis

B. Back pain

A client has a flattened nasolabial fold and drooping of the mouth on the left side. Which of the following cranial nerves is most likely to be involved? A. Cranial nerve V (Trigeminal) B. Cranial nerve VII (Facial) C. Cranial nerve XII (Hypoglossal) D. Cranial nerve XI (Accessory)

B. Cranial nerve VII (Facial)

epistaxis

Bleeding from the nose, anterior events of this are venous in nature and respond to pressure; posterior are arterial and could indicate non healing lesions on the septum or carcinoma

Nocturia is: A. an advanced and fixed foreskin too tight to retract over the glans. B. awakening in the night with a need to urinate. C. a circumscribed collection of serous fluid in the tunica vaginalis surrounding the testes. D. a prolonged, painful erection of the penis without sexual desire.

B. awakening in the night with a need to urinate.

Which is the first physical change associated with puberty in girls? A. areolar elevation B. breast bud development C. height spurt D. pubic hair development E. menarche

B. breast bud development

The _____________ coordinates movement, maintains equilibrium, and helps maintain posture. A. extrapyramidal system B. cerebellum C. upper and lower motor neurons D. basal ganglia

B. cerebellum

This is the first visit for a woman, age 38 years. The practitioner instructs her that a baseline mammogram is recommended for women between the ages of 35 and 39 years and that the clinical examination schedule would be based on age. The recommendation for women ages 40 to 49 years is: A. every year B. every 2 years C. twice a year D. only the baseline examination is needed unless the woman has symptoms

B. every 2 years

The Glasgow Coma Scale (GCS) is divided into three areas. They include: A. pupillary response, a reflex test, and assessing pain B. eye opening, motor response to stimuli, and verbal response C. response to fine touch, stereognosis, and sense of position D. orientation, rapid alternating movements, and the Romberg test

B. eye opening, motor response to stimuli, and verbal response

When assessing an infant, the examiner completes Ortolani maneuver by: A. lifting the newborn and noting a C-shaped curvature of the spin B. gently lifting and abducting the infant's flexed knees while palpating the greater trochanter with the fingers C. comparing the height of the tops of the knees when the knees are flexed up D. palpating the length of the clavicles

B. gently lifting and abducting the infant's flexed knees while palpating the greater trochanter with the fingers

2-year-old child has been brought to the clinic for a health examination. A common finding would be: A. kyphosis B. lordosis C. scoliosis D. no deviation is normal

B. lordosis

The nurse asks the client to close their eyes, then moves the client's finger up and down. The client identifies the direction of movement. Which of the following is being tested? A. Stereognosis B. Topognosis C. Kinesthesia D. Graphesthesia

C. Kinesthesia

Plantar (Babinski) Reflex

Dorsiflexion of the big toe is a positive Babinski response from a CNS lesion in the corticospinal tract

To test for stereognosis, you would: A. have the person close his or her eyes, and then raise the person's arm and ask the person to describe its location B. touch the person with a tuning fork C. place a coin in the person's hand and ask him or her to identify it D. touch the person with a cold object

C. place a coin in the person's hand and ask him or her to identify it

An abnormal sensation of burning or tingling is best described as: A. paralysis. B. paresis. C. paresthesia. D. paraphasia.

C. paresthesia.

The divisions of the spinal vertebrae include which of the following? A. Cervical, thoracic, and scaphoid B. Scapular, clavicular, and lumbar C. Thoracic, lumbar, and coccygeal D. Cervical, lumbar, and iliac

C. Thoracic, lumbar, and coccygeal

Which of the following refers to the four layers of large, flat abdominal muscles? A. Linea alba B. Rectus abdominus C. Ventral abdominal wall D. None of the above

C. Ventral abdominal wall

Which of the following women should not be referred to a physician for further evaluation? A. a 26-year-old with multiple nodules palpated in each breast B. a 48-year-old who has a 6-month history of reddened and sore left nipple and areolar area C. a 25-year-old with asymmetric breasts and inversion of nipples since adolescence D. a 64-year-old with ulcerated area at tip of right nipple; no masses, tenderness, or lymph nodes palpated

C. a 25-year-old with asymmetric breasts and inversion of nipples since adolescence

Increased deposits of subcutaneous fat on the abdomen occur in: A. toddlers. B. teenagers. C. aging adults. D. pregnant women.

C. aging adults.

The extrapyramidal system is located in the: A. hypothalamus. B. cerebellum. C. basal ganglia. D. medulla.

C. basal ganglia.

A 24-year-old man has scrotal pain and marked erythema. The examiner considers epididymitis. What finding is consistent with this problem? A. An uneven scrotal size and shape is observed. B. The patient has anorexia and nausea. C. The patient reports an acute onset of severe pain. D. Urinalysis shows elevated WBCs and bacteria.

D. Urinalysis shows elevated WBCs and bacteria.

diaphoresis

Excessive or profuse sweating or perspiration

Scaphoid Contour

decrease in fat deposits, malnourished state, or flaccid muscle tone

Heart conditions that accompany Diastolic murmurs

•Aortic Insufficiency: most common, Marfan syndrome, retrograde blood flow into left ventricle. Diaphragm at 2nd and 4th intercostal along sternal border, sit up and lean forward and hold breath •Pulmonary Insufficiency: high pitched, diaphragm, 2nd or 3rd intercostal, enhanced during inspiration. •Mitral Stenosis: most common, bell at 5th intercostal, low pitched rumbling, left lateral position •Tricuspid Stenosis: forward blood flow from right atrium though stenosed tricuspid valve, bell at 4th intercostal along sternal border.

Grading of Heart Murmurs

•Grade I -barely audible •Grade 2-clearly audible but faint •Grade 3-moderately loud, easy to hear •Grade 4- Loud, associated with thrill •Grade 5- Very loud- partly off chest •Grade 6- Loudest can be heard with stethoscope lifted off chest

Amenorrhea

Absence of menses.

When are girls at their peak of growth velocity?

At menarche.

What infection has clue cells?

Type 1

Bristol stool grade characterized by hard lumps like nut; hard to pass

ankyloglossia

Complete attachment of tongue to floor of mouth via the frenulum.

hematoma

localized swelling filled with blood

pannus

skin fold of the abdomen in obese individuals

HDL cholesterol

this type of cholesterol should be between 30-75mg/dl

(first heart sound) Occurs with closure of the AV valves and signals the beginning of systole.

Bullous Myringitis

-Painful hemorrhagic vesicles appear on TM or ear canal or both -s/s earache, blood-tinged discharge from the ear and conductive hearing loss -caused by mycoplasma, viral, or bacterial otitis media

Exudative tonsillitis

-Red throat with white exudate on tonsils -Fever, enlarged cervical nodes = Group A strep or mono

Pharyngitis

-Redness and vascularity of pillars and uvula -s/s sore, scratchy throat - no fever, exudate or enlargement of cervical lymph nodes -causes: viral and bacterial

Serous effusion of the ear

-Usually caused by viral URI or by sudden changes in atmospheric pressure as from flying or diving. Eustachian tube can't equalize the air pressure in middle ear and outside air. Air absorbed from middle ear into the bloodstream, and serous fluid accumulated there instead. -Symptoms: fullness and popping sensation in the ear, mild conduction hearing loss, ,and sometimes pain -Amber fluid behind the eardrum. Air bubbles can be seen, but not always

Cystic fluid in the tunica vaginalis surrounding the testes is called: A. hydrocele. B. varicocele. C. orchitis. D. cryptorchidism.

A. hydrocele.

Complete neurologic examination

A 50 year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination?

Stress incontinence

A 52 year-old patient states then when she sneezes or coughs she "wets herself a little". She is very concerned something may be wrong with her. The nurse suspects that the problem is:

A patient has been diagnosed with a ganglion cyst over the dorsum of his left wrist. He asks the nurse, "What is this thing?" The nurse's best answer would be, "It is:

A) A common benign tumor."

Ideally, for an adult the percentage of total calories coming from fat should be limited to:

30%

When assessing a preschool child, the father states that his daughter enjoys jumping rope. Which age is his daughter most likely to be?

5 years old

Directions for Self-Breast Exam

5-7 days after period OR same time every month for menopausal women. Lawn Mower pattern

Deep (palpation)

5-8cm RLQ, RUQ, LUQ, LLQ No organ enlargemtn shoulad be palpable, nor should there be any abnormal masses, bulges, or swelling. normally only the aort and the edge of the liver are palpable. When the large colon or the bladder is full palpation is possible. Enlarged organs can be caused by cholecystitis, hepatitis, cirrhosis. Masses/bulges or swelling can be d/t tumors, fluid, feces, flatus, or fat

Cerebellum

A 30 year-old women tells the nurse the she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain would the nurse be concerned about with these findings?

Which of the following infant reflex responses is considered normal?

A 4-month-old baby's toes fan in response to stroking the lateral surface of the infant's sole.

Acute gout

A 40 year-old man has come into the clinic with complaints of "extreme tenderness in my toes." The nurse notices that his toes are slightly swollen, reddened, and warm to touch. His complaints would suggest:

"The enlargement of your prostate is caused by hormone changes and not cancer"

A 60 year-old man has just been told he has benign prostatic hypertrophy. He has a friend who just died from cancer of the prostate, and he is concerned this will happen to him. How should the nurse respond?

"You need to get up slowly when you've been lying or sitting "

A 70-year old woman tells the nurse that every time she gets up in the morning or after she's been sitting she gets "really dizzy" and feels like she is going to fall over. The nurse's best response would be:

A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe?

A brownish discoloration to the skin of the lower leg

Gastroesophageal Reflux Disease

A condition causing a backflow of stomach acid through an incompetent esophageal sphincter

Fissure

A fissure is a thin crack within epidermis or epithelium, and is due to excessive dryness.

stridor

A high pitched sound generated from partially obstructed air flow in the upper airway. Heard primarily during inspiration. seen in croup, foreign body obstruction, large airway tumors;

Which of the following would be a normal finding in an 80-year-old patient?

A high-tone frequency loss

Linear Lesions

A linear shape to a lesion often occurs for some external reason such as scratching. Also striate.

During inspection you note that the patient's costal angle is 85 degrees. This patient has:

A normal finding

Fluid

A nurse notices that a patient has ascites, which indicates the presence of:

Which of the following examination findings is cause for concern in an adult?

A palpable lymph node is fixed in its setting

The nurse is preparing to perform a manual compression test on a patient. Which of these statements is true about this procedure?

A palpable wave transmission occurs when the valves are incompetent.

Adduction

A patient is being assessed for range of joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called:

Crepitation

A patient states, "I can hear a crunching or grating sound when i kneel." She also states that, "it is very difficult to get out of bed in the morning because of stiffness and pain in my joints." The nurse should assess for signs of what problem?

ateriosclerosis

A thickening or hardening of the walls of an artery, with impairment of blood circulation

What vesicular pattern is concerning?

A unilateral pattern would be concerning for feeding the tumor.

Menstrual history because it is generally nonthreatening.

A woman is in the clinic for an annual gynecologic examination. The nurse should plan to begin the interview with the:

Lordosis

During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question? A) "How do you feel today?" B) "Would you please repeat the following words?" C) "Have these medications had any effect on your pain?" D) "Has this pain affected your ability to get dressed by yourself?"

A) "How do you feel today?"

The presence of primitive reflexes in a newborn infant is indicative of: A. immaturity of the nervous system. B. prematurity of the infant. C. mental retardation. D. spinal cord alterations.

A. immaturity of the nervous system

A 47-year-old client tells the nurse, "I don't want to develop osteoarthritis like both of my parents." Which of the following can the nurse instruct this client? A. "Eating a well-balanced diet and regular exercise are the best defense." B. "Over-the-counter analgesics will help prevent the progression of the disease." C. "If your parents had the disease, you are at increased risk of developing the disease." D. "Calcium supplements will prevent the disorder."

A. "Eating a well-balanced diet and regular exercise are the best defense."

During a visit for a school physical, the 13 year old girl being examined questions the asymmetry of her breasts. The best response is: A. "One breast may grow faster than the other during development." B. "I will give you a referral for a mammogram." C. "You will probably have fibrocystic disease when you are older." D. "This may be an indication of hormonal imbalance. We will check again in 6 months."

A. "One breast may grow faster than the other during development."

When the nurse is interviewing the client, she knows that Parkinson's disease affects: A. 8-15% of adults over 65 years of age B. 15-21% of adults over 65 years of age C. 5-25% of adults over 55 years of age D. 9-17% of adults over 55 years of age

A. 8-15% of adults over 65 years of age

Mr. Quigley is a 56-year-old man who presents with a complaint of testicular swelling. On examination you note swelling that occurs in the epididymis as a result of a cyst. Which of the following conditions best describes these clinical findings? A. A spermatocele B. Epispadias C. Balanitis D. A hydrocele

A. A spermatocele

When performing an assessment on an elderly client, the nurse notes that the client has kyphosis. Which of the following findings did the nurse observe in this client? A. An exaggerated convex curve of the thoracic spine B. Decreased bone density C. A lateral curvature of the spine D. An exaggerated inward curvature of the lower spine

A. An exaggerated convex curve of the thoracic spine

The nurse is performing an assessment on a 40-year-old client and is unable to elicit a patellar reflex. Which of the following is the most appropriate initial action? A. Utilize reinforcement techniques that enhance the reflex. B. Complete the remainder of the assessment, then reassess the reflexes. C. Consider this a normal finding for a client of this age.

A. Utilize reinforcement techniques that enhance the reflex.

A hydrocele is: A. a circumscribed collection of serous fluid in the tunica vaginalis surrounding the testes. B. a meatus opening on the dorsal side of the glans or shaft. C. an acute inflammation of the testes. D. awakening in the night with a need to urinate.

A. a circumscribed collection of serous fluid in the tunica vaginalis surrounding the testes.

Which of the following physiological processes takes place within the musculoskeletal system? A. Hematopoiesis B. Hemolysis C. Hemoptysis D. Hemianopsia

A. Hematopoiesis

Epispadias is: A. a meatus opening on the dorsal side of the glans or shaft. B. a circumscribed collection of serous fluid in the tunica vaginalis surrounding the testes. C. undescended testes. D. an acute inflammation of the testes.

A. a meatus opening on the dorsal side of the glans or shaft.

The inguinal canal is: A. a narrow tunnel inferior to the inguinal ligament. B. a muscular duct continuous with the epididymis. C. a narrow tunnel superior to the inguinal ligament. D. the joining of the vas deferens and the seminal vesicle.

A. a narrow tunnel inferior to the inguinal ligament.

The nurse explains to Mrs. Barber that obese clients have an increased risk for arthritis in weight-bearing joints. A. True B. False

A. True

When the nurse is educating Mr. Phelps, she should include information regarding the use of safety equipment, including seat belts, because older adults have decreased reaction time, resulting in accident and injury. A. True B. False

A. True

The corona is: A. a shoulder where the glans joins the shaft. B. a hood or flap of skin over the glans. C. a corpus spongiosum cone of erectile tissue. D. folds of thin skin on the scrotal wall.

A. a shoulder where the glans joins the shaft.

Mr. Jenkins is a 43-year-old patient who goes to the ambulatory health center with complaints of muscle pain. When testing for muscle strength, the examiner: A. applies an opposing force against the individual's actions during ROM of a joint. B. asks the individual to try to break the examiner's joint movements during ROM. C. measures the degree of muscle tension developed during active extension and flexion of a joint. D. can assume that if an individual has adequate active ROM that muscle strength is fully developed.

A. applies an opposing force against the individual's actions during ROM of a joint.

Mr. Kimbel is a 71-year-old patient who comes to the clinic with his daughter, who is concerned about a mole on her father's abdomen. You know that moles: A. are common on the abdomen. B. are uncommon on the abdomen. C. always require a biopsy. D. are no cause for concern.

A. are common on the abdomen.

Moles on the abdomen: A. are common. B. are uncommon. C. require a biopsy. D. are no cause for concern.

A. are common.

Shifting dullness is a test for: A. ascites B. splenic enlargement C. inflammation of the kidney D. hepatomegaly

A. ascites

The symptoms occurring with lactose intolerance include: A. bloating and flatulence. B. gray stools. C. hematemesis. D. anorexia.

A. bloating and flatulence.

Auscultation of the abdomen is begun in the right lower quadrant (RLQ) because: A. bowel sounds are always normally present here B. peristalsis through the descending colon is usually active C. this is the location of the pyloric sphincter D. vascular sounds are best heard in this area

A. bowel sounds are always normally present here

Undescended testes are called: A. cryptorchidism. B. phimosis. C. orchitis. D. a varicocele.

A. cryptorchidism.

The penis: A. is composed of two corpora cavernosa and one corpus spongiosum. B. is composed of glans, shaft, and scrotum C. contains the urethra, ejaculatory duct, and testes. D. All of the above

A. is composed of two corpora cavernosa and one corpus spongiosum.

Right upper quadrant tenderness may indicate pathology in the: A. liver, pancreas, or ascending colon B. liver and stomach C. sigmoid colon, spleen, or rectum D. appendix or ileocecal valve

A. liver, pancreas, or ascending colon

Sarah Jones, 81, is having an annual mammogram. Prior to the mammogram, the nurse does a breast exam. Expected findings would include: A. palpable, firm, stringy lactiferous ducts. B. increased glandularity. C. multiple, nontender 1+ cm shoddy axillary nodes. D. Incorrect a unilateral venous pattern.

A. palpable, firm, stringy lactiferous ducts.

Crepitation is an audible sound that is produced by: A. roughened articular surfaces moving over each other. B. tendons or ligaments that slip over bones during motion. C. joints that are stretched when placed in hyperflexion or hyperextension. D. an inflamed bursa.

A. roughened articular surfaces moving over each other.

The bulge sign is a test for: A. swelling in the supra patellar pouch B. carpal tunnel syndrome C. Heberden's nodes D. olecranon bursa inflammation

A. swelling in the supra patellar pouch

Automatic associated movements of the body are under the control and regulation of: A. the basal ganglia. B. the thalamus. C. the hypothalamus. D. Wernicke's area.

A. the basal ganglia.

1. During the assessment of deep tendon reflexes, the nurse finds that a patient's responses are bilaterally normal. What number is used to indicate normal deep tendon reflexes when the documenting this finding? ____+

ANS: 2 Responses to assessment of deep tendon reflexes are graded on a 4-point scale. A rating of 2+ indicates normal or average response. A rating of 0 indicates no response, and a rating of 4+ indicates very brisk, hyperactive response with clonus, which is indicative of disease.

A 14-year-old boy who has been diagnosed with Osgood-Schlatter disease reports painful swelling just below the knee for the past 5 months. Which response by the nurse is appropriate?

ANS: "Your disease is due to repeated stress on the patellar tendon. It is usually self-limited, and your symptoms should resolve with rest." Osgood-Schlatter disease is painful swelling of the tibial tubercle just below the knee. It is most likely due to repeated stress on the patellar tendon. It is usually self-limited, occurring during rapid growth and most often in males. The symptoms resolve with rest. The other responses are not appropriate.

When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale?

ANS: 5 Complete range of motion against gravity is normal muscle strength and is recorded as Grade 5 muscle strength.

52. The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma? a. 6 b. 12 c. 15 d. 24

ANS: A A fully alert, normal person has a score of 15, whereas a score of 7 or less reflects coma on the Glasgow Coma Scale (see Figure 23-59).

33. In the assessment of a 1-month-old infant, the nurse notices a lack of response to noise or stimulation. The mother reports that in the last week he has been sleeping all of the time, and when he is awake all he does is cry. The nurse hears that the infant's cries are very high pitched and shrill. What should be the nurse's appropriate response to these findings? a. Refer the infant for further testing. b. Talk with the mother about eating habits. c. Do nothing; these are expected findings for an infant this age. d. Tell the mother to bring the baby back in 1 week for a recheck.

ANS: A A high-pitched, shrill cry or cat-sounding screech occurs with central nervous system damage. Lethargy, hyporeactivity, and hyperirritability, as well as the parent's report of significant changes in behavior all warrant referral. The other options are not correct responses.

35. To assess the head control of a 4-month-old infant, the nurse lifts up the infant in a prone position while supporting his chest. The nurse looks for what normal response? The infant: a. Raises the head, and arches the back. b. Extends the arms, and drops down the head. c. Flexes the knees and elbows with the back straight. d. Holds the head at 45 degrees, and keeps the back straight.

ANS: A At 3 months of age, the infant raises the head and arches the back as if in a swan dive. This response is the Landau reflex, which persists until 1 years of age (see Figure 23-43). The other responses are incorrect.

During a speculum inspection of the vagina, the nurse would expect to see what at the end of the vaginal canal? A) Cervix B) Uterus C) Ovaries D) Fallopian tubes

ANS: A At the end of the canal, the uterine cervix projects into the vagina

46. In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect? a. Hyperreflexia b. Fasciculations c. Loss of muscle tone and flaccidity d. Atrophy and wasting of the muscles

ANS: A Hyperreflexia, diminished or absent superficial reflexes, and increased muscle tone or spasticity can be expected with upper motor neuron lesions. The other options reflect a lesion of lower motor neurons (see Table 23-7).

The nurse is preparing to interview a postmenopausal woman. Which of these statements is true with regard to the history of a postmenopausal woman? A) The nurse should ask a postmenopausal woman if she ever has vaginal bleeding. B) Once a woman reaches menopause, the nurse does not need to ask any further history questions. C) The nurse should screen for monthly breast tenderness. D) Postmenopausal women are not at risk for contracting sexually transmitted infections and thus these questions can be omitted.

ANS: A Postmenopausal bleeding warrants further workup and referral. The other statements are not true.

When assessing a newborn infant's genitalia, the nurse notices that the genitalia are somewhat engorged. The labia majora are swollen, the clitoris looks large, and the hymen is thick. The vaginal opening is difficult to visualize. The infant's mother states that she is worried about the labia being swollen. The nurse should reply: A) "This is a normal finding in newborns and should resolve within a few weeks." B) "This could indicate an abnormality and may need to be evaluated by a physician." C) "We will need to have estrogen levels evaluated to make sure that they are within normal limits." D) "We will need to keep close watch over the next few days to see if the genitalia decrease in size."

ANS: A It is normal for a newborn's genitalia to be somewhat engorged. A sanguineous vaginal discharge or leukorrhea is normal during the first few weeks because of the maternal estrogen effect. During the early weeks, the genital engorgement resolves, and the labia minora atrophy and remain small until puberty.

During an examination, which tests will the nurse collect to screen for cervical cancer? A) Endocervical specimen, cervical scrape, and vaginal pool B) Endocervical specimen, vaginal pool, and acetic acid wash C) Endocervical specimen, KOH preparation, and acetic acid wash D) Cervical scrape, acetic acid wash, saline mount ("wet prep")

ANS: A Laboratories may vary in method, but usually the test consists of three specimens: endocervical specimen, cervical scrape, and vaginal pool. The other tests (acetic acid wash, KOH preparation, and saline mount) are used to test for sexually transmitted infections

A woman is in the clinic for an annual gynecologic examination. The nurse should plan to begin the interview with the: A) menstrual history because it is generally nonthreatening. B) obstetric history because it is the most important information. C) urinary system history because there may be problems in this area as well. D) sexual history because it will build rapport to discuss this first.

ANS: A Menstrual history is usually nonthreatening; thus it is a good place to start. Obstetric, urinary, and sexual histories are also part of the interview but not necessarily the best topics with which to start.

37. To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate? Ask the child to: a. Hop on one foot. b. Stand on his head. c. Touch his finger to his nose. d. Make "funny" faces at the nurse.

ANS: A Normally, a child can hop on one foot and can balance on one foot for approximately 5 seconds by 4 years of age and can balance on one foot for 8 to 10 seconds at 5 years of age. Children enjoy performing these tests. Failure to hop after 5 years of age indicates incoordination of gross motor skills. Asking the child to touch his or her finger to the nose checks fine motor coordination; and asking the child to make "funny" faces tests CN VII. Asking a child to stand on his or her head is not appropriate.

17. While obtaining a health history of a 3-month-old infant from the mother, the nurse asks about the infant's ability to suck and grasp the mother's finger. What is the nurse assessing? a. Reflexes b. Intelligence c. CNs d. Cerebral cortex function

ANS: A Questions regarding reflexes include such questions as, "What have you noticed about the infant's behavior," "Are the infant's sucking and swallowing seem coordinated," and "Does the infant grasp your finger?" The other responses are incorrect.

38. During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. No associated rigidity is observed with movement. Which of these statements is most accurate? a. These findings are normal, resulting from aging. b. These findings could be related to hyperthyroidism. c. These findings are the result of Parkinson disease. d. This patient should be evaluated for a cerebellar lesion.

ANS: A Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion. Tremors associated with Parkinson disease include rigidity, slowness, and a weakness of voluntary movement. The other responses are incorrect.

When performing an external genitalia examination of a 10-year-old girl, the nurse notices that there is no pubic hair, and the mons and the labia are covered with fine vellus hair. These findings are consistent with stage _____ of sexual maturity, according to the Sexual Maturity Rating scale. A) 1 B) 2 C) 3 D) 4

ANS: A Sexual Maturity Rating stage 1 is the preadolescent stage. There is no pubic hair. The mons and labia are covered with fine, vellus hair as on the abdomen. See Table 26-1.

An 11-year-old girl is in the clinic for a sports physical. The nurse notices that she has begun to develop breasts, and during the conversation the girl reveals that she is worried about her development. The nurse should use which of these techniques to best assist the young girl in understanding the expected sequence for development? The nurse should: A) use the Tanner's table on the five stages of sexual development. B) describe her development and compare it with that of other girls her age. C) use Jacobsen's table on expected development on the basis of height and weight data. D) reassure her that her development is within normal limits and should tell her not to worry about the next step.

ANS: A Tanner's table on the five stages of pubic hair development is helpful in teaching girls the expected sequence of sexual development (see Table 26-1). The other responses are not appropriate.

49. The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)? a. Cerebrum b. Cerebellum c. CNs d. Medulla oblongata

ANS: A The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement. The other structures are not responsible for a person's level of consciousness.

2. The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the __________ lobe. a. Frontal b. Parietal c. Occipital d. Temporal

ANS: A The frontal lobe has areas responsible for personality, behavior, emotions, and intellectual function. The parietal lobe has areas responsible for sensation; the occipital lobe is responsible for visual reception; and the temporal lobe is responsible for hearing, taste, and smell.

During an examination the nurse observes a female patient's vestibule and expects to see the: A) urethral meatus and vaginal orifice. B) vaginal orifice and vestibular (Bartholin) glands. C) urethral meatus and paraurethral (Skene) glands. D) paraurethral (Skene) and vestibular (Bartholin) glands.

ANS: A The labial structures encircle a boat-shaped space, or cleft, termed the vestibule. Within it are numerous openings. The urethral meatus and vaginal orifice are visible. The ducts of the paraurethral (Skene) glands and the vestibular (Bartholin) glands are present but not visible.

43. During an assessment of a 62-year-old man, the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements. These findings would be consistent with: a. Parkinsonism. b. Cerebral palsy. c. Cerebellar ataxia. d. Muscular dystrophy.

ANS: A The stooped posture, shuffling walk, short steps, flat facial expression, and pill-rolling finger movements are all found in parkinsonism. (See Table 23-8 for more information and for the descriptions of the other options.)

The uterus is usually positioned tilting forward and superior to the bladder. This position is known as: A) anteverted and anteflexed. B) retroverted and anteflexed. C) retroverted and retroflexed. D) superiorverted and anteflexed.

ANS: A The uterus is freely movable, not fixed, and usually tilts forward and superior to the bladder (a position labeled as anteverted and anteflexed).

The nurse is reviewing the changes that occur with menopause. Which of these are changes 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 uterine hypertrophy

ANS: A The uterus shrinks because of its decreased myometrium. The ovaries atrophy to 1 to 2 cm and are not palpable after menopause. The sacral ligaments relax, and the pelvic musculature weakens, so the uterus droops. The cervix shrinks and looks paler with a thick glistening epithelium. The vaginal epithelium atrophies, becoming thinner, drier, and itchy. The vaginal pH becomes more alkaline, and secretions are decreased. This results in a fragile mucosal surface that is at risk for bleeding and vaginitis.

47. A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual? a. Hyporeflexia b. Increased muscle tone c. Positive Babinski sign d. Presence of pathologic reflexes

ANS: A With a herniated intervertebral disk or lower motor neuron lesion, loss of tone, flaccidity, atrophy, fasciculations, and hyporeflexia or areflexia are demonstrated. No Babinski sign or pathologic reflexes would be observed (see Table 23-7). The other options reflect a lesion of upper motor neurons.

A woman who is 22 weeks pregnant has a vaginal infection. She tells the nurse that she is afraid that this infection will hurt the fetus. The nurse knows that which of these statements is true? A) If intercourse is avoided, then the risk for infection is minimal. B) A thick mucus plug forms that protects the fetus from infection. C) The acidic pH of vaginal secretions promotes the growth of pathogenic bacteria. D) The mucus plug that forms in the cervical canal is a good medium for bacterial growth.

ANS: B A clot of thick, tenacious mucus forms in the spaces of the cervical canal (the mucus plug), which protects the fetus from infection. Cervical and vaginal secretions increase during pregnancy and are thick, white, and more acidic. The acidic pH keeps pathogenic bacteria from multiplying in the vagina, but the increase in glycogen increases the risk of candidiasis (commonly called a yeast infection) during pregnancy.

26. The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception, the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to identify these as one "very sharp prick." What would be the most accurate explanation for this? a. The patient has hyperesthesia as a result of the aging process. b. This response is most likely the result of the summation effect. c. The nurse was probably not poking hard enough with the pin in the other areas. d. The patient most likely has analgesia in some areas of arm and hyperalgesia in others.

ANS: B At least 2 seconds should be allowed to elapse between each stimulus to avoid summation. With summation, frequent consecutive stimuli are perceived as one strong stimulus. The other responses are incorrect.

7. The ability that humans have to perform very skilled movements such as writing is controlled by the: a. Basal ganglia. b. Corticospinal tract. c. Spinothalamic tract. d. Extrapyramidal tract.

ANS: B Corticospinal fibers mediate voluntary movement, particularly very skilled, discrete, and purposeful movements, such as writing. The corticospinal tract, also known as the pyramidal tract, is a newer, "higher" motor system that humans have that permits very skilled and purposeful movements. The other responses are not related to skilled movements.

A 54-year-old woman who has just completed menopause is in the clinic today for a yearly physical examination. Which of these statements should the nurse include in patient education? "A postmenopausal woman: A) is not at any greater risk for heart disease than a younger woman is." B) should be aware that she is at increased risk for dyspareunia because of decreased vaginal secretions." C) has only stopped menstruating; there really are no other significant changes with which she should be concerned." D) is likely to have difficulty with sexual pleasure as a result of drastic changes in the female sexual response cycle."

ANS: B Decreased vaginal secretions leave the vagina dry and at risk for irritation and pain with intercourse (dyspareunia). The other statements are incorrect.

54. The nurse is assessing the neurologic status of a patient who has a late-stage brain tumor. With the reflex hammer, the nurse draws a light stroke up the lateral side of the sole of the foot and inward, across the ball of the foot. In response, the patient's toes fan out, and the big toe shows dorsiflexion. The nurse interprets this result as: a. Negative Babinski sign, which is normal for adults. b. Positive Babinski sign, which is abnormal for adults. c. Clonus, which is a hyperactive response. d. Achilles reflex, which is an expected response.

ANS: B Dorsiflexion of the big toe and fanning of all toes is a positive Babinski sign, also called up-going toes. This response occurs with upper motor neuron disease of the corticospinal (or pyramidal) tract and is an abnormal finding for adults.

50. During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which conclusion by the nurse is correct? Severe nystagmus in both eyes: a. Is a normal occurrence. b. May indicate disease of the cerebellum or brainstem. c. Is a sign that the patient is nervous about the examination. d. Indicates a visual problem, and a referral to an ophthalmologist is indicated.

ANS: B End-point nystagmus at an extreme lateral gaze normally occurs; however, the nurse should carefully assess any other nystagmuses. Severe nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem.

The nurse is preparing to examine the external genitalia of a school-age girl. Which of these positions would be most appropriate in this situation? A) In the parent's lap B) In a frog-leg position on the examining table C) In the lithotomy position with the feet in stirrups D) Lying flat on the examining table with legs extended

ANS: B For school-age children it is best to place them on the examining table in a frog-leg position. With toddlers and preschoolers, it is best to have the child on the parent's lap in a frog-leg position.

A married couple has come to the clinic seeking advice on pregnancy. They have been trying to conceive for 4 months and have not been successful. What should the nurse do first? A) Ascertain whether either of them has been using broad-spectrum antibiotics. B) Explain that couples are considered infertile after 1 year of unprotected intercourse. C) Immediately refer the woman to an expert in pelvic inflammatory disease—the most common cause of infertility. D) Explain that couples are considered infertile after 3 months of engaging in unprotected intercourse and that they will need a referral to a fertility expert.

ANS: B Infertility is considered after 1 year of engaging in unprotected sexual intercourse without conceiving. The other actions are not appropriate

The nurse is palpating a female patient's adnexa. The findings include a firm, smooth uterine wall; the ovaries are palpable and feel smooth and firm. The fallopian tube is firm and pulsating. The nurse's most appropriate course of action would be to: A) tell the patient that her examination was normal. B) give her an immediate referral to a gynecologist. C) suggest that she return in a month for a recheck to verify the findings. D) tell the patient that she may have an ovarian cyst that should be evaluated further.

ANS: B Normally the uterine wall feels firm and smooth, with the contour of the fundus rounded. Ovaries are not often palpable, but when they are, they normally feel smooth, firm, and almond shaped and are highly movable, sliding through the fingers. The fallopian tube is not palpable normally. No other mass or pulsation should be felt. Pulsation or palpable fallopian tube suggests ectopic pregnancy, which warrants immediate referral

18. In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what response should the nurse make? a. "Does your family know you are drinking every day?" b. "Does the tremor change when you drink alcohol?" c. "We'll do some tests to see what is causing the tremor." d. "You really shouldn't drink so much alcohol; it may be causing your tremor."

ANS: B Senile tremor is relieved by alcohol, although not a recommended treatment. The nurse should assess whether the person is abusing alcohol in an effort to relieve the tremor.

A 50-year-old woman calls the clinic because she has noticed some changes in her body and breasts and wonders if they could be due to the hormone replacement therapy (HRT) she started 3 months ago. The nurse should tell her: A) "Hormone replacement therapy is at such a low dose that side effects are very unusual." B) "Hormone replacement therapy has several side effects, including fluid retention, breast tenderness, and vaginal bleeding." C) "It would be very unusual to have vaginal bleeding with hormone replacement therapy, and I suggest you come in to the clinic immediately to have this evaluated." D) "It sounds as if your dose of estrogen is too high; I think you may need to decrease the amount you are taking and then call back in a week."

ANS: B Side effects of hormone replacement therapy include fluid retention, breast pain, and vaginal bleeding. The other responses are not correct.

When the nurse is discussing sexuality and sexual issues with adolescents, a permission statement helps to convey that it is normal to think or feel a certain way. Which of these is the best example of a permission statement? A) "It is okay that you have become sexually active." B) "Often girls your age have questions about sexual activity. Have you any questions?" C) "If it is okay with you, I'd like to ask you some questions about your sexual history." D) "Often girls your age engage in sexual activity. It is okay to tell me if you have had intercourse."

ANS: B Start with a permission statement, "Often girls your age experience . . . ." This conveys that it is normal to think or feel a certain way, and it is important to relay that the topic is normal and unexceptional.

28. The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding? a. Extinction b. Astereognosis c. Graphesthesia d. Tactile discrimination

ANS: B Stereognosis is the person's ability to recognize objects by feeling their forms, sizes, and weights. Astereognosis is an inability to identify objects correctly, and it occurs in sensory cortex lesions. Tactile discrimination tests fine touch. Extinction tests the person's ability to feel sensations on both sides of the body at the same point.

A 52-year-old patient states that when she sneezes or coughs she "wets herself a little." She is very concerned that something may be wrong with her. The nurse suspects that the problem is: A) dysuria. B) stress incontinence. C) hematuria. D) urge incontinence.

ANS: B Stress incontinence is involuntary urine loss with physical strain, sneezing, or coughing. Dysuria is pain or burning with urination. Hematuria is bleeding with urination. Urge incontinence is involuntary urine loss but it occurs due to an overactive detrusor muscle in the bladder that contracts and causes an urgent need to void

During an examination, the nurse would expect the cervical os of a woman who has never had children to appear: A) stellate. B) small and round. C) as a horizontal irregular slit. D) everted.

ANS: B The cervical os in a nulliparous woman is small and round. In the parous woman, it is a horizontal, irregular slit that also may show healed lacerations on the sides. See Figure 26-13.

During an internal examination, the nurse notices that the cervix bulges outside the introitus when the patient is asked to strain. The nurse will document this as: A) uterine prolapse, graded first degree. B) uterine prolapse, graded second degree. C) uterine prolapse, graded third degree. D) a normal finding.

ANS: B The cervix should not be found to bulge into the vagina. Uterine prolapse is graded as follows: first degree—cervix appears at introitus with straining; second degree—cervix bulges outside introitus with straining; and third degree—whole uterus protrudes, even without straining (essentially, uterus is inside out).

3. Which statement concerning the areas of the brain is true? a. The cerebellum is the center for speech and emotions. b. The hypothalamus controls body temperature and regulates sleep. c. The basal ganglia are responsible for controlling voluntary movements. d. Motor pathways of the spinal cord and brainstem synapse in the thalamus.

ANS: B The hypothalamus is a vital area with many important functions: body temperature controller, sleep center, anterior and posterior pituitary gland regulator, and coordinator of autonomic nervous system activity and emotional status. The cerebellum controls motor coordination, equilibrium, and balance. The basal ganglia control autonomic movements of the body. The motor pathways of the spinal cord synapse in various areas of the spinal cord, not in the thalamus.

12. A mother of a 1-month-old infant asks the nurse why it takes so long for infants to learn to roll over. The nurse knows that the reason for this is: a. A demyelinating process must be occurring with her infant. b. Myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated. c. The cerebral cortex is not fully developed; therefore, control over motor function gradually occurs. d. The spinal cord is controlling the movement because the cerebellum is not yet fully developed.

ANS: B The infant's sensory and motor development proceeds along with the gradual acquisition of myelin, which is needed to conduct most impulses. Very little cortical control exists, and the neurons are not yet myelinated. The other responses are not correct.

1. The two parts of the nervous system are the: a. Motor and sensory. b. Central and peripheral. c. Peripheral and autonomic. d. Hypothalamus and cerebral.

ANS: B The nervous system can be divided into two parts—central and peripheral. The central nervous system includes the brain and spinal cord. The peripheral nervous system includes the 12 pairs of cranial nerves (CNs), the 31 pairs of spinal nerves, and all of their branches.

During the examination portion of a patient's visit, she will be in lithotomy position. Which statement below reflects some things that the nurse can do to make this more comfortable for her? A) Ask her to place her hands and arms behind her head. B) Elevate her head and shoulders to maintain eye contact. C) Allow her to choose to have her feet in the stirrups or have them resting side by side on the edge of the table. D) Allow her to keep her buttocks about 6 inches from the edge of the table to prevent her from feeling as if she will fall off.

ANS: B The nurse should elevate her head and shoulders to maintain eye contact. The patient's arms should be placed at her sides or across the chest, not behind the head, because this position only tightens the abdominal muscles. The feet should be placed into the stirrups, knees apart, and buttocks at the edge of the examining table. Place the stirrups so the legs are not abducted too far

22. During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find? a. Firm, rigid resistance to movement b. Mild, even resistance to movement c. Hypotonic muscles as a result of total relaxation d. Slight pain with some directions of movement

ANS: B Tone is the normal degree of tension (contraction) in voluntarily relaxed muscles. It shows a mild resistance to passive stretching. Normally, the nurse will notice a mild, even resistance to movement. The other responses are not correct.

The nurse is palpating an ovarian mass during an internal examination of a 63-year-old woman. Which findings of the mass's characteristics would suggest the presence of an ovarian cyst? Select all that apply. A) Heavy and solid B) Mobile and fluctuant C) Mobile and solid D) Fixed E) Smooth and round F) Poorly defined

ANS: B, E An ovarian cyst (fluctuant ovarian mass) is usually asymptomatic, and would feel like a smooth, round, fluctuant, mobile, nontender mass on the ovary. A mass that is heavy, solid, fixed, and poorly defined suggests malignancy. A benign mass may feel mobile and solid.

10. A patient has a severed spinal nerve as a result of trauma. Which statement is true in this situation? a. Because there are 31 pairs of spinal nerves, no effect results if only one nerve is severed. b. The dermatome served by this nerve will no longer experience any sensation. c. The adjacent spinal nerves will continue to carry sensations for the dermatome served by the severed nerve. d. A severed spinal nerve will only affect motor function of the patient because spinal nerves have no sensory component.

ANS: C A dermatome is a circumscribed skin area that is primarily supplied from one spinal cord segment through a particular spinal nerve. The dermatomes overlap, which is a form of biologic insurance; that is, if one nerve is severed, then most of the sensations can be transmitted by the spinal nerve above and the spinal nerve below the severed nerve.

During the interview a patient reveals that she has some vaginal discharge. She is worried that it may be a sexually transmitted infection. The nurse's most appropriate response to this would be: A) "Oh, don't worry. Some cyclic vaginal discharge is normal." B) "Have you been engaging in unprotected sexual intercourse?" C) "I'd like some information about the discharge. What color is it?" D) "Have you had any urinary incontinence associated with the discharge?"

ANS: C Ask questions that help the patient reveal more information about her symptoms in a nonthreatening manner. Assess vaginal discharge further by asking about the amount, color, and odor. Normal vaginal discharge is small, clear or cloudy, and always nonirritating.

16. When taking the health history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of these would be the best question for obtaining this information? a. "Does your muscle tone seem tense or limp?" b. "After the seizure, do you spend a lot of time sleeping?" c. "Do you have any warning sign before your seizure starts?" d. "Do you experience any color change or incontinence during the seizure?"

ANS: C Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor. The other questions do not solicit information about an aura.

The changes normally associated with menopause occur generally because the cells in the reproductive tract are: A) aging. B) becoming fibrous. C) estrogen dependent. D) able to respond to estrogen.

ANS: C Because cells in the reproductive tract are estrogen dependent, decreased estrogen levels during menopause bring dramatic physical changes. The other options are not correct.

53. A man who was found wandering in a park at 2 AM has been brought to the emergency department for an examination; he said he fell and hit his head. During the examination, the nurse asks him to use his index finger to touch the nurse's finger, then his own nose, then the nurse's finger again (which has been moved to a different location). The patient is clumsy, unable to follow the instructions, and overshoots the mark, missing the finger. The nurse should suspect which of the following? a. Cerebral injury b. Cerebrovascular accident c. Acute alcohol intoxication d. Peripheral neuropathy

ANS: C During the finger-to-finger test, if the person has clumsy movement with overshooting the mark, either a cerebellar disorder or acute alcohol intoxication should be suspected. The person's movements should be smooth and accurate. The other options are not correct.

A patient has had three pregnancies and two live births. The nurse would record this information as gravida _____, para _____, AB _____. A) 2; 2; 1 B) 3; 2; 0 C) 3; 2; 1 D) 3; 3; 1

ANS: C Gravida is number of pregnancies. Para is number of births. Abortions are interrupted pregnancies, including elective abortions and spontaneous miscarriages.

During an external genitalia examination of a woman, the nurse notices several lesions around the vulva. The lesions are pink, moist, soft, and pointed papules. The patient states that she is not aware of any problems in that area. The nurse recognizes that these lesions may be: A) syphilitic chancre. B) herpes simplex virus type 2 (herpes genitalis). C) human papillomavirus (HPV), or genital warts. D) pediculosis pubis (crab lice).

ANS: C HPV lesions are painless, warty growths that the woman may not notice. Lesions are pink or flesh colored, soft, pointed, moist, warty papules that occur in single or multiple cauliflower-like patches around the vulva, introitus, anus, vagina, or cervix. Herpetic lesions are painful clusters of small, shallow vesicles with surrounding erythema. Syphilitic chancres begin as a solitary silvery papule that erodes to a red, round or oval, superficial ulcer with a yellowish discharge. Pediculosis pubis causes severe perineal itching and excoriations and erythematous areas. See Table 26-2.

During the interview with a female patient, the nurse gathers data that indicate that the patient is perimenopausal. Which of these statements made by this patient leads to this conclusion? A) "I have noticed that my muscles ache at night when I go to bed." B) "I will be very happy when I can stop worrying about having a period." C) "I have been noticing that I sweat a lot more than I used to, especially at night." D) "I have only been pregnant twice, but both times I had breast tenderness as my first symptom."

ANS: C Hormone shifts occur during the perimenopausal period, and associated symptoms of menopause may occur, such as hot flashes, night sweats, numbness and tingling, headache, palpitations, drenching sweats, mood swings, vaginal dryness, and itching. The other responses are not correct.

27. The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect? a. Hyperalgesia b. Hyperesthesia c. Peripheral neuropathy d. Lesion of sensory cortex

ANS: C Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Peripheral neuropathy is worse at the feet and gradually improves as the examiner moves up the leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome. The other responses are incorrect.

The nurse is examining a 35-year-old female patient. During the history, the nurse notices that she has had two term pregnancies, and both babies were delivered vaginally. During the internal examination the nurse observes that the cervical os is a horizontal slit with some healed lacerations and that the cervix has some nabothian cysts that are small, smooth, and yellow. In addition, the nurse notices that the cervical surface is granular and red, especially around the os. Finally, the nurse notices the presence of stringy, opaque, odorless secretions. Which of these findings are abnormal? A) Nabothian cysts are present. B) The cervical os is a horizontal slit. C) The cervical surface is granular and red. D) Stringy and opaque secretions are present.

ANS: C Normal findings: Nabothian cysts may be present on the cervix after childbirth. The cervical os is a horizontal, irregular slit in the parous woman. Secretions vary according to the day of the menstrual cycle, and may be clear and thin or thick, opaque, and stringy. The surface is normally smooth, but cervical eversion, or ectropion may occur where the endocervical canal is "rolled out." Abnormal finding: The cervical surface should not be reddened or granular, which may indicate a lesion.

When performing the bimanual examination, the nurse notices that the cervix feels smooth and firm, is round, and is fixed in place (does not move). When cervical palpation is performed, the patient complains of some pain. The nurse's interpretation of these results should be which of these? A) These findings are all within normal limits. B) The cervical consistency should be soft and velvety—not firm. C) The cervix should move when palpated; an immobile cervix may indicate malignancy. D) Pain may occur during palpation of the cervix.

ANS: C Normally the cervix feels smooth and firm, as the consistency of the tip of the nose. It softens and feels velvety at 5 to 6 weeks of pregnancy (Goodell's sign). The cervix should be evenly rounded. With a finger on either side, the examiner should be able to move the cervix gently from side to side, and doing so should produce no pain for the patient. Hardness of the cervix may occur with malignancy. Immobility may occur with malignancy, and pain may occur with inflammation or ectopic pregnancy.

A woman states that 2 weeks ago she had a urinary tract infection that was treated with an antibiotic. As a part of the interview, the nurse should ask, "Have you noticed: A) a change in your urination patterns?" B) any excessive vaginal bleeding?" C) any unusual vaginal discharge or itching?" D) any changes in your desire for intercourse?"

ANS: C Several medications may increase the risk of vaginitis. Broad-spectrum antibiotics alter the balance of normal flora, which may lead to the development of vaginitis. The other questions are not correct

48. A patient is unable to perform rapid alternating movements such as rapidly patting her knees. The nurse should document this inability as: a. Ataxia. b. Astereognosis. c. Presence of dysdiadochokinesia. d. Loss of kinesthesia.

ANS: C Slow clumsy movements and the inability to perform rapid alternating movements occur with cerebellar disease. The condition is termed dysdiadochokinesia. Ataxia is an uncoordinated or unsteady gait. Astereognosis is the inability to identify an object by feeling it. Kinesthesia is the person's ability to perceive passive movement of the extremities or the loss of position sense.

13. During an assessment of an 80-year-old patient, the nurse notices the following: an inability to identify vibrations at her ankle and to identify the position of her big toe, a slower and more deliberate gait, and a slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate: a. CN dysfunction. b. Lesion in the cerebral cortex. c. Normal changes attributable to aging. d. Demyelination of nerves attributable to a lesion.

ANS: C Some aging adults show a slower response to requests, especially for those calling for coordination of movements. The findings listed are normal in the absence of other significant abnormal findings. The other responses are incorrect.

40. The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment? a. CNs, motor function, and sensory function b. Deep tendon reflexes, vital signs, and coordinated movements c. Level of consciousness, motor function, pupillary response, and vital signs d. Mental status, deep tendon reflexes, sensory function, and pupillary response

ANS: C Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be closely monitored for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.

8. A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse? a. Thalamus b. Brainstem c. Cerebellum d. Extrapyramidal tract

ANS: C The cerebellar system coordinates movement, maintains equilibrium, and helps maintain posture. The thalamus is the primary relay station where sensory pathways of the spinal cord, cerebellum, and brainstem form synapses on their way to the cerebral cortex. The brainstem consists of the midbrain, pons, and medulla and has various functions, especially concerning autonomic centers. The extrapyramidal tract maintains muscle tone for gross automatic movements, such as walking.

The nurse is preparing for an internal genitalia examination of a woman. Which order of the examination is correct? A) Bimanual, speculum, rectovaginal B) Speculum, rectovaginal, bimanual C) Speculum, bimanual, rectovaginal D) Rectovaginal, bimanual, speculum

ANS: C The correct sequence is speculum examination, then bimanual examination after removing the speculum, and then rectovaginal examination. The examiner should change gloves before performing the rectovaginal examination to avoid spreading any possible infection

During an internal examination of a woman's genitalia, the nurse will use which technique for proper insertion of the speculum? A) Instruct the woman to bear down, open the speculum blades, and apply in a swift, upward movement. B) Insert the blades of the speculum on a horizontal plane, turning them to a 30-degree angle while continuing to insert them. Ask the woman to bear down after the speculum is inserted. C) Instruct the woman to bear down, turn the width of the blades horizontally, and insert the speculum at a 45-degree angle downward toward the small of the woman's back. D) Lock the blades open by turning the thumbscrew. Once the blades are open, apply pressure to the introitus and insert the blades at a 45-degree angle downward to bring the cervix into view.

ANS: C The examiner should instruct the woman to bear down, turn the width of the blades horizontally, and insert the speculum at a 45-degree angle downward toward the small of the woman's back. See the text under "Speculum Examination" for more detail.

31. When the nurse is testing the triceps reflex, what is the expected response? a. Flexion of the hand b. Pronation of the hand c. Extension of the forearm d. Flexion of the forearm

ANS: C The normal response of the triceps reflex is extension of the forearm. The normal response of the biceps reflex causes flexion of the forearm. The other responses are incorrect.

Which statement would be most appropriate when the nurse is introducing the topic of sexual relationships during an interview? A) "Now it is time to talk about your sexual history. When did you first have intercourse?" B) "Women often feel dissatisfied with their sexual relationships. Would it be okay to discuss this now?" C) "Often women have questions about their sexual relationship and how it affects their health. Do you have any questions?" D) "Most women your age have had more than one sexual partner. How many would you say you have had?"

ANS: C The nurse should begin with an open-ended question to assess individual needs. The nurse should include appropriate questions as a routine part of the history, because doing so communicates that the nurse accepts the individual's sexual activity and believes it is important. The nurse's comfort with discussion prompts the patient's interest and possibly relief that the topic has been introduced. This establishes a database for comparison with any future sexual activities and provides an opportunity to screen sexual problems.

6. A patient with a lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. The nurse knows that the best explanation why this occurs is which one of these statements? a. A problem exists with the sensory cortex and its ability to discriminate the location. b. The lack of oxygen in his heart has resulted in decreased amount of oxygen to the areas experiencing the pain. c. The sensory cortex does not have the ability to localize pain in the heart; consequently, the pain is felt elsewhere. d. A lesion has developed in the dorsal root, which is preventing the sensation from being transmitted normally.

ANS: C The sensory cortex is arranged in a specific pattern, forming a corresponding map of the body. Pain in the right hand is perceived at a specific spot on the map. Some organs, such as the heart, liver, and spleen, are absent from the brain map. Pain originating in these organs is referred because no felt image exists in which to have pain. Pain is felt by proxy, that is, by another body part that does h

5. While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact? a. Corticospinal tract, medulla, and basal ganglia b. Pyramidal tract, hypothalamus, and sensory cortex c. Lateral spinothalamic tract, thalamus, and sensory cortex d. Anterior spinothalamic tract, basal ganglia, and sensory cortex

ANS: C The spinothalamic tract contains sensory fibers that transmit the sensations of pain, temperature, and crude or light touch. Fibers carrying pain and temperature sensations ascend the lateral spinothalamic tract, whereas the sensations of crude touch form the anterior spinothalamic tract. At the thalamus, the fibers synapse with another sensory neuron, which carries the message to the sensory cortex for full interpretation. The other options are not correct.

When the nurse is interviewing a preadolescent girl, which opening statement would be least threatening? A) "Do you have any questions about growing up?" B) "What has your mother told you about growing up?" C) "When did you notice that your body was changing?" D) "I remember being very scared when I got my period. How do you think you'll feel?"

ANS: C Try the open-ended, "When did you ... ?" rather than "Do you ... ?" This is less threatening because it implies that the topic is normal and unexceptional.

An 18-year-old patient is having her first pelvic examination. Which action by the nurse is appropriate? A) Invite her mother to be present during the examination. B) Avoid the lithotomy position this first time because it can be uncomfortable and embarrassing. C) Raise the head of the examination table and give her a mirror so that she can view the exam. D) Drape her fully, leaving the drape between her legs elevated to avoid embarrassing her with eye contact.

ANS: C Use the techniques of the educational or mirror pelvic examination. This is a routine examination with some modifications in attitude, position, and communication. First, the woman is considered an active participant, one who is interested in learning and in sharing decisions about her own health care. The woman props herself up on one elbow, or the head of the table is raised. Her other hand holds a mirror between her legs, above the examiner's hands. The woman can see all that the examiner is doing and has a full view of her genitalia. The mirror works well for teaching normal anatomy and its relationship to sexual behavior. You can ask her if she would like to have a family member, friend, or chaperone present for the examination. The drape should be pushed down between the woman's legs so that the nurse can see her face.

39. While the nurse is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse that he is on a cruise ship and is 30 years old. The nurse knows that this finding is indicative of a(n): a. Great sense of humor. b. Uncooperative behavior. c. Inability to understand questions. d. Decreased level of consciousness.

ANS: D A change in consciousness may be subtle. The nurse should notice any decreasing level of consciousness, disorientation, memory loss, uncooperative behavior, or even complacency in a previously combative person. The other responses are incorrect.

9. Which of these statements about the peripheral nervous system is correct? a. The CNs enter the brain through the spinal cord. b. Efferent fibers carry sensory input to the central nervous system through the spinal cord. c. The peripheral nerves are inside the central nervous system and carry impulses through their motor fibers. d. The peripheral nerves carry input to the central nervous system by afferent fibers and away from the central nervous system by efferent fibers.

ANS: D A nerve is a bundle of fibers outside of the central nervous system. The peripheral nerves carry input to the central nervous system by their sensory afferent fibers and deliver output from the central nervous system by their efferent fibers. The other responses are not related to the peripheral nervous system.

23. When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as: a. Ataxia. b. Lack of coordination. c. Negative Homans sign. d. Positive Romberg sign.

ANS: D Abnormal findings for the Romberg test include swaying, falling, and a widening base of the feet to avoid falling. A positive Romberg sign is a loss of balance that is increased by the closing of the eyes. Ataxia is an uncoordinated or unsteady gait. Homans sign is used to test the legs for deep-vein thrombosis.

14. A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting, she gets "really dizzy" and feels like she is going to fall over. The nurse's best response would be: a. "Have you been extremely tired lately?" b. "You probably just need to drink more liquids." c. "I'll refer you for a complete neurologic examination." d. "You need to get up slowly when you've been lying down or sitting."

ANS: D Aging is accompanied by a progressive decrease in cerebral blood flow. In some people, this decrease causes dizziness and a loss of balance with a position change. These individuals need to be taught to get up slowly. The other responses are incorrect.

A 35-year-old woman is at the clinic for a gynecologic examination. During the examination, she asks the nurse, "How often do I need to have this Pap test done?" Which reply by the nurse is correct? A) "It depends. Do you smoke?" B) "This will need to be done annually until you are 65." C) "If you have 2 consecutive normal Pap tests, then you can wait 5 years between tests." D) "After age 30, if you have 3 consecutive normal Pap tests, then you may be screened every 2 to 3 years."

ANS: D Cervical cancer screening with the Pap test continues annually until age 30. After age 30, if the woman has 3 consecutive normal Pap tests, then women may be screened every 2 to 3 years.

42. A 32-year-old woman tells the nurse that she has noticed "very sudden, jerky movements" mainly in her hands and arms. She says, "They seem to come and go, primarily when I am trying to do something. I haven't noticed them when I'm sleeping." This description suggests: a. Tics. b. Athetosis. c. Myoclonus. d. Chorea.

ANS: D Chorea is characterized by sudden, rapid, jerky, purposeless movements that involve the limbs, trunk, or face. Chorea occurs at irregular intervals, and the movements are all accentuated by voluntary actions. (See Table 23-5 for the descriptions of athetosis, myoclonus, and tics.)

A 22-year-old woman is being seen at the clinic for problems with vulvar pain, dysuria, and fever. On physical examination, the nurse notices clusters of small, shallow vesicles with surrounding erythema on the labia. There is also inguinal lymphadenopathy present. The most likely cause of these lesions is: A) pediculosis pubis. B) contact dermatitis. C) human papillomavirus. D) herpes simplex virus type 2.

ANS: D Herpes simplex virus type 2 presents with clusters of small, shallow vesicles with surrounding erythema that erupt on the genital areas. There is also the presence of inguinal lymphadenopathy. The individual reports local pain, dysuria, and fever. See Table 26-2 for more information and descriptions of the other conditions.

30. In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side? a. Lack of reflexes b. Normal reflexes c. Diminished reflexes d. Hyperactive reflexes

ANS: D Hyperreflexia is the exaggerated reflex observed when the monosynaptic reflex arc is released from the influence of higher cortical levels. This response occurs with upper motor neuron lesions (e.g., a cerebrovascular accident). The other responses are incorrect.

A 65-year-old woman is in the office for routine gynecologic care. She had a complete hysterectomy 3 months ago after cervical cancer was detected. The nurse knows that which of these statements is true with regard to this visit? A) Her cervical mucosa will be red and dry looking. B) She will not need to have a Pap smear done. C) The nurse can expect to find that her uterus will be somewhat enlarged and her ovaries small and hard. D) The nurse should plan to lubricate the instruments and the examining hand well to avoid a painful examination.

ANS: D In the aging adult woman, natural lubrication is decreased; to avoid a painful examination, the nurse should take care to lubricate instruments and the examining hand adequately. Menopause, with the resulting decrease in estrogen production, shows numerous physical changes. The cervix shrinks and looks pale and glistening. With the bimanual examination, the uterus feels smaller and firmer and the ovaries are not palpable normally. Women should continue cervical cancer screening up to age 70 years if they have an intact cervix and are in good health. Women who have had a total hysterectomy for benign gynecologic disease do not need cervical cancer screening, but if the hysterectomy was done for cervical cancer, then Pap tests should continue until the patient has a 10-year history of no abnormal results.

A 22-year-old woman has been considering using oral contraceptives. As a part of her history, the nurse should ask: A) "Do you have a history of heart murmurs?" B) "Will you be in a monogamous relationship?" C) "Have you thought this choice through carefully?" D) "If you smoke, how many cigarettes do you smoke per day?"

ANS: D Oral contraceptives, together with cigarette smoking, increase the risk for cardiovascular side effects. If cigarettes are used, then the nurse should assess smoking history. The other questions are not appropriate.

A woman who is 8 weeks pregnant is in the clinic for a checkup. The nurse reads on her chart that her cervix is softened and looks cyanotic. The nurse knows that the woman is exhibiting _____ sign and _____ sign. A) Tanner's; Hegar's B) Hegar's; Goodell's C) Chadwick's; Hegar's D) Goodell's; Chadwick's

ANS: D Shortly after the first missed menstrual period, the female genitalia show signs of the growing fetus. The cervix softens (Goodell's sign) at 4 to 6 weeks, and the vaginal mucosa and cervix look cyanotic (Chadwick's sign) at 8 to 12 weeks. These changes occur because of increased vascularity and edema of the cervix and hypertrophy and hyperplasia of the cervical glands. Hegar's sign occurs when the isthmus of the uterus softens at 6 to 8 weeks. Tanner's sign is not a correct response.

During a health history, a 22-year old woman asks, "Can I get that vaccine for HPV? I have genital warts and I'd like them to go away!" What is the nurse's best response? A) "The HPV vaccine is for girls and women ages 9 to 26, so we can start that today." B) "This vaccine is only for girls who have not started to have intercourse yet." C) "Let's check with the physician to see if you are a candidate for this vaccine." D) "The vaccine cannot protect you if you already have an HPV infection."

ANS: D The HPV (human papillomavirus) vaccine is appropriate for girls and women age 9 to 26 and is given to prevent cervical cancer by preventing HPV infections before girls become sexually active. However, it cannot protect the woman if an HPV infection is already present.

21. The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient: a. Demonstrates the ability to hear normal conversation. b. Sticks out the tongue midline without tremors or deviation. c. Follows an object with his or her eyes without nystagmus or strabismus. d. Moves the head and shoulders against resistance with equal strength.

ANS: D The following normal findings are expected when testing the spinal accessory nerve (CN XI): The patient's sternomastoid and trapezius muscles are equal in size; the person can forcibly rotate the head both ways against resistance applied to the side of the chin with equal strength; and the patient can shrug the shoulders against resistance with equal strength on both sides. Checking the patient's ability to hear normal conversation checks the function of CN VIII. Having the patient stick out the tongue checks the function of CN XII. Testing the eyes for nystagmus or strabismus is performed to check CNs III, IV, and VI.

25. During the taking of the health history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." When assessing his sensory system, which action by the nurse is most appropriate? a. The nurse would not test the sensory system as part of the examination because the results would not be valid. b. The nurse would perform the tests, knowing that mental status does not affect sensory ability. c. The nurse would proceed with an explanation of each test, making certain that the wife understands. d. Before testing, the nurse would assess the patient's mental status and ability to follow directions.

ANS: D The nurse should ensure the validity of the sensory system testing by making certain that the patient is alert, cooperative, comfortable, and has an adequate attention span. Otherwise, the nurse may obtain misleading and invalid results.

44. During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion. Which statement concerning these findings is most accurate? This patient's response: a. Indicates a lesion of the cerebral cortex. b. Indicates a completely nonfunctional brainstem. c. Is normal and will go away in 24 to 48 hours. d. Is a very ominous sign and may indicate brainstem injury.

ANS: D These findings are all indicative of decerebrate rigidity, which is a very ominous condition and may indicate a brainstem injury.

A 25-year-old woman comes to the emergency department with a sudden fever of 101° F and abdominal pain. Upon examination, the nurse notices that she has rigid, boardlike lower abdominal musculature. When the nurse tries to perform a vaginal examination, the patient has severe pain when the uterus and cervix are moved. The nurse knows that these signs and symptoms are suggestive of: A) endometriosis. B) uterine fibroids. C) ectopic pregnancy. D) pelvic inflammatory disease.

ANS: D These signs and symptoms are suggestive of acute pelvic inflammatory disease, also known as acute salpingitis. See Table 26-7. For description of endometriosis and uterine fibroids, see Table 26-6; for description of ectopic pregnancy, see Table 26-7.

The nurse is explaining the mechanism of the growth of long bones to a mother of a toddler. Where does lengthening of the bones occur?

ANS: Epiphyses Lengthening occurs at the epiphyses, or growth plates. The other options are not correct.

The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)?

ANS: Flexion and extension The knee is a hinge joint, permitting flexion and extension of the lower leg on a single plane. The knee is not capable of the other movements listed.

A patient has been diagnosed with a ganglion cyst over the dorsum of his left wrist. He asks the nurse, "What is this thing?" The nurse's best answer would be, "It is:

ANS: a common benign tumor." A ganglionic cyst is a common benign tumor; it does not become malignant, and it does not need to be drained. It is not caused by chronic repetitive motion injury.

An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because:

ANS: of the shortening of the vertebral column. Postural changes are evident with aging; decreased height is most noticeable and is due to shortening of the vertebral column. Long bones do not shorten with age. Intervertebral disks actually get thinner with age. Subcutaneous fat is not lost but is redistributed to the abdomen and hips.

The ankle joint is the articulation of the tibia, the fibula, and the:

ANS: talus. The ankle or tibiotalar joint is the articulation of the tibia, fibula, and talus. The other bones listed are foot bones, but not part of the ankle joint.

3 symptoms of ovarian cancer?

Abdominal bloating, abdominal distension, and urinary frequency.

Abducens abduct the eyes (both eyes look away from nose)

lordosis

Abnormal anterior curvature of the lumbar spine (sway-back condition)

kyphosis

Abnormal condition of outward curvature (convexity) of the thoracic spine.

stenosis

Abnormal constriction or narrowing of a structure

bronchophony

Abnormal transmission of sounds from the lungs or bronchii. Pathology that increases lung density will enhance transmission of voice sounds ex// you hear a clear "nighty-nine"

Menopause?

Absence of menses for 12 consecutive months, usually occurring between 48 and 55 years old.

Deeply pigmented, velvety axillary skin suggests?

Acanthosis Nigricans

Use the Tanner's table on the five steps of sexual development

An 11 year-old girl is in the clinic for a sports physical. The nurse notices that she has begun to develop breasts, and during the conversation the girl reveals she is worried about her development. The nurse should use which of these techniques to best assist the young girl in understanding the expected sequence for development. The nurse should:

Which of the following is accurate regarding the third and fourth heart sounds?

An S 4 sound is normal in children.

bruit

An abnormal blowing or swishing sound heard on auscultation of an artery or an organ.

orthopnea

An abnormal condition in which a person must sit or stand to breathe deeply or comfortably.

Prostate

An accessory glandular structure for the male genital organs is the:

Excoriation

An excoriation is a scratch mark. It may be linear or a picked scratch (prurigo). Excoriations may occur in the absence of a primary dermatosis.

10. A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:

B) peritonitis.

A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is: A) diarrhea. B) peritonitis. C) laxative use. D) gastroenteritis.

B) peritonitis.

B) Functional scoliosis.

A patient tells the nurse that "all my life I've been called 'knock knees.'" The nurse knows that another term for "knock knees" is:

B) Genu valgum.

Absent bowel sounds

Are abnormal. Indicative of late intestinal obstruction, both mechanical (extraluminal lesions such as adhesions, hernias, and masses) and nonmechanical (gastrointestinal lumen remains unobstructed but the muscles of the intestinal wall cannot move its content) in nature.

Umbilicus

Ask pt. to flex neck and perform the valsalva maneuver. Observe for protrusion of the intesting through the umbilicus. Normal is the umbilicus is depressed and beneath the abdominal surface. Umbilical hernia in the adult is the the portrusion of part of the intestine through an incomplete umbilical ring. Confirmed by inserting the finger into the navel and feeling an opening in the fascia. Oftenhing, can be seen with coughing, sneezing, laughing and straining. Umbilicus with a nodule may be manifestation of abdominal carcinoma w/metastasis. Intra-abdominal pressure from ascites, masses, or pregnancy can cause the umbilicus to protrude

Are you able to palpate the ovaries of a post-menopausal woman?

At about 3-5 years after menopause they atrophy and usually cannot be palpated. If you do palpate them you should investigate for an ovarian cyst or cancer.

Which of the following techniques is incorrect and affects the accuracy of auscultation?

Auscultating through clothing.

75% of the breast lymph drains into which node?

Axillary.

31. A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate?

B) "A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles."

A 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate?

B) "A hernia is a loop of bowel protruding through a weak spot in the abdominal muscles."

The nurse is examining the hip area of a patient and palpates a flat depression on the upper, lateral side of the thigh when the patient is standing. The nurse interprets this finding as the:

B) Greater trochanter.

The nurse knows that during an abdominal assessment, deep palpation is used to determine?

B) Enlarged organs

A patient has been diagnosed with osteoporosis and asks the nurse, "What is osteoporosis?" The nurse explains to the patient that osteoporosis is defined as:

B) Loss of bone density.

A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition?

B) Test for Murphy's sign

A patient comes to the emergency department after a boxing match, and his left eye is swollen almost shut. He has bruises on his face and neck. He says he is worried because he "can't see well" from his left eye. The physician suspects retinal damage. The nurse recognizes that signs of retinal detachment include: A) loss of central vision. B) shadow or diminished vision in one quadrant or one half of the visual field. C) loss of peripheral vision. D) sudden loss of pupillary constriction and accommodation.

B) shadow or diminished vision in one quadrant or one half of the visual field.

During the examination of a 30-year-old woman, she questions you about "the 2 large moles" that are below her left breast. After examining the area, how do you respond? A. "I think you should be examined by a dermatologist." B. "This appears to be a normal finding of supernumerary nipples, due to the small areolae and nipples that are present." C. "These are Montgomery's glands, which are common." D. "Is there a possibility you are pregnant?"

B. "This appears to be a normal finding of supernumerary nipples, due to the small areolae and nipples that are present."

The abdomen normally moves when breathing until the age of ____ years. A. 4 B. 7 C. 14 D. 75

B. 7

When performing a straight-leg-raise test, the client complains of sharp pain in the lower back with radiation down one leg. What does this finding indicate? A. The presence of arthritis in the lumbar spine B. A herniated disk

B. A herniated disk

The cremasteric response: A. is positive when disease of the pyramidal tract is present B. is positive when the ipsilateral testicle elevates upon stroking of the inner aspect of the thigh C. is a reflex of the receptors in the muscles of the abdomen D. is not a valid neurologic examination

B. is positive when the ipsilateral testicle elevates upon stroking of the inner aspect of the thigh

Breast asymmetry: A. increases with age and parity B. may be normal C. indicates a neoplasm D. is accomplished by enlarged axillary lymph nodes

B. may be normal

Murphy sign is best described as: A. the pain felt when the hand of the examiner is rapidly removed from an inflamed appendix B. pain felt when taking a deep breath when the examiner's fingers are on the approximate location of the inflamed gallbladder C. a sharp pain felt by the patient when one hand of the examiner is used to thump the other at the costovertebral angle D. not a valid examination technique

B. pain felt when taking a deep breath when the examiner's fingers are on the approximate location of the inflamed gallbladder

Finding mild tenderness is normal when: A. palpating the kidneys. B. palpating the sigmoid colon. C. palpating the uterus. D. None of the above.

B. palpating the sigmoid colon.

The spermatic cord is most commonly described as: A. combining the vas deferens and seminal vesicle. B. the vas deferens approximated with other vessels. C. a muscular duct continuous with the epididymis. D. a narrow tunnel superior to the inguinal ligament.

B. the vas deferens approximated with other vessels

The most common site of breast tumors is: A. upper inner quadrant B. upper outer quadrant C. lower inner quadrant D. lower outer quadrant

B. upper outer quadrant

Adnexa is/are: A. an absence of menstruation. B. uterine accessory organs. C. a membranous fold of tissue partly closing the vaginal orifice. D. painful intercourse.

B. uterine accessory organs.

What is the most common vaginal infection?

impetigo

Bacterial inflammatory skin disease characterized by honey crusted vesicles, pustules, and crusted-over lesions.

What is the Gail model?

Breast cancer risk assessment tool. Provides a 5-year and a lifetime estimate for risk of invasive breast cancer.

Type 7

Bristol stool grade characterized by liquid state; watery, no solid pieces

Type 3

Bristol stool grade characterized by sausage with cracks in surface

Type 4

Bristol stool grade characterized by smooth sausage shape

Mr. Hutchins is a 32-year-old patient who presents for follow-up examination. On examination you note painful clusters of small vesicles with surrounding erythema that erupt on the glans or foreskin. These are signs of: A. cystitis B. urethritis. C. herpes progenitalis. D. Peyronie disease.

C. herpes progenitalis.

To palpate the temporomandibular joint, the nurse's fingers should be placed in the depression _____of the ear.

C) Anterior to the tragus

A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain would the nurse be concerned about with these findings?

C) Cerebellum

40. During a health history, the patient tells the nurse, "I have pain all the time in my stomach. It's worse two hours after I eat, but it gets better if I eat again!" The nurse suspects that the patient has which condition, based on these symptoms?

C) Duodenal ulcer

A patient is having difficulty in swallowing food and medications. The nurse should document this as:

C) Dysphagia

The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status? A) Mental status assessment diagnoses specific psychiatric disorders. B) Mental disorders occur in response to everyday life stressors. C) Mental status functioning is inferred through assessment of an individual's behaviors. D) Mental status can be assessed directly, just like other systems of the body (e.g., cardiac and breath sounds).

C) Mental status functioning is inferred through assessment of an individual's behaviors.

Mrs. Bicker brings her infant son to the health clinic for a routine examination. When performing Ortolani's maneuver on the newborn infant, you feel a clunk as you abduct the infant's legs and flexed knees. The presence of a "clunk" is indicative of: A. tibial torsion. B. genu valgum. C. hip dislocation. D. talipes equinovarus.

C. hip dislocation.

Select the sequence of techniques used during an examination of the abdomen. A. percussion, inspection, palpation, auscultation B. inspection, palpation, percussion, auscultation C. inspection, auscultation, percussion, palpation D. auscultation, inspection palpation, percussion

C. inspection, auscultation, percussion, palpation

A 70-year-old woman has come for a health examination. Which of the following is a common age-related change in the curvature of the spinal column? A. lordosis B. scoliosis C. kyphosis D. lateral scoliosis

C. kyphosis

Linea alba is/are the: A. midline abdominal muscles extending from the rib cage to the pubic bone. B. ligament extending from the pubic bone to the anterosuperior iliac spine. C. midline tendinous seam joining the abdominal muscles. D. angle formed by the twelfth rib and the vertebral column.

C. midline tendinous seam joining the abdominal muscles.

During the assessment of extraocular movements, two back-and-forth oscillations of the eyes in the extreme lateral gaze occurs. This response indicates: A. that the individual needs to be referred for a more complete eye examination. B. a disease of the vestibular system and that should be evaluated. C. an expected movement of the eyes during this procedure. D. this assessment should be repeated in 15 minutes to allow the eyes to rest.

C. an expected movement of the eyes during this procedure.

During the examination of a 70-year-old man, you note gynecomastia. You would: A. refer for a biopsy B. refer for a mammogram C. review the medications for drugs that have gynecomastia as a side effect D. proceed with the examination. This is a normal part of the aging process

C. review the medications for drugs that have gynecomastia as a side effect`

The examiner is going to inspect the breasts for retraction. The best position for this part of the examination is: A. lying supine with arms at the sides B. leaning forward with hands outstretched C. sitting with hand pushing onto hips D. one arm at the side, the other arm elevated

C. sitting with hand pushing onto hips

Mr. Lee comes to the office for a routine health assessment. As part of it, you perform a screening MS exam. This consists of all the following except: A. inspection and palpation of joints integrated with each body region. B. observation of ROM as the individual proceeds through motions required for preparation for the exam and during the exam. C. testing muscle strength of the major muscle groups. D. age-specific measures.

C. testing muscle strength of the major muscle groups.

Cryptorchidism is: A. an advanced and fixed foreskin too tight to retract over the glans. B. a circumscribed collection of serous fluid in the tunica vaginalis surrounding the testes. C. undescended testes. D. hard, subcutaneous plaques associated with painful bending of the erect penis.

C. undescended testes.

A bimanual technique may be the preferred approach for a woman: A. who is pregnant B. who is having the first breast examination by a health care provider C. with pendulous breasts D. who has felt a change in the breast during self-examination

C. with pendulous breasts

The examiner is going to measure the patient's legs for length discrepancy. The normal finding would be: A. no difference in measurements B. 0.5 cm difference C. within 1 cm of each other D. 2 cm difference

C. within 1 cm of each other

You question a patient about alcohol consumption. What acronym for an alcoholism screening tool might be used?

CAGE

choanal atresia

Cartilage/bony growth that blocks nasal passage. Newborns are nasal breathers-can't get air. Block one nare and then block other nare to determine if breathing through. Airway breather-keeps mouth open; surgery next-break or remove cartilage.

Murmurs

Caused by a flow of blood across a partial obstruction (valve stenosis) or valve irregularity (leaks...) or increased flow through normal structures (pregnancy and anemia), flow into a dilated chamber (aneurysm), backward flow, shunting of blood out of a high pressure area through a hole

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?

D) Percuss and palpate the mid-line area above the supra-pubic bone.

Romberg test

Client stands with feet together and eyes closed; note balance

A patient tells the nurse that he has noticed that one of his moles has started to burn and bleed. When assessing his skin, the nurse would pay special attention to the danger signs for pigmented lesions and would be concerned with which additional finding?

Color variation

Target Lesion

Concentric rings like a dartboard. Also known as iris lesion

Raised, friable,or lobed wartlike lesions on the cervix occur with what?

Condylomata or cervical cancer.

frenulum

Membrane securing the tongue to the floor of the mouth

The nurse is providing patient education for a man who has been diagnosed with a rotator cuff injury. The nurse knows that a rotator cuff injury involves the:

D) Glenohumeral joint.

The nurse is examining a 2-month-old infant and notices asymmetry of the infant's gluteal folds. The nurse should assess for other signs of what disorder?

D) Hip dislocation

The physician comments that a patient has abdominal borborygami. The nurse knows that this term refers to?

D) Hyperactive bowel sounds

In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side?

D) Hyperactive reflexes

The nurse is explaining to a patient that there are "shock absorbers" in his back to cushion the spine and to help it move. The nurse is referring to his:

D) Intervertebral disks.

Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called:

D) Ligaments.

A professional tennis player comes into the clinic complaining of a sore elbow. The nurse will assess for tenderness at the:

D) Medial and lateral epicondyle.

The nurse is testing the function of cranial nerve XI. Which of these best describes the response the nurse should expect if the nerve is intact? The patient:

D) Moves the head and shoulders against resistance with equal strength.

4. The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?

D) Percuss and palpate the midline area above the suprapubic bone.

D) Negative Ortolani's sign.

The right lower quadrant of the abdomen contains which of the following organs? A. Duodenum B. Liver C. Sigmoid colon D. Appendix

D. Appendix

Crepitation

Crusting

Crust occurs when plasma exudes through an eroded epidermis. It is rough on the surface and is yellow or brown in color. Bloody crust appears red, purple or black.

The range of normal liver span in the right midclavicular line in the adult is: A. 2-6 cm B. 4-8 cm C. 8-14 cm D. 6-12 cm

D. 6-12 cm

The nurse is assessing a client with carpal tunnel syndrome. When the nurse percusses lightly over the median nerve, the client feels numbness, tingling, and pain along the median nerve. The nurse documents which of the following? A. Positive thenar atrophy B. A positive Phalen's test C. A positive Dupuytren's contracture D. A positive Tinel's sign

D. A positive Tinel's sign

The glandular breast tissue contains between 15 and 20 lobes radiating from the nipple. Gynecomastia can accompany: A. nutritional status. B. the reproductive stage. C. gender. D. All of the above

D. All of the above

Umbilical hernias in infants: A. appear at 2 to 3 weeks of age. B. are more prominent when the baby cries. C. disappear by the time the baby is 1 year old. D. All of the above

D. All of the above

Which of the following statements describes post-menopausal breast changes? A. Glandular tissue decreases. B. Fibrous connective tissue increases. C. Fat tissue atrophies. D. All of the above

D. All of the above

Mr. Liggett is a 42-year-old patient who presents with a painful left testicle. On examination you note abnormal dilation and tortuosity of the veins along the spermatic cord. Which of the following conditions best describes this clinical finding? A. Varicocele B. Priapism C. Hypospadias D. Epididymitis

D. Epididymitis

The rotator cuff of the body is associated with which of the following joints? A. Radiocarpal joint B. Temporomandibular joint C. Acetabular joint D. Glenohumeral joint

D. Glenohumeral joint

During the examination of the breasts of a pregnant woman, you would expect to find: A. peau d'orange B. nipple retraction C. a unilateral, obvious venous pattern D. a blue vascular pattern over both breasts

D. a blue vascular pattern over both breasts

The vas deferens is: A. a narrow tunnel inferior to the inguinal ligament. B. a narrow tunnel superior to the inguinal ligament. C. the joining of the vas deferens with the seminal vesicle. D. a muscular duct continuous with the epididymis.

D. a muscular duct continuous with the epididymis.

The cremaster is: A. a sperm storage site. B. the muscle that controls the size of the scrotum. C. a muscular duct continuous with the epididymis. D. a shoulder where the glans joins the shaft.

D. a shoulder where the glans joins the shaft.

During the performance of the McMurray test, the examiner hears and feels a click, which is an indication of: A. a torn cruciate ligament. B. subluxation of the knee. C. dislocation of the femoral head. D. a torn meniscus

D. a torn meniscus

Hyperactive bowel sounds are: A. high pitched B. rushing C. tinkling D. all of the above

D. all of the above

Ascites is defined as: A. a bowel obstruction. B. a proximal loop of the large intestine. C. an abnormal enlargement of the spleen. D. an abnormal accumulation of serous fluid within the peritoneal cavity.

D. an abnormal accumulation of serous fluid within the peritoneal cavity.

Mr. Kinder is a 59-year-old patient who comes to the clinic for follow-up after an emergency room visit. On examination of the abdomen, you note ascites. Ascites is: A. a bowel obstruction. B. a proximal part of the large intestine. C. an abnormal enlargement of the spleen. D. an abnormal accumulation of serous fluid within the peritoneal cavity.

D. an abnormal accumulation of serous fluid within the peritoneal cavity.

Orchitis is: A. a meatus opening on the dorsal side of the glans or shaft. B. hard, subcutaneous plaques associated with painful bending of the erect penis. C. a circumscribed collection of serous fluid in the tunica vaginalis surrounding the testes. D. an acute inflammation of the testes.

D. an acute inflammation of the testes.

Anterior and posterior stability are provided to the knee joint by the: A. medial and lateral menisci B. patellar tendon and ligament C. medial collateral ligament and quadriceps muscle D. anterior and posterior cruciate ligaments

D. anterior and posterior cruciate ligaments

A thickened synovial membrane is described as feeling: A. rigid. B. pliable. C. constricted. D. boggy.

D. boggy.

An expected postmenopausal breast change includes: A. increased glandular tissue B. decreased fibrous connective tissue C. increased fatty tissue D. decrease in breast size

D. decrease in breast size

The knee joint is the articulation of three bones, the: A femur, fibula, and patella. B. femur, radius, and olecranon process. C. fibula, tibia, and patella. D. femur, tibia, and patella.

D. femur, tibia, and patella.

Any lump found in the breast should be referred for further evaluation. A benign lesion will usually have 3 of the following characteristics. Which one is characteristic of a malignant lesion? A. soft B. well-defined margins C. freely movable D. irregular shape

D. irregular shape

The relative proportion of glandular, fibrous, and adipose breast tissue depends on: A. environmental factors B. genetics C. sex D. nutritional state

D. nutritional state

The timing of joint pain may assist the examiner in determining the cause. The joint pain associated with rheumatic fever would: A. be worse in the morning B. be worse later in the day C. be worse in the morning but improve during the day D. occur 10 to 14 days after an untreated sore throat

D. occur 10 to 14 days after an untreated sore throat

To examine for the function of the trigeminal nerve in an infant, you would: A. startle the baby B. hold an object within the child's line of vision C. pinch the nose of the child D. offer the baby a bottle

D. offer the baby a bottle

A positive Blumberg sign indicates: A. a possible aortic aneurysm B. the presence of renal artery stenosis C. an enlarged, nodular liver D. peritoneal inflammation

D. peritoneal inflammation

Methods to enhance abdominal wall relaxation during examination include: A. a cool environment. B. having the patient place arms above the head. C. examining painful areas first. D. positioning the patient with the knees bent.

D. positioning the patient with the knees bent.

Mrs. Griffin is a 31-year-old patient who is pregnant. She comes to the clinic complaining of "morning sickness." The cause of this ailment is: A. hormone changes. B. esophageal reflux. C. an increase in water being reabsorbed from the colon. D. unknown.

D. unknown.

Mr. Thompson is a 44-year-old patient who presents to the office with complaints of urinary burning. On examination you note an infection of the urethra. This is also known as: A. progenitalis. B. orchitis. C. prepuce. D. urethritis.

D. urethritis.

Kaposi's sarcoma in AIDs

Deep purple lesions. A low grade vascular tumor associated with human herpesvirus 8. Lesions may be raised or flat. Antiretroviral therapy can reduce prevalence

presbyopia

Defect in vision in advancing age involving loss of accommodation or recession of near vision; due to loss of elasticity of crystalline lens

When assessing an elderly patient, which finding should be reported immediately to the patient's provider?

Detection of an S3

Do you listen for Epigastric and Renal Bruits with the bell or the diaphragm?

Diaphragm

dyspnea

Difficult or labored breathing

dysphagia

Difficulty in swallowing

A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying "I'm just getting old!" After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer's disease? Select all that apply

Difficulty performing familiar tasks, such as placing a telephone call Misplacing items, such as putting dish soap in the refrigerator Rapid mood swings, from calm to tears, for no apparent reason Getting lost in one's own neighborhood

torus palantinus

Discrete, hard lobulated growth in the posterior portion of hard palate, benign, usually painless and asymptomatic

When taking the history on a patient with a seizure disorder, the nurse assess whether a patient has an aura. Which is the best question to ask to obtain this information?

Do you have any warning signs before the seizure starts? An aura is a subjective sensation that precedes a seizure - could be auditory, visual, or motor.

In obtaining a history on a 74 year old patient the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands, affecting his ability to hold things. How should the nurse respond?

Does the tremor change when you drink alcohol?

The nurse is percussing over the lungs of a patient with pneumonia. The nurse knows that percussion over an area of atelectasis in the lungs would reveal:

Dullness

During an abdominal assessment, the nurse would consider which of these findings as normal?

Increased intracranial pressure

During an assessment of a 22 year-old woman who has had a head injury form a car accident 4 hours ago, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to light. What does finding this suggest?

Vertigo

During the history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this as:

"I'd like some information about the discharge. What color is it?"

During the interview a patient reveals that she has some vaginal discharge. She is worried that it might be a sexually transmitted infection. The nurse's most appropriate response to this would be:

"I have been noticing that I sweat a lot more than I used to , especially at night."

During the interview with a female patient, the nurse gathers data that indicates that the patient is perimenopausal. Which of these statements made by this patient leads to this conclusion?

The nurse is assessing for inflammation in a dark-skinned person. Which is the best technique?

Palpate the skin for edema and increased warmth.

4th Step

Palpation: Liver, spleen, kidneys, aorta, bladder, inguinal lymph nodes

A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient?

Enlarged and tender inguinal nodes

Which type of health history would you perform on this patient who has been at your clinic three times in the past year and is returning for a hypertension check-up?

Episodic health history

When performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next?

Examine the patient's lower arm and hand, and check for the presence of infection or lesions

Ligaments

Fibrous bands running directly from one bone to another that strengthen the joint and movement in undesirable directions are called:

nocturia

Excessive urination at night

What would be signs of infestations during a pelvic exam?

Excoriations, red, maculopapules. Look for lice or nits at the bases of the pubic hairs.

Two behavioral risk factors for cervical cancer?

Failure to undergo screenings and multiple sex partners.

T or F? The majority of women diagnosed with breast cancer have a family history of breast cancer?

False. 50% have no family history.

A 72-year-old male presents to the office with shortness of breath and coarse cough. He is barrel chested with an A/P diameter greater than 1:2. You see he has had COPD for many years. You would expect his nail angle to be:

Greater than 160 degrees

What can dysplasia of the cervix look like?

HPV- makes it look like mosaicism Can also be very friable and bleeds easy.

How do you assess sexual maturity during the vaginal exam?

Hair distribution. Tanner stages- 1. No hair, 2. Sparse, 3. Darker, coarser, and curlier, 4. Like adults but not on thighs yet. 5. Adult

Besides cancer what could be other causes of enlarged axillary nodes?

Hand or arm infection, recent immunization, skin tests, or generalized lymphadenopathy.

Partial Obstruction

High pitched, tinking hyperactive B/S. Caused by powerful peristaltic action of the bowel segment attempting to eject its contents through a narrow constricted area. C/O abdominal cramping

The area of the brain that controls temperature, appetite, sex drive and sleep center is

Hypothalamus

Why do we have a client put their hands over their head to inspect the breast?

If cancer is attached to both the skin and fascia over the pectoral muscles, contraction of the pectorals will cause the skin to dimple.

Are catch-up vaccinations allowed for HPV vaccine?

If first was given, can catch up with other 2 doses between the ages of 13-26.

What are possible concerns inverted nipple?

If has always been inverted, it would be a normal variant. It would make breast feeding difficult. If new inversion, would be concerning for cancer.

what does the costal angle indicate

If the angle increases greater than 90 degrees can indicate chronic overinflation such as in emphysema

What should be checked for if menarche is late in relation to development of breasts and pubic hair?

Imperforate hymen.

You are preparing to examine the external genitalia of a school-age girl. Which of the following positions would be most appropriate in this situation?

In a frog-leg position on the examining table

Galactorrhea

Inappropriate discharge of milk-containing fluid 6 or more months after childbirth or cessation of breastfeeding.

What causes primary dysmenorrhea?

Increased prostaglandin production during the luteal phase of menstrual cycle. It is when estrogen and progesterone levels are decreasing.

Pulsation

Inspect epigastric area. In the normal build,, a nonexaggerated pulsation of the abdominal aorta may be visible in the epigastric area. In heavier patients, pulsation may not be visible. Widened pulse pressure and strong epigastric pulsations may indicate an aortic aneurysm. An exaggerated pulsation can also occur in aortic regurgitation and right ventricular hypertrophophy.

1st Step

Inspection: contour, symmetry, abdominis muscles, pigmentation and color, scars, striae, respiratory movement, masses, peristalsis, pulsation, umbilicus

Spontaneous, unilateral bloody discharge from one or two ducts of the breast could indicate?

Intraductal papilloma, ductal carcinoma in situ, or Paget's disease of the breast.

Vaginismus?

Involuntary spasms of the muscles surrounding the vaginal orifice making it painful or impossible to have intercourse.

While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensation, which of these areas must be intact?

Lateral spinothalamic tract, thalamus, and sensory cortex

The nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation?

Lateral to the extensor tendon of the great toe

Ballotment

Leg extended, compress the suprapatellar pouch and then push the patella sharply against the femur, watching for fluid returning to the pouch

Polymenorrhea?

Less than 21 days between menstrual cycles.

What of this muscle can cause sagging of the pelvic floor and prolapse of the pelvic organs?

Levator Ani

Lichenification

Lichenification is caused by chronic rubbing, which results in palpably thickened skin with increased skin markings and lichenoid scale. It occurs in chronic atopic eczema and lichen simplex.

Straight Leg Raising

Lift the straight leg, if pt has low back pain with nerve pain that radiates down the leg = sciatica from compression of the spinal nerve root as it passes through the vertebral foramen

Consensual light reflex

Light goes into one eye and the opposite eye's pupil constrict

Direct light reflex

Light goes into the eye and that eye's pupil constricts

Corneal Light reflex

Light shone from the side, and watch for shadowing on the iris - shadowing might mean lesions

A client tells the nurse during the nutritional assessment that she tries to keep her fat intake at less than 15% of her total caloric intake per day, and the nurse responds:

Limiting fat prevents some diseases, but your fat intake is much lower than recommended. The recommended amount of fat is 25% to 30% of total calories.

A hard immobile cervix is a sign of ?

Malignancy

Unilateral nipple discharge is most usually?

Malignant

During the aging process, the hair can look gray or white and begin to feel thin and fine. The nurse knows that this occurs because of a decrease in the number of functioning:

Melanocytes

Indications for a pelvic exam in adolescents?

Menstrual abnormalities, unexplained abdominal pain, vaginal discharge, contraceptive prescription, cultures in sexually active girl, pt's request for examination.

Nonpuerperal Galactorrhea

Milky nipple discharge unrelated to a prior pregnancy or lactation. Can be caused by hypothyroidism, pituitary prolactinoma, meds.

During an assessment of the cranial nerves, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these cranial nerves?

Motor component of CN 7

Motor component of VII

Masses

No masses should be present. Presents of masses or nodules may indicate tumors, metastases of an internal malignancy or pregnancy.

What are recommendations for self breast exam?

No real recommendations-self-awareness is goal. Women can start in their 20's. If done monthly should be done 5-7 days after onset off menses. Report changes in breast to PCP.

Feeling the liver edge

Normally feels smooth, soft, sharp, and regular. Normally about 3 cm below the right costal margin in the midclavicular line

Spleen percussion/palpation

Normally the lowest interspace in the left anterior axillary line is tympanitic. After a deep breath, if percussion changes from tympanitic, enlargement is suspected and you'll need to palpate the spleen, but be careful not to cause rupture

Explain role of CA-125 in ovarian cancer?

Not specific or sensitive. Helps to catch relapse after treatment.

Which of the following correctly describes the method to assess accommodation?

Note constriction as gaze shifts from across the room to an object 6 inches away.

Pederson speculum better for who?

Nullliparas, or small vaginas, or if exam is painful since it is a flatter speculum.

After completing an initial assessment on a patient, the nurse has charted that his respirations are eupneic and his pulse is 58. This type of data would be:

Objective

The nurse is performing a general survey. Which action is a component of the general survey?

Observing the patient's body stature and nutritional status

Striae

Occur when there has been rapid or porlonged stretching of the skin. May be caused by Cushing's, abdominal tumors, obesity, ascites, or pregnancy.

PMS

Occurs 5 days before menses for 3 consecutive cycles. (emotional, behavioral, and physical symptoms). Ceases within 4 days after starting menstruation and interferes with daily activities.

If you are doing a PAP and culture, which should be done first?

PAP you can get cultures without a pap by using a q-tip on the vaginal wall (wet mount)

STI and recent IUD insertion with pelvic pain is a red flag for what condition?

PID

Differentials for acute pelvic pain in menstruating girls or women?

PID, Ruptured ovarian cyst, appendicitis, ectopic pregnancy, and ovarian torsion.

What is he purpose of a rectovaginal exam?

Palpate a retroverted uterus, the uterosacral ligaments, cul-de-sac, and adnexa, and screen for colon cancer in women over the age of 50.

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?

Percuss and palpate the midline area above the suprapubic bone.

Stomach (Percussion)

Percuss for a gastric air bubble in the LUQ at the left lower anterior rib cage and left epigastric region. The tympany of the gastric air bubble is lower in pitch than tympany of the intestine

Liver descent Percussion

Percuss the liver by asking the Pt. to take a deep breath and hold. Percuss at the right midclavicular line tympany to dullness then exhale. Normally the ara of lwer border dullness descends 2-3cm. Greater is cirrhosis, less then is abdominal tumors, pregnancy, or ascites

Spleen (Percussion)

Percuss the lower level of the left lung posterior to the midaxiallary continue down until dullness is ascertained. Normal 6-8cm above the left costal margin. Dullness beyond 8cm may be due to full stomach or a feces filled intestine. Enlargement can be due to portal hypertension resulting from liver disease. Other causes mononucleosis, thrombosis, stenosis, atresia, angiomatous deformities of the portal or splenic vein, cysts, or aneurysm of the splenic artery.

Bladder (Percussion)

Percuss upward from the symphysis pubis to the umbilicus. Note where the sound changes from dullness to tympany A full bladder is dull. A recently empty bladder should not be percussable above the symphysis pubis

During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process?

Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure

The nurse is reviewing risk factors for venous disease. Which of these situations best describes a person at highest risk for development of venous disease?

Person who has been on bed rest for 4 days

thoracic expansion

Place hands on lower posterior chest wall with thumbs toward spine. Assess expansion of chest as thumbs move. Movement should be symmetric.

Liver (Palpation)

Place left hand under the pt. right flank at about the 11th or 12th rib. Press up with the left hand toward the abdominal wall. Pace the right hand parallel to the midline at the right midclavicular line below the right costal margin or below. Deep breath...push down deeply and under the costal margin with your right fingers on inspiration, the liver will descend and contact the hand. Note level, size, shape, consistency and any masses. A normal liver edge presents as a firm, sharp, regular ridge with a mooth surface. Normally the liver is not palpable although it may be felt in extremely thin adults. Enlarged liver can be d/t CHF, hepatitis, encephalopathy, cirrhosis, cysts, or cancer.

Inguinal Lymph Nodes (Palpatation)

Place the patient in a supine position with the knees slighlty flexed. It is normal to palpate small movable nodes less than 1cm and nontender. Greater then 1cm of non-moveable can be attributed to localized or systemic infection. More serious may include cancer or lymphomas.

Plantar reflex present

Location of Bartholin's glands?

Posteriorly behind and on each side off the vaginal opening at 5:00 and 7:00. Not usually visible.

Cervical Lymph Nodes

Pre-auricular Post-auricular Tonsillar Occipital Submental Submandibular Posterior cervical Superficial cervical Deep cervical chain Supraclavicular

Causes of an enlarged uterus?

Pregnancy, fibromas, or malignancy.

Causes of secondary amenorrhea?

Pregnancy, lactation, menopause, low body weight, stress, chronic illness, and hypothalamic-pituitary-ovarian dysfunction.

Aorta (Palpatation)

Press the upper abd. with one hand on each side of the abd. aorta slightly to the left of the midline. Asses width - should be 2.5 - 4.0cm and pulsates in an anterior direction. Lateral pulsation of increase width suggest an abdominal aortic aneurysm.

Brudzinski

Pt supine, your hands behind pt's head and flex the neck forward, until chin touches the chest if possible. Neck stiffness with resistance and flexion of hips and knees is a positive sign. May be a sign of acute bacterial meningitis or subarachnoid hemorrhage

During a morning assessment, the nurse notices that the patient's sputum is frothy and pink. Which condition could this finding indicate?

Pulmonary edema

PERRLA

Pupils, Equal, Round, Reactive to, Light, Accommodate

Parotid Glands- Stenson's Duct

Side of cheek

diaphragmatic excursion

Test for resonance where you percuss down the scapular line while patient holds breath. Mark the area. Then have patient exhale and percuss up from the marked line. Normal is 3-5cm

What happens to vaginal secretions just before menarche?

There is a physiologic increase that is normal.

Estrogen dependent

The changes normally associated with menopause occur generally because the cells in the reproductive tract are:

After physical examination of a client, the nurse documents which finding as a symptom?

The client complains of itching.

Peripheral neuropathy

The nurse is performing a neurologic assessment on a 41 year-old woman with a history of diabetes. When testing her ability to feel vibrations of a tuning fork, the nurse notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally , but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect?

The nurse should ask a postmenopausal woman if she ever has vaginal bleeding.

The nurse is preparing to interview a postmenopausal woman. Which of these statements is true with regard to the history of a postmenopausal woman?

Moves the head and shoulders against resistance with equal strength.

The nurse is testing the function of the cranial nerve XI. Which of these best describes the response the nurse should expect if the nerve is intact? The patient:

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

The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultating precedes percussion and palpation of the abdomen?

Sister Mary Joesph's Nodule

The umbilicus that appears as a nodule may be the manifestation of abdominal carcinoma with metastasis to the umbilicus

If patient has a known mass, which breast should you examine first?

The unaffected breast.

Trochlear eye movement adductor of eyes (cross eyed) motor

What are the recommendations for using HRTs?

Use only for menopausal symptoms and for the shortest acceptable duration-approx. 1-2 years.

The nurse is auscultating the chest in an adult. Which technique is correct?

Use the diaphragm of the stethoscope held firmly against the chest.

Obturator Muscle test

Used for Pelvic abscess is suspected or appendicitis. Flex the right leg at the hip and knee at a right angle, rotate the leg both internally and externally. No pain should be present. Pain in hypogastric area can be caused by ruptrued appendix or pelvic abscess.

Ballottement

Used to displace excess fluid in the abdominal cavity in order to locate an organ or mass. Extend fingers of the right hand straigh line perpendicular to the abd. surface and jab. Internal organs should not be felt. The presence of ascities transmits external pressure to an internal organ or mass. Determines the presence of a free-floating abdominal mass that can indicate acancerous process in the abd cavity.

What are the most common vulvo-vaginal complaints?

Vaginal itching and vaginal discharge.

Introitus?

Vaginal opening

Ectocervix?

Vaginal surface of the cervix.

Vagus pharynx and larynx (talking and swallowing) (motor) sensation from carotid body carotid sinus pharynx and viscera (sensory)

While conducting an assessment of the thorax and lungs you ask the patient to flex the neck forward as you palpate the spinous process in this area. The superior process that you palpate is called the:

Vertebra prominens

During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation?

When part of the lung is obstructed or collapsed

Consider this a normal finding and proceed with the examination.

When performing a genital examination on a 25 year-old man, the nurse notices deeply pigmented, wrinkled scrotal skin with large sebaceous follicles. On the basis of this information the nurse would:

Normal abdominal aortic pulsations

While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would expect that there are:

Which of the following best explains why infants and toddlers are at greater risk for ear infections than are older children and adults?

Wider, shorter, and horizontal eustachian tube.

onychomycosis

Yellow, thickened nail due to fungal infection

Is Gardasil used in men?

Yes, prevents genital warts. Can be given between 9 and 26 years old.

Risk factors for chlamydia?

Younger then 26 years old, multiple sex partners, and a prior history of STIs.

crackles

a discontinuous type of adventitious sound; heard during inspiration; dry sounds of this type sound like hairs rubbing together, wet sounds bubble like a straw at the bottom of a glass; heard in COPD, heart failure, pneumonia, pulmonary edema

When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is:

a normal finding in a healthy adult.

tactile fremitus

a palpable vibration; sounds generated from the larynx are transmitted through lung parenchyma to the chest wall, where you feel them as vibrations; Place hand on posterior chest and flatten palm, ask patient to recite 'ninety nine' or 'one one one', repeat bilaterally and compare

a positive Babinski's sign, which is anormal for adults

bronchitis

lung condition often indicated by primarily normal findings with occasional crackles and wheezes; rasping cough with mucoid sputum; Acute or chronic inflammation or infection of the bronchi.

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. Inspection b. Auscultation c. Palpation d. Percussion

a. Inspection

Marsha ate 28 grams of protein - PRO; 120 grams of carbohydrate - CHO; and 25 grams of fat. Convert these to calories. She ate(a. _______) calories of PRO; (b. ______) calories of CHO; and (c. ______) calories of fat. Next what per cent of her diet was PRO? (d. _____) What per cent was CHO? (e. _______ ) What per cent was fat? (f. __________) Is she following recommended ranges for this meal? Yes or no? (g. ______)

a.28g PRO x 4 = 112 cal b 120g CHO x 4 = 480 cal c.25g fat x 9 cal = 225 cal Total calories 817 d.112/817 = 0.137 = 13.7% e.480/817 = 0.588 = 58.8% f. 225/817 = 0.275 = 27.5% g. Rec ranges - PRo 10-20 CHO 50-60 Fat 20-30 (Yes)

food frequency questionaire

asks how many times a day, week, month individual eats particular foods

To assess an older patient's ability to consume foods, the examiner should:

assess the oral cavity for the condition of the teeth and presence of lesions.

paroxysmal nocturnal dyspnea

awakening from sleep with SOB and needing to be upright to achieve comfort

A patient has been diagnosed with osteoporosis and asks the nurse, "What is osteoporosis?" The nurse explains to the patient that osteoporosis is defined as: A) increased bone matrix. B) loss of bone density. C) new, weaker bone growth. D) increased phagocytic activity.

An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because: A) long bones tend to shorten with age. B) of the shortening of the vertebral column. C) there is a significant loss of subcutaneous fat. D) there is a thickening of the intervertebral disks.

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

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

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. Nothing. b. Talk with the client about possible fears associated with the breast exam. c. Instruct the client on how to perform the breast exam again. d. Instruct the client on getting an annual mammogram instead.

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

bronchial

lung sounds heard next to trachea; high pitched and loud, longer during expiratory phase

During the history of a 78-year-old man, his wife states that he occasionally has problems with short-term memory loss and confusion: "He can't even remember how to button his shirt." In doing the assessment of his sensory system, which action by the nurse is most appropriate?

before testing, the nurse would assess the patient's mental status and ability to follow directions at this time.

In assessing for an S4 heart sound with a stethoscope, the nurse would listen with the:

bell at the apex with the patient in the left lateral position

When reviewing the musculoskeletal system, the nurse recalls that hematopoiesis takes place in the:

bone marrow

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. Inform all about the low-cost breast cancer screening program. c. Encourage all females to increase their intake of vitamins A and E. d. Encourage all females to complete monthly breast exams.

c. Encourage all females to increase their intake of vitamins A and E.

A client with fibrocystic breast disease says she has increased breast pain and tenderness with menses. Which of the following can help this client? a. Nothing can be done to help this client. b. Discuss how this can be a precursor to breast cancer. c. Review how reducing caffeine and salt and wearing a support bra might help. d. Explain how a breast biopsy is indicated.

c. Review how reducing caffeine and salt and wearing a support bra might help.

Organs of the R lower quadrant

cecum, appendix, R ovary and tube, R ureter, R spermatic chord

second trimester

colostrum may be expressed nipples darken may note linea nigra or striae gravidarum BP may drop even more drop is most pronounced at 20 weeks

Rinne test

compares air conduction and bone conduction. place stem of the vibrating tuning fork on the person mastoid process and ask him or her to signal when the sound goes away. Air conduction should be twice bone conduction

A 50 year old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform a

complete neurological assessment

Weakness of the perineal body from childbirth predisposes women to what?

cystocele and rectocele

The nurse is explaining to a patient that there are "shock absorbers" in his back to cushion the spine and to help it move. The nurse is referring to his: A) vertebral column. B) nucleus pulposus. C) vertebral foramen. D) intervertebral disks.

The nurse is providing patient education for a man who has been diagnosed with a rotator cuff injury. The nurse knows that a rotator cuff injury involves the: A) nucleus pulposus. B) articular process. C) medial epicondyle. D) glenohumeral joint.

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. This is the hardest area to feel for changes. b. Who told you that you have to do that? c. I'm not sure why that is important, but it sounds like it is. d. Breast tissue extends into the axilla.

d. Breast tissue extends into the axilla.

subculture

fairly large groups of people with shared characteristics that are not common to all members of a culture

decreased LoC

The nurse knows that a normal finding when assessing the respiratory system of an elderly adult is:

decreased mobility of the thorax

paralysis

decreased or loss of motor power due to problem with motor nerve fibers

A patient has a positive Homans' sign. The nurse knows that a positive Homans' sign may indicate:

deep vein thrombosis

Osteoarthritis

degenerative joint disease hard non-tender nodules over the distal interphalangeal joints

Light Palpation

depress 1 cm

bronchiovesicular sounds are...

expected near the major airways

axillary nodes

drain the breast and upper arm (armpit)

cervical nodes

drain the head and neck (head and neck)

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:

elevated pressure related to heart failure.

What are the age recommendations for a clinical breast exam?

every 3 years for 20-30 year olds every year for >=40 years old

A patient comes to the clinic and states that he has noticed that his skin is redder than normal. The nurse understands that this condition is due to hyperemia and knows that it can be caused by:

excess blood in the dilated superficial capillaries

the wife of a 65 year old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. he also becomes angry easily. the nurse recalls the the part of the brain responsible for these behaviors is the:

frontal lobe

The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen's test. To perform this test, the nurse should instruct the patient to:

hold both hands back to back while flexing the wrists 90 degrees for 60 seconds.

The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to:

hyperactive bowel sounds

hyperactive reflexes

Generalized hyperresonance on respiratory percussion

hyperinflated lungs of COPD or asthma

hypoglossal movement of the tongue (motor)

epitrochlear node

in the antecubital (where arm bends) fossa and drains the head and lower arm

dysmetria

inability to control the distance, power, and speed of a muscular contraction

abnormal findings tumor

inspection- localized distention auscultation- normal bowel sounds percussion- dull over mass if it reaches up to skin surface palpation- define borders distinguish from enlarged organ or normally palpable structure

abnormal findings feces

inspection- localized distention auscultation- normal bowel sounds percussion- tympany predominates scattered dullness over fecal mass palpation- plastic-like or rope-like mass with feces in intestines

abnormal findings ascites

inspection- single curve, everted umbilicus, bulging flanks when supine auscultation- normal bowel sounds over intestines however diminished over ascitic fluid percussion- tympany at top where intestines float. dull over fluid palpation- taut skin increased intra-abdominal pressure limit palpation

tic

involuntary compulsive repetitive twitching of a muscle group due to a neurologic cause

emphysema

lung condition indicated by barrel chest, dyspnea on exertion, pursed lips, deep breathing, and underweight, hyperinflation of air sacs, permanent destruction of alveolar walls

The functional units of the musculoskeletal system are the

joints

6L below the ear at superior to the jaw bone

jugulodigastric

coloboma

keyhole appearance of pupil

preterm labor

labor occurring after 20 weeks and before completion of 37 weeks gestation

While gathering equipment after an injection, a nurse accidentally received a prick from an improperly capped needle. To interpret this sensations, which of these areas must be in tact?

lateral spinothalamic tract, thalamus, sensory tract The spinothalamic tract contains sensory fibers that transmit the sensations of pain, temperature, and crude or light touch. Fibers carrying pain and temperature sensations ascend the lateral spinothalamic tract, whereas those of crude touch form the anterior spinothalamic tract. At the thalamus, the fibers synapse with another sensory neuron, which carries the message to the sensory cortex for full interpretation.

A patient has had a "terrible itch" for several months that he has been scratching continuously. On examination, the nurse might expect to find:

lichenification

maneuver to screen for retraction

lift arms slowly over head, push hands onto hips, push two palms together, and lean forward

Organs of the R upper quadrant

liver, gallbladder, duodenum, head of pancreas, R kidney, hepatic flexure of colon, part of ascending and transverse colon

glasgow coma scale best motor response to pain 5

localizes pain

bronchiovesicular

over major bronchi where fewer alveoli are located

The bulbar conjuctiva

overlies the sclera

Murphy's sign

pain when pressure is applied to the right upper quadrant to help detect gallbladder problems

The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a:

papule

When assessing a patient's pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulsus:

paradoxus

During an assessment of a 62-year-old man the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements. These findings would be consistent with:

parkinsonism

Organs of the L lower quadrant

part of the descending colon, sigmoid colon, L ovary and tube, L ureter, L spermatic chord

When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be:

proximal to distal.

A patient complains of leg pain that wakes him at night. He states that he "has been having problems" with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed "a sore" on the inner aspect of the right ankle. On the basis of this history information, the nurse interprets that the patient is most likely experiencing:

problems related to arterial insufficiency.

Exopthalamus

protrusion of the eyeball, a common feature of Graves', triggered by autoreactive T lymphocytes.

what is the purpose of a health history

provide a database of subjective information about the patients past and present health

During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is:

xerosis

intention tremor

rate varies worse with voluntary movement as in reaching toward a visually guided target

wernicke's area

receptive aphasia temporal lobe associated with language

In completing a physical assessment, the nurse recognizes that respiratory function of older adult clients normally declines because of:

reduced inspiratory and expiratory effort.

corneal reflex

reflex controlled by trigeminal nerve; blink reflex

corneal light reflex

reflex in which light reflects symmetrically from both eyes

signals the beginning of systole coincides with the first heart sound and is loudest at the apex

signals the end of diastole coincides with the second heart sound is loudest at the base

positive signs

signs that are direct evidence of the fetus such as auscultation of fetal heart tones

presumptive signs

signs that the woman experiences such as amenorrhea breast tenderness nausea fatigue and urinary frequency

extinction

simultaneously touch both sides of the body at the same point person should be able to feel both sensations

The component of the conduction system referred to as the pacemaker of the heart is the:

sinoatrial (SA) node.

Xanthelasma

slightly raised, yellowish, well-circumscibed plaques that appear along the nasal portions of one or both eyelids. May accompany lipid disorders

Vesicular Sounds

soft, low pitched. Heard through inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration

A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing?

spastic hemiparesis

glasgow coma scale best verbal response 3

speech inappropriate

vaginal bleeding

spotting during the first trimester is not always a sign of pending pregnancy in second and third trimester can be indicative of more serious conditions

Liver Span Percussion

stand to the right. Start at midclavicular line below the umbilicus and percuss upward to determin the lower border of the liver mark where tympany changes to dullness. Then at the right midclavicular line percuss down from an area of lung resonance to one of dullness and mark. Normal is 6-12 Man 10.5, women 7inches. Increase size hepatitis, cirrhosis, cardiac or renal congestion, cysts, or metastatic tumors

A common mistake made by health care professionals is to:

stereotype individuals based on color or ethnic group.

During an examination of the anterior thorax, the nurse keeps in mind that the trachea bifurcates anteriorly at the:

sternal angle

Organs of the L upper quadrant

stomach, spleen, L lobe of the liver, body of pancreas, L kidney, splenic flexure of the colon, part of transverse and descending colon

A 52-year-old patient states that when she sneezes or coughs she "wets herself a little." She is very concerned that something may be wrong with her. You know that this is called:

stress incontinence and is usually due to muscle weakness.

retinal detachment

sudden vision change, floaters, or flashes of light indicate an emergency due to this possible eye trauma

where do you palpate the point of maximal impulse

the apex also known as the apical impulse located in the fourth or fifth ICS medial to the midclavicular line

A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because:

the woman could be at increased risk for infection and lesions because of her chronic disease

LDL cholesterol

this type of cholesterol should be less than 130mg/dl

C6-C8

thumb middle finger and fifth finger

A 45-year-old farmer comes in for a skin evaluation and complains of hair loss on his head. He has noticed that his hair seems to be breaking off in patches and that he has some scaling on his head. The nurse would begin the examination suspecting:

tinea capitis

glasgow coma scale eye opening response 2

to pain

Glasgow coma scale Eye opening response 3

to speech

female genitals (internal)

vagina, rugae, cervix, squamocolumnar junction, anterior/posterior fornix, rectouterine pouch, cul-de-sac of douglas, uterus, fallopian tubes, and ovaries

Grade 5

very loud, heard with stethoscope partly off chest, heave and thrill palpable

Grade 2

very soft but distinctly audible

When auscultating the lungs of an adult patient, the nurse notes that over the posterior lower lobes low-pitched, soft breath sounds are heard, with inspiration being longer than expiration. The nurse interprets that these are:

vesicular breath sounds and are normal in that location.

how is fremitus produced?

vibration of the larynx

diminished breath sounds would most likely be heard

when the bronchial tree is obstructed

Bronchovesicular Sounds

with inspiratory and expiratory sounds about equal in length, at times separated by a silent interval. Detecting differences in pitch and intensity is often easier during expiration.

Methods for assessing cognitive functioning

•A&O: person, time, place •Remote, immediate, and recent memory •Cognitive function: tell me what a proverb means, "if you found an envelope on the ground, what would you do", calculations

Intervertebral disks

The nurse is explaining to a patient that there are "shock absorbers" in his back to cushion the spine and help it move. The nurse is referring to his:

They are usually high-pitched, gurgling, irregular sounds.

The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds?

rheumatoid arthritis

inflammatory condition painful swelling stiff joints swelling of soft tissue symmetric swelling hands are warm and veins are engorged

claudication

A cardinal symptom of peripheral arterial disease where skeletal muscle oxygen demand exceeds blood oxygen supply. Characterized by cramping, aching, sense of fatigue

egophony

A change in vocal resonance in the presence of a lung consolidation condition in which the transmission of the "eee" sound becomes a nasal "ay" sound.

ischemia

A condition in which the supply of blood to a part of the body is severely reduced

preeclampsia

A condition specific to pregnancy that is rarely seen before 20 weeks symptoms include hypertension and protein in urine

atherosclerosis

A disorder in which cholesterol and calcium build up inside the walls of the blood vessels, forming plaque, which eventually leads to partial or complete blockage of blood flow.

Testes

A male patient with possible fertility problems asks the nurse where sperm is produced. The nurse knows that sperm production occurs in the:

Involuntary movement of an eye following its uncovering during the cover/uncover test indicates that:

A muscle weakness or muscle imbalance exists

What is a nabothian cyst?

A normal finding on the cervix. It is a translucent, fluid-filled cyst.

"Do you use a condom with each episode of sexual intercourse?"

A nurse is assessing a patient's risk of contracting a sexually transmitted infection (STI). An appropriate question to ask would be:

When percussing over the liver of a patient, the nurse notices a dull sound. The nurse should: A) consider this a normal finding. B) palpate this area for an underlying mass. C) reposition the hands and attempt to percuss in this area again. D) consider this an abnormal finding and refer the patient for additional treatment.

A) consider this a normal finding.

29. Just before going home, a new mother asks the nurse about the infant's umbilical cord. Which of these statements is correct?

A) "It should fall off by 10 to 14 days."

Just before going home, a new mother asks the nurse about the infant's umbilical cord. Which of these statements is correct?

A) "It should fall off by 10 to 14 days."

The nurse is reviewing a patient's medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?

A) 6

34. The nurse is reviewing statistics for lactose intolerance. In the United States, the incidence of lactose intolerance is higher in adults of which ethnic group?

A) African-Americans

A) Ask the patient to lock her fingers and "pull."

The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which of these structures? A) Cerebrum B) Cerebellum C) Cranial nerves D) Medulla oblongata

A) Cerebrum

The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)?

A) Flexion and extension

The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband's personality and ability to understand. He also cries and becomes angry very easily.The nurse recalls that the cerebral lobe responsible for these behaviors is the _____ lobe.

A) Frontal

A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual?

A) Hyporeflexia

The functional units of the musculoskeletal system are the:

A) Joints

A) Parkinsonism.

When palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the upper left quadrant with deep palpation. Which of these structures is most likely to be involved?

A) Spleen

During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. There is no associated rigidity with movement. Which of these statements is most accurate? A) These are normal findings resulting from aging. B) These could be related to hyperthyroidism. C) These are the result of Parkinson disease. D) This patient should be evaluated for a cerebellar lesion.

A) These are normal findings resulting from aging.

A) This is a positive Allis sign and suggests hip dislocation.

During the history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this as:

A) Vertigo.

24. During an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be manifested by:

A) projectile vomiting.

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that: A) she may have macular degeneration. B) her vision is normal for someone her age. C) she has the beginning stages of cataract formation. D) she has increased intraocular pressure or glaucoma.

A) she may have macular degeneration.

39. The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should:

B) examine the tender area last.

Older adults have: A. decreased salivation leading to dry mouth. B. increased gastric acid secretion. C. increased liver size. D. decreased incidence of gallstones.

A. decreased salivation leading to dry mouth.

An area of the body that is supplied mainly from one spinal segment through a particular spinal nerve is identified as a: A. dermatome. B. dermal segmentation. C. hemisphere. D. crossed representation.

A. dermatome.

The medical record indicates that a person has an injury to Broca's area. When meeting this person you expect: A. difficulty speaking B. receptive aphasia C. visual disturbances D. emotional lability

A. difficulty speaking

A positive Babinski sign is: A. dorsiflexion of the big toe and fanning of all toes B. plantar flexion of the big toe with a fanning of all toes C. the expected response in healthy adults D. withdrawal of the stimulated extremity from the stimulus

A. dorsiflexion of the big toe and fanning of all toes

The relative proportion of glandular, fibrous, and fatty tissue varies depending on age, cycle, pregnancy, lactation, and general nutritional state. A known risk factor for breast cancer includes: A. early menarche or late menopause B. low breast tissue density C. breastfeeding an infant for more than 6 months D. low-fat, low cholesterol diet

A. early menarche or late menopause

For the spleen to be palpable, it must be: A. enlarged three times its normal size. B. enlarged twice its normal size. C. located superficially under the 11th rib. D. rotated to the left side.

A. enlarged three times its normal size.

Mr. Walker is a 56-year-old man who comes to the ambulatory health center for a routine health assessment. On examination, you note hepatomegaly, which is: A. enlargement of the liver. B. bowel protrusion through abdominal musculature. C. inflammation of the peritoneum. D. a burning sensation in the upper abdomen.

A. enlargement of the liver.

Gynecomastia is: A. enlargement of the male breast B. presence of "mast" cells in the male breast C. cancer of the male breast D. presence of supernumerary breast on the male chest

A. enlargement of the male breast

Examination of the shoulder includes four motions. These are: A. forward flexion, internal rotation, abduction, and external rotation B. abduction, adduction, pronation, and supination C. circumduction, inversion, eversion, and rotation D. elevation, retraction, protraction, and circumduction

A. forward flexion, internal rotation, abduction, and external rotation

11. A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are no other injuries. During the assessment what would the nurse expect to find when testing the patient's deep tendon reflexes? a. Reflexes will be normal. b. Reflexes cannot be elicited. c. All reflexes will be diminished but present. d. Some reflexes will be present, depending on the area of injury.

ANS: A A reflex is a defense mechanism of the nervous system. It operates below the level of conscious control and permits a quick reaction to potentially painful or damaging situations.

29. The nurse is testing the deep tendon reflexes of a 30-year-old woman who is in the clinic for an annual physical examination. When striking the Achilles heel and quadriceps muscle, the nurse is unable to elicit a reflex. The nurse's next response should be to: a. Ask the patient to lock her fingers and pull. b. Complete the examination, and then test these reflexes again. c. Refer the patient to a specialist for further testing. d. Document these reflexes as 0 on a scale of 0 to 4+.

ANS: A Sometimes the reflex response fails to appear. Documenting the reflexes as absent is inappropriate this soon in the examination. The nurse should try to further encourage relaxation, varying the person's position or increasing the strength of the blow. Reinforcement is another technique to relax the muscles and enhance the response. The person should be asked to perform an isometric exercise in a muscle group somewhat away from the one being tested. For example, to enhance a patellar reflex, the person should be asked to lock the fingers together and pull.

During a vaginal examination of a 38-year-old woman, the nurse notices that the vulva and vagina are erythematous and edematous with thick, white, curdlike discharge adhering to the vaginal walls. The woman reports intense pruritus and thick white discharge from her vagina. The nurse knows that these history and physical examination findings are most consistent with which of these conditions? A) Candidiasis B) Trichomoniasis C) Atrophic vaginitis D) Bacterial vaginosis

ANS: A The woman with candidiasis often reports intense pruritus and thick white discharge. The vulva and vagina are erythematous and edematous. The discharge is usually thick, white, and curdlike. Infection with trichomoniasis causes a profuse, watery, gray-green, and frothy discharge. Bacterial vaginosis causes a profuse discharge that has a "foul, fishy, rotten" odor. Atrophic vaginitis may have a mucoid discharge. See Table 26-5 for complete descriptions of each option.

34. Which of these tests would the nurse use to check the motor coordination of an 11-month-old infant? a. Denver II b. Stereognosis c. Deep tendon reflexes d. Rapid alternating movements

ANS: A To screen gross and fine motor coordination, the nurse should use the Denver II with its age-specific developmental milestones. Stereognosis tests a person's ability to recognize objects by feeling them and is not appropriate for an 11-month-old infant. Testing the deep tendon reflexes is not appropriate for checking motor coordination. Testing rapid alternating movements is appropriate for testing coordination in adults.

15. During the taking of the health history, a patient tells the nurse that "it feels like the room is spinning around me." The nurse would document this finding as: a. Vertigo. b. Syncope. c. Dizziness. d. Seizure activity.

ANS: A True vertigo is rotational spinning caused by a neurologic dysfunction or a problem in the vestibular apparatus or the vestibular nuclei in the brainstem. Syncope is a sudden loss of strength or a temporary loss of consciousness. Dizziness is a lightheaded, swimming sensation. Seizure activity is characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances.

A woman has just been diagnosed with HPV, or genital warts. The nurse should counsel her to receive regular examinations because this virus makes her at a higher risk for _____ cancer. A) uterine B) cervical C) ovarian D) endometrial

ANS: B HPV is the virus responsible for most cases of cervical cancer, not the other options.

41. During an assessment of a 22-year-old woman who sustained a head injury from an automobile accident 4 hours earlier, the nurse notices the following changes: pupils were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm and reacts to light. What do these findings suggest? a. Injury to the right eye b. Increased intracranial pressure c. Test inaccurately performed d. Normal response after a head injury

ANS: B In a person with a brain injury, a sudden, unilateral, dilated, and nonreactive pupil is ominous. CN III runs parallel to the brainstem. When increasing intracranial pressure pushes down the brainstem (uncal herniation), it puts pressure on CN III, causing pupil dilation. The other responses are incorrect.

A nurse is assessing a patient's risk of contracting a sexually transmitted infection (STI). An appropriate question to ask would be: A) "You know that it's important to use condoms for protection, right?" B) "Do you use a condom with each episode of sexual intercourse?" C) "Do you have a sexually transmitted infection?" D) "You are aware of the dangers of unprotected sex, aren't you?"

ANS: B In reviewing a patient's risk for sexually transmitted infections, the nurse should ask, in a nonconfrontational manner, whether condoms are used at each episode of sexual intercourse. Asking a person whether he or she has an infection does not address the risk.

A patient calls the clinic for instructions before having a Papanicolaou (Pap) smear. The most appropriate instructions from the nurse are: A) "If you are menstruating, please use pads to avoid placing anything into the vagina." B) "Avoid intercourse, inserting anything into the vagina, or douching within 24 hours of your appointment." C) "If you suspect that you have a vaginal infection, please gather a sample of the discharge to bring with you." D) "We would like you to use a mild saline douche before your examination. You may pick this up in our office."

ANS: B When instructing a patient before a Papanicolaou (Pap) smear is obtained, the nurse should follow these guidelines: Do not obtain during the woman's menses or if a heavy infectious discharge is present. Instruct the woman not to douche, have intercourse, or put anything into the vagina within 24 hours before collecting the specimens. Any specimens will be obtained during the visit, not beforehand.

1. A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying "I'm just getting old!" After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer disease? Select all that apply. a. Occasionally forgetting names or appointments b. Difficulty performing familiar tasks, such as placing a telephone call c. Misplacing items, such as putting dish soap in the refrigerator d. Sometimes having trouble finding the right word e. Rapid mood swings, from calm to tears, for no apparent reason f. Getting lost in one's own neighborhood

ANS: B, C, E, F Difficulty performing familiar tasks, misplacing items, rapid mood swings, and getting lost in one's own neighborhood can be warning signs of Alzheimer disease. Occasionally forgetting names or appointments, and sometimes having trouble finding the right word are part of normal aging. (For other examples of Alzheimer disease, see Table 23-2.)

36. While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of the arms and legs; fanning of the fingers, and curling of the index finger and thumb in a C position, followed by the infant bringing in the arms and legs to the body. What does the nurse know about this response? a. This response could indicate brachial nerve palsy. b. This reaction is an expected startle response at this age. c. This reflex should have disappeared between 1 and 4 months of age. d. This response is normal as long as the movements are bilaterally symmetric.

ANS: C The Moro reflex is present at birth and usually disappears at 1 to 4 months. Absence of the Moro reflex in the newborn or its persistence after 5 months of age indicates severe central nervous system injury. The other responses are incorrect.

24. The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of "always dropping things and falling down." While testing rapid alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect? a. Vestibular disease b. Lesion of CN IX c. Dysfunction of the cerebellum d. Inability to understand directions

ANS: C When a person tries to perform rapid, alternating movements, responses that are slow, clumsy, and sloppy are indicative of cerebellar disease. The other responses are incorrect.

ANS: flexion. Flexion, or bending a limb at a joint, would be required to move the hand to the mouth. Extension is straightening a limb at a joint. Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body.

A 46-year-old woman is in the clinic for her annual gynecologic examination. She voices a concern about ovarian cancer because her mother and sister died of it. The nurse knows that which of these statements is correct regarding ovarian cancer? A) Ovarian cancer rarely has any symptoms. B) The Pap smear detects the presence of ovarian cancer. C) Women at high risk for ovarian cancer should have annual transvaginal ultrasonography for screening. D) Women over age 40 years should have a thorough pelvic examination every 3 years.

ANS: C With ovarian cancer, the patient may have abdominal pain, pelvic pain, increased abdominal size, bloating, and nonspecific gastrointestinal symptoms, or she may be asymptomatic. The Pap smear does not detect the presence of ovarian cancer. Annual transvaginal ultrasonography may detect ovarian cancer at an earlier stage in women who are at high risk for it.

32. The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How should the nurse document this finding? a. Positive Babinski sign b. Plantar reflex abnormal c. Plantar reflex present d. Plantar reflex 2+ on a scale from "0 to 4+"

ANS: C With the same instrument, the nurse should draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot, similar to an upside-down J. The normal response is plantar flexion of the toes and sometimes of the entire foot. A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and fanning of all toes. The plantar reflex is not graded on a 0 to 4+ scale.

ANS: Crepitation Crepitation is an audible and palpable crunching or grating that accompanies movement and occurs when articular surfaces in the joints are roughened, as with rheumatoid arthritis. The other options are not correct.

A patient who has had rheumatoid arthritis for years comes to the clinic to ask about changes in her fingers. The nurse will assess for signs of what problems?

ANS: Swan neck deformities Changes in the fingers caused by chronic rheumatoid arthritis include swan neck and boutonniere deformities. Heberden's nodes and Bouchard's nodules are associated with osteoarthritis. Dupuytren's contractures occur because of chronic hyperplasia of the palmar fascia and causes contractures of the digits (see Table 22-4).

The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal women. Which of these actions is the best way to prevent or delay bone loss in this group?

ANS: Taking calcium and vitamin D supplements Physical activity, such as fast walking, delays or prevents bone loss in perimenopausal women. The faster the pace of walking, the higher the preventive effect on the risk of hip fracture. The other options are not correct.

ANS: This is a positive Allis sign and suggests hip dislocation. Finding one knee significantly lower than the other is a positive Allis sign and suggests hip dislocation. Normally the tops of the knees are at the same elevation. The other statements are not correct.

An 80-year-old woman is visiting the clinic for a checkup. She states, "I can't walk as much as I used to." The nurse is observing for motor dysfunction in her hip and should have her:

ANS: abduct her hip while she is lying on her back. Limitation of abduction of the hip while supine is the most common motion dysfunction found in hip disease. The other options are not correct.

ANS: acute gout. Acute gout occurs primarily in men over 40 years of age. Clinical findings consist of redness, swelling, heat, and extreme tenderness. Gout is a metabolic disorder of disturbed purine metabolism, associated with elevated serum uric acid. See Table 22-1 for descriptions of the other terms.

A patient is being assessed for range of joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called:

ANS: adduction. Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body. Flexion is bending a limb at a joint; extension is straightening a limb at a joint.

ANS: adhesive capsulitis. Dislocated shoulder occurs with trauma involving abduction, extension, and external rotation (e.g., falling on an outstretched arm or diving into a pool). See Table 22-2 for a description of the other conditions.

To palpate the temporomandibular joint, the nurse's fingers should be placed in the depression _____ of the ear.

ANS: anterior to the tragus The temporomandibular joint can be felt in the depression anterior to the tragus of the ear. The other locations are not correct.

When reviewing the musculoskeletal system, the nurse recalls that hematopoiesis takes place in the:

ANS: bone marrow. The musculoskeletal system functions to encase and protect inner vital organs, support the body, produce red blood cells in the bone marrow, and store minerals.

The nurse notices that a woman in an exercise class is unable to jump rope. The nurse knows that to jump rope, one's shoulder has to be capable of:

ANS: circumduction. Circumduction is defined as moving the arm in a circle around the shoulder.

The nurse is assessing a patient's ischial tuberosity. To palpate the ischial tuberosity, the nurse knows that it is best to have the patient:

ANS: flex the hip. The ischial tuberosity lies under the gluteus maximus muscle and is palpable when the hip is flexed.

An imaginary line connecting the highest point on each iliac crest would cross the _____ vertebra.

ANS: fourth lumbar An imaginary line connecting the highest point on each iliac crest crosses the fourth lumbar vertebra.

ANS: functional scoliosis. Functional scoliosis is flexible; it is apparent with standing and disappears with forward bending. Structural scoliosis is fixed; the curvature shows both when standing and when bending forward. See Table 22-7 for description of herniated nucleus pulposus. These findings are not indicative of a dislocated hip.

A patient tells the nurse that "all my life I've been called 'knock knees.'" The nurse knows that another term for "knock knees" is:

ANS: genu valgum. Genu valgum is also known as "knock knees" and is present when there is more than 2.5 cm between the medial malleoli when the knees are together.

The nurse is providing patient education for a man who has been diagnosed with a rotator cuff injury. The nurse knows that a rotator cuff injury involves the:

ANS: glenohumeral joint. A rotator cuff injury involves the glenohumeral joint, which is enclosed by a group of four powerful muscles and tendons that support and stabilize it. The nucleus pulposus is located in the center of each intervertebral disk. The medial epicondyle is located at the elbow.

The nurse is examining the hip area of a patient and palpates a flat depression on the upper, lateral side of the thigh when the patient is standing. The nurse interprets this finding as the:

ANS: greater trochanter. The greater trochanter of the femur is palpated when the person is standing, and it appears as a flat depression on the upper lateral side of the thigh. The iliac crest is the upper part of the hip bone; the ischial tuberosity lies under the gluteus maximus muscle and is palpable when the hip is flexed. The gluteus muscle is part of the buttocks.

ANS: herniated nucleus pulposus. Lateral tilting and sciatic pain with straight leg raising are findings that occur with a herniated nucleus pulposus. The other options are not correct.

The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen's test. To perform this test, the nurse should instruct the patient to:

ANS: hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. For the Phalen's test, the nurse should ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. The Phalen's test reproduces numbness and burning in a person with carpal tunnel syndrome. The other actions are not correct for testing for carpal tunnel syndrome.

The nurse is explaining to a patient that there are "shock absorbers" in his back to cushion the spine and to help it move. The nurse is referring to his:

ANS: intervertebral disks. Intervertebral disks are elastic fibrocartilaginous plates that cushion the spine like shock absorbers and help it move. The vertebral column is the spinal column itself. The nucleus pulposus is located in the center of each disk. The vertebral foramen is the channel, or opening, for the spinal cord in the vertebrae.

The functional units of the musculoskeletal system are the:

ANS: joints. Joints are the functional units of the musculoskeletal system because they permit the mobility needed for the activities of daily living. The skeleton (bones) is the framework of the body.

Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called:

ANS: ligaments. Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement in undesirable directions are called ligaments.

ANS: limited range of motion during the Moro's reflex. For a fractured clavicle, the nurse should observe for limited arm range of motion and unilateral response to the Moro's reflex. The other tests are not appropriate for this problem.

ANS: lordosis. Lordosis compensates for the enlarging fetus, which would shift the center of balance forward. This shift in balance in turn creates strain on the low back muscles, felt as low back pain during late pregnancy by some women. Scoliosis is lateral curvature of portions of the spine; ankylosis is extreme flexion of the wrist, as seen with severe rheumatoid arthritis; and kyphosis is an enhanced thoracic curvature of the spine.

A patient has been diagnosed with osteoporosis and asks the nurse, "What is osteoporosis?" The nurse explains to the patient that osteoporosis is defined as:

ANS: loss of bone density. After age 40, loss of bone matrix (resorption) occurs more rapidly than new bone formation. The net effect is a gradual loss of bone density, or osteoporosis. The other options are not correct.

A professional tennis player comes into the clinic complaining of a sore elbow. The nurse will assess for tenderness at the:

ANS: medial and lateral epicondyle. The epicondyles, the head of radius, and tendons are common sites of inflammation and local tenderness, or "tennis elbow." The other locations are not affected.

ANS: metacarpophalangeal The joint located just above the ring on the finger is the metacarpophalangeal joint. The interphalangeal joint is located distal to the metacarpophalangeal joint. The tarsometatarsal and tibiotalar joints are found in the foot and ankle. See Figure 22-10 for a diagram of the bones and joints of the hand and fingers.

ANS: negative Ortolani's sign. Normally this maneuver feels smooth and has no sound. With a positive Ortolani's sign, the nurse will feel and hear a "clunk" as the head of the femur pops back into place. A positive Ortolani's sign reflects hip instability. The Allis test also tests for hip dislocation, but is done by comparing leg lengths.

ANS: of sharp pain that increases with movement A fracture causes sharp pain that increases with movement. The other pains do not occur with a fracture.

ANS: olecranon bursitis. Subcutaneous nodules are raised, firm, and nontender and occur with rheumatoid arthritis in the olecranon bursa and along the extensor surface of the ulna. See Table 22-3 for a description of the other conditions.

During a neonatal examination, the nurse notices that the newborn infant has six toes. This finding is documented as:

ANS: polydactyly. Polydactyly is the presence of extra fingers or toes. Syndactyly is webbing between adjacent fingers or toes. The other terms are not correct.

When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be:

ANS: proximal to distal. The musculoskeletal assessment should be done in an orderly approach, head to toe, proximal to distal, from the midline outward. The other options are not correct.

A patient is able to flex his right arm forward without difficulty or pain but is unable to abduct his arm because of pain and muscle spasms; the nurse should suspect:

ANS: rotator cuff lesions. Rotator cuff lesions may cause limited range of motion and pain and muscle spasm during abduction, whereas forward flexion stays fairly normal. The other options are not correct.

The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal woman. A participant shows that she needs more instruction when she states, "I will:

ANS: start swimming to increase my weight-bearing exercise." Weight-bearing exercises include walking, low-impact aerobics, dancing, or stationary cycling. Swimming is not considered a weight-bearing exercise. The other responses are correct.

ANS: suspect that the infant may have weakness of the shoulder muscles. An infant who starts to "slip" between the nurse's hands shows weakness of the shoulder muscles. An infant with normal muscle strength wedges securely between the nurse's hands. The other responses are not correct.

The nurse has completed the musculoskeletal examination of a patient's knee and has found a positive bulge sign. The nurse interprets this finding to indicate:

ANS: swelling from fluid in the suprapatellar pouch. For swelling in the suprapatellar pouch, the bulge sign confirms the presence of fluid. The other options are not correct.

The articulation of the mandible and the temporal bone is known as the:

ANS: temporomandibular joint. The articulation of the mandible and the temporal bone is the temporomandibular joint. The other responses are not correct.

ANS: tophi. Tophi are collections of sodium urate crystals resulting from chronic gout in and around the joint that cause extreme swelling and joint deformity. They appear as hard, painless nodules (tophi) over the metatarsophalangeal joint of the first toe and they sometimes burst with a chalky discharge (See Table 22-6). See Table 22-6 for descriptions of the other conditions.

A woman who has had rheumatoid arthritis for years is starting to notice that her fingers are drifting to the side. The nurse knows that this condition is commonly referred to as:

ANS: ulnar deviation. Fingers drift to the ulnar side because of stretching of the articular capsule and muscle imbalance caused by chronic rheumatoid arthritis. Radial drift is not seen. See Table 22-4 for descriptions of swan neck deformity and Dupuytren's contracture.

ANS: your acromion process." The bump of the scapula's acromion process is felt at the very top of the shoulder. The other options are not correct.

A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation?

An enlarged spleen should not be palpated because it can rupture easily

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor?

An increased loss of elastin and a decrease in subcutaneous fat in the elderly

nystagmus

An involuntary, rhythmic oscillation of the eyeballs; may be lateral, vertical, or rotary

Side effects of medication

An older man is concerned about his sexual performance. The nurse knows that in the absence of disease, a withdrawal from sexual activity later in life may be due to:

Ulcer

An ulcer is full thickness loss of epidermis or epithelium. It may be covered with a dark-coloured crust called an eschar

During a mental status assessment, which question by the nurse would best assess a person's judgment? A) "Do you feel that you are being watched, followed, or controlled?" B) "Tell me about what you plan to do once you are discharged from the hospital." C) "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?" D) "What would you do if you found a stamped, addressed envelope lying on the sidewalk?"

B) "Tell me about what you plan to do once you are discharged from the hospital."

27. During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least:

B) 5 minutes.

In obtaining a history on a 74-year-old patient the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. With this information, what should the nurse's response be? A) "Does your family know you are drinking every day?" B) "Does the tremor change when you drink the alcohol?" C) "We'll do some tests to see what is causing the tremor." D) "You really shouldn't drink so much alcohol; it may be causing your tremor."

B) "Does the tremor change when you drink the alcohol?"

11. The nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?

B) "It prevents distortion of bowel sounds that might occur after percussion and palpation."

20. The nurse knows that during an abdominal assessment, deep palpation is used to determine:

B) enlarged organs.

B) Difficulty performing familiar tasks, such as placing a telephone call C) Misplacing items, such as putting dish soap in the refrigerator E) Rapid mood swings, from calm to tears, for no apparent reason F) Getting lost in one's own neighborhood

The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment?

B) Examine the tender area last

B) Five minutes

The nurse is assessing a patient's ischial tuberosity. To palpate the ischial tuberosity, the nurse knows that it is best to have the patient:

B) Flex the hip

An imaginary line connecting the highest point on each iliac crest would cross the _____ vertebra.

B) Fourth lumbar

B) Increased intracranial pressure

The nurse is preparing to do a mental status examination. Which statement is true regarding the mental status examination? A) A patient's family is the best resource for information about the patient's coping skills. B) It is usually sufficient to gather mental status information during the health history interview. C) It takes an enormous amount of extra time to integrate the mental status examination into the health history interview. D) It is usually necessary to perform a complete mental status examination to get a good idea of the patient's level of functioning.

B) It is usually sufficient to gather mental status information during the health history interview.

B) Mild, even resistance to movement

During the neurologic assessment of a "healthy" 35-year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find? A) Firm, rigid resistance to movement B) Mild, even resistance to movement C) Hypotonic muscles as a result of total relaxation D) Slight pain with some directions of movement

B) Mild, even resistance to movement

B) Motor component of VII

A mother of a 1-month-old infant asks the nurse why it takes so long for infants to learn to roll over. The nurse knows that the reason for this is that:

B) Myelin is needed to conduct the impulses, and the neurons of a newborn are not yet myelinated.

The nurse would use bimanual palpation technique in which situation? A) Palpating the thorax of an infant B) Palpating the kidneys and uterus C) Assessing pulsations and vibrations D) Assessing the presence of tenderness and pain

B) Palpating the kidneys and uterus

A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition? A) Obturator test B) Test for Murphy's sign C) Assess for rebound tenderness D) Iliopsoas muscle test

B) Test for Murphy's sign

The nurse is assessing the abdomen of an aging adult. Which of these statements regarding the aging adult and abdominal assessment is true?

B) The abdominal musculature is thinner

23. The nurse is assessing the abdomen of an aging adult. Which of these statements regarding the aging adult and abdominal assessment is true?

B) The abdominal musculature is thinner.

12. The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds?

B) They are usually high-pitched, gurgling, irregular sounds.

The nurse is listening to bowel sounds. Which of these statements is true about bowel sounds?

B) They are usually high-pitched, gurgling, irregular sounds.

B) This is most likely the result of the summation effect.

During an examination, the nurse notices severe nystagmus in both eyes of a patient. Which of these conclusions by the nurse is correct?

B) This may indicate disease of the cerebellum or brainstem.

A woman who has had rheumatoid arthritis for years is starting to notice that her fingers are drifting to the side. The nurse knows that this condition is commonly referred to as:

B) Ulnar deviation.

The nurse is performing an eye assessment on an 80-year-old patient. Which of these findings is considered abnormal? A) A decrease in tear production B) Unequal pupillary constriction in response to light C) The presence of arcus senilis seen around the cornea D) Loss of the outer hair on the eyebrows due to a decrease in hair follicles

B) Unequal pupillary constriction in response to light

17. An older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related to:

B) decreased gastric acid secretion.

The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen's test. To perform this test, the nurse should instruct the patient to:

C) Hold both hands back to back while flexing the wrists 90 degrees for 60 seconds.

C) Dysfunction of the cerebellum

The nurse is explaining the mechanism of the growth of long bones to a mother of a toddler. Where does lengthening of the bones occur?

C) Epiphyses

During a health history, the patient tells the nurse, "I have pain all the time in my stomach. It's worse two hours after I eat, but it gets better if I eat again!" The nurse suspects that the patient has which condition, based on these symptoms?

C) Duodenal ulcer

An STD characterized by clusters of small, painful vesicles caused by a virus is: A. chancre. B. herpes genitalis. C. orchitis. D. cystitis.

B. herpes genitalis.

C) Herniated nucleus pulposus.

During an examination, the nurse can assess mental status by which activity? A) Examining the patient's electroencephalogram B) Observing the patient as he or she performs an IQ test C) Observing the patient and inferring health or dysfunction D) Examining the patient's response to a specific set of questions

C) Observing the patient and inferring health or dysfunction

C) Of sharp pain that increases with movement.

C) Olecranon bursitis.

C) Peripheral neuropathy

The area of the nervous system that is responsible for mediating reflexes is the:

C) Spinal cord

37. During an assessment the nurse notices that a patient's umbilicus is enlarged and everted. It is midline, and there is no change in skin color. The nurse recognizes that the patient may have which condition?

C) Umbilical hernia

During an assessment the nurse notices that a patient's umbilicus is enlarged and everted. It is midline, and there is no change in skin color. The nurse recognizes that the patient may have which condition?

C) Umbilical hernia

The nurse notices the presence of periorbital edema when performing an eye assessment on a 70-year-old patient. The nurse should: A) check for the presence of exophthalmos. B) suspect that the patient has hyperthyroidism. C) ask the patient if he or she has a history of heart failure. D) assess for blepharitis because this is often associated with periorbital edema.

C) ask the patient if he or she has a history of heart failure.

21. The nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would be:

C) gastrointestinal bleeding.

18. A patient is complaining of a sharp pain along the costovertebral angles. The nurse knows that this symptom is most often indicative of:

C) kidney inflammation.

The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient: A) will have no decrease in any of his abilities, including response time. B) will have difficulty on tests of remote memory because this typically decreases with age. C) may take a little longer to respond, but his general knowledge and abilities should not have declined. D) will have had a decrease in his response time because of language loss and a decrease in general knowledge.

C) may take a little longer to respond, but his general knowledge and abilities should not have declined.

9. While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are:

C) normal abdominal aortic pulsations.

While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are: A) pulsations of the renal arteries. B) pulsations of the inferior vena cava. C) normal abdominal aortic pulsations. D) increased peristalsis from a bowel obstruction.

C) normal abdominal aortic pulsations.

An eight-month-pregnant female client tells the nurse, "I am okay except I have a backache and I never had a backache before." Which of the following can the nurse instruct the client about this health concern? A. "This is a normal occurrence and nothing to worry about." B. "Back pain is often intensified during pregnancy in women who have a history of previous back pain." C. "As your baby has grown, your center of gravity has shifted, putting pressure on the lower spine." D. "Weakened abdominal muscles have caused your posture to change."

C. "As your baby has grown, your center of gravity has shifted, putting pressure on the lower spine."

A 70-year-old woman tells the nurse that every time she gets up in the morning or after she's been sitting she gets "really dizzy" and feels like she is going to fall over. The nurse's best response would be:

D) "You need to get up slowly when you've been lying or sitting."

Priapism is: A. a meatus opening on the dorsal side of the glans or shaft. B. an advanced and fixed foreskin too tight to retract over the glans. C. a prolonged, painful erection of the penis without sexual desire. D. a circumscribed collection of serous fluid in the tunica vaginalis surrounding the testes.

C. a prolonged, painful erection of the penis without sexual desire.

When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale?

D) 5

6. A 22-year-old man comes to the clinic for an examination after falling off his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation?

D) An enlarged spleen should not be palpated because it can rupture easily.

A 22-year-old man comes to the clinic for an examination after falling off of his motorcycle and landing on his left side on the handlebars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation?

D) An enlarged spleen should not be palpated because it can rupture easily.

During an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs with?

D) Ascites

During the history of a 78-year-old man, his wife states that he occasionally has problems with shortterm memory loss and confusion: "He can't even remember how to button his shirt." In doing the assessment of his sensory system, which action by the nurse is most appropriate?

D) Before testing, the nurse would assess the patient's mental status and ability to follow directions at this time.

When reviewing the musculoskeletal system, the nurse recalls that hematopoiesis takes place in the:

D) Bone marrow.

D) Chorea.

The nurse notices that a woman in an exercise class is unable to jump rope. The nurse knows that to jump rope, one's shoulder has to be capable of:

D) Circumduction

A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic examination?

D) Complete neurologic examination

The nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a __________ profile.

D) Concave

A 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of about 10 cm. The nurse should?

D) Consider this a normal finding and proceed with the examination.

The nurse is aware that one change that may occur in the GI system of an aging adult is?

D) Decreased gastric acid secretion

D) Decreased level of consciousness.

D) Dislocated shoulder.

The nurse is assessing a patient for possible peptic ulcer disease and knows that which condition often causes this problem?

D) Frequent use of non-steroidal anti-inflammatory drugs

35. The nurse is assessing a patient for possible peptic ulcer disease and knows that which condition often causes this problem?

D) Frequent use of nonsteroidal antiinflammatory drugs

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? A) Percuss and palpate in the lumbar region. B) Inspect and palpate in the epigastric region. C) Auscultate and percuss in the inguinal region. D) Percuss and palpate the midline area above the suprapubic bone.

D) Percuss and palpate the midline area above the suprapubic bone.

D) Positive Romberg sign.

A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as?

D) Protuberant

To detect diastasis recti, the nurse should have the patient perform which of these maneuvers?

D) Raise the head while remaining supine

25. To detect diastasis recti, the nurse should have the patient perform which of these maneuvers?

D) Raise the head while remaining supine.

2. Which structure is located in the left lower quadrant of the abdomen?

D) Sigmoid colon

Which structure is located in the left lower quadrant of the abdomen? A) Liver B) Duodenum C) Gallbladder D) Sigmoid colon

D) Sigmoid colon

D) Spastic hemiparesis

The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed? A) Avoid palpation of reported "tender" areas because this may cause the patient pain. B) Quickly palpate a tender area to avoid any discomfort that the patient may experience. C) Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths. D) Start with light palpation to detect surface characteristics and to accustom the patient to being touched.

D) Start with light palpation to detect surface characteristics and to accustom the patient to being touched.

The nurse has completed the musculoskeletal examination of a patient's knee and has found a positive bulge sign. The nurse interprets this finding to indicate:

D) Swelling from fluid in the suprapatellar pouch

D) positive Romberg sign.

7. A patient's abdomen is bulging and stretched in appearance. The nurse should describe this finding as:

D) protuberant.

The left kidney usually: A. can be felt easily. B. can only be felt when the person breathes deeply. C. is 1 cm lower than the right kidney. D. cannot be felt.

D. cannot be felt.

Mr. Yoder is a 49-year-old patient who comes to the clinic for a physical examination for his job. On examination, you perform a Phalen's test. This is used to assess for the presence of: A. elbow joint subluxation. B. wrist ROM. C. osteoporosis. D. carpal tunnel syndrome.

D. carpal tunnel syndrome.

The Landau reflex in the infant is seen when: A. the head is held and then flops forward as the baby is pulled to a sitting position by holding the wrists B. the toes curl down tightly in response to touch on the ball of the baby's foot C. the infant attempts to place his foot on the table while being held with the top of the foot touching the underside of the table D. the baby raises the head and arches the back, as in a swan dive

D. the baby raises the head and arches the back, as in a swan dive

Mild, even resistance to movement

During the neurologic assessment of a "healthy" 35 year-old patient, the nurse asks him to relax his muscles completely. The nurse then moves each extremity through full range of motion. Which of these results would the nurse expect to find?

Hidradenitis Suppurativa?

Sweat gland infection.

This stool would indicate anal patency.

The nurse is caring for a newborn infant. Thirty hours after birth, the infant passes a dark green meconium stool. The nurse recognizes that this is important because:

Level of consciousness, motor function, pupillary response, and vital signs

The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment?

Flexion and extension

The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)?

Hold both hands back to back while flexing the wrists 90 degrees for 60 seconds

The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen's test. To perform this test, the nurse should instruct the patient to:

Where are the most glands of the breast located?

The upper outer quadrant of the axilla. (Tail of Spence) Most common site of breast cancer.

The nurse documents which clinical finding as an abnormal finding in the assessment of an adult client?

There is a 1:3 anterior-posterior to transverse diameter ratio.

reinforcement

a technique to relax the muscle and enhance the response if a reflex response fails to appear. Ask the person to perform an isometric exercise then strike the tendon

tonsillolith

a tonsil stone or calculus which forms in rear of mouth in the crevasses of palatine tonsil. Made up of dead white blood cells, oral bacteria and profuse amounts of minerals in secretions

A 70 year old woman tells the nurse that every time she gets up in the morning or after she's been sitting she gets really dizzy and feels like she's going to fall over. The nurse should respond:

You need to get up slowly when you've been lying or sitting

The functional units of the musculoskeletal system are the: A) joints. B) bones. C) muscles. D) tendons.

The nurse is checking the range of motion in a patient's knee and knows that the knee is capable of which movement(s)? A) Flexion and extension B) Supination and pronation C) Circumduction D) Inversion and eversion

The nurse is examining a 6-month-old infant and places the infant's feet flat on the table and flexes his knees up. The nurse notes that the right knee is significantly lower than the left. Which of these statements is true of this finding? A) This is a positive Allis sign and suggests hip dislocation. B) The infant probably has a dislocated patella on the right. C) This is a normal finding for the Allis test for an infant of this age. D) The infant should return to the clinic in 2 weeks to see if this has changed.

The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal women. Which of these actions is the best way to prevent or delay bone loss in this group? A) Taking calcium and vitamin D supplements B) Taking medications to prevent osteoporosis C) Performing physical activity, such as fast walking D) Assessing bone density annually

A mother brings her newborn baby boy in for a checkup; she tells the nurse that he doesn't seem to be moving his right arm as much as his left and that he seems to have pain when she lifts him up under the arms. The nurse suspects a fractured clavicle and would observe for: A) a negative Allis test. B) a positive Ortolani's sign. C) limited range of motion during the Moro's reflex. D) limited range of motion during Lasègue's test

A patient is being assessed for range of joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called: A) flexion. B) abduction. C) adduction. D) extension.

The nurse is assessing a 1-week-old infant and is testing his muscle strength. The nurse lifts the infant with hands under the axillae and notices that the infant starts to "slip" between the hands. The nurse should: A) suspect a fractured clavicle. B) suspect that the infant may have a deformity of the spine. C) suspect that the infant may have weakness of the shoulder muscles. D) consider this a normal finding because the musculature of an infant this age is undeveloped.

The nurse is explaining the mechanism of the growth of long bones to a mother of a toddler. Where does lengthening of the bones occur? A) Bursa B) Calcaneus C) Epiphyses D) Tuberosities

The client tells the nurse, "At times I have drainage from my right breast." What should the nurse do with this information? a. Write it in the medical record and say nothing to the client. b. Phone for a mammogram for the client immediately. 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 14-year-old female client is upset because her breast development is not equal. What can the nurse say to this client? a. Don't worry about that! b. They look equal to me. c. Maybe you should talk with your mother about breast surgery? d. Breast tissue growth is uneven but will even out as you get older

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

General health questions for the breast/axilla focused interview include a description of the breasts, changes in the breasts with menstruation, and date of the last menstrual period. A 58-year-old client says to the nurse, "My saggy breasts embarrass me!" What can the nurse say to this client in response? a. Maybe you can have breast augmentation surgery? b. Wearing a good bra will help. c. Don't be silly. d. Breasts sag because of declining estrogen levels.

d. Breasts sag because of declining estrogen levels.

Rovsing Sign

inflammation secondary to appendicitis. Press deeply and evenly in the LLQ for 5 seconds. No pain should be present. Pain in RLQ is abnormal and positive.

The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? They are:

expected near the major airways.

A 62-year-old male states that his doctor told him that he has an "inguinal hernia." He asks you to explain what a hernia is. You:

explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.

spinal bifida

incomplete closure of the posterior part of the vertebrae results in a neural tube defect

During percussion, the nurse knows that a dull percussion note elicited over a lung lobe most likely results from:

increased density of lung tissue

Hyperactive bowel sounds

increased motility of the bowel and can result from gastroenteritis, diarrhea, laxative use, and subsiding ileus

Vaginal Speculum Exam

lubricate with water so that sample is not contaminated, insert two fingers first and then speculum vertically, putting pressure on the posterior vaginal wall

Kidney (Palpatation)

stand at right side. Place one hand on the right costovertebral angle on the back and the other hand below and parallel to the costal margin. As they take adeep breath press hands firmly together and try of feel the lower pole fo the kidney. At peak of inspiration press the fingers together with greater pressure from above than from below. Exhale and hold breath briefly. Release fingers and kidney has been captured. Note size shape, and consistency. Kidneys should not be palpable in the normal adult. Enlargment can be d/t hydronephrosis, neoplasms, or polycystic kidney disease.

why do you assess tenderness

tenderness occurs with local inflammation, could be inflammation of the peritoneum or underlying organ and with an organ whose capsule is stretched

ABCDE of skin assessment

•A: Asymmetry •B: Irregular Borders •C: changes in color •D: Diameter over 1/4in or 6mm •E: evolving/changing

FINAL FINAL FINAL

Set pelajaran terkait

Patient Safety 103: Human Factors and Safety

Exam 5 burns/emergency

TEAS practice test A

Chapter 17

psych 101 chapter 16 review questions

NU270 Quality Improvement

SCM Exam 2

ch 14

Module 10 - terms

Fundamental Practice A

Real Estate Finance: Chapter 12 The Secondary Mortgage Market

Solve Equations

CA Broker Exam V.4

Ch. 8

Cisco 1 Chapter 2 Exam

Survivors of abuse and violence Practice Q's/Child, partner, and elder abuse

OB/GYN Quiz Week 3

History Ch 1,2,3,4

Extrema and Derivative Theorems

PrepU - Exam 1