Nursing Health Assessment Ch 16 & 17

A patient tells the nurse that her stools have bright red blood in them. The nurse suspects which problem? 1. Gallbladder disease 2. Hemorrhoids 3. Rectal polyps 4. Upper intestinal bleeding

2. Hemorrhoids

Which finding does the nurse recognize as abnormal when examining a male patient? 1. Testes that are palpable and firm within the scrotal sac bilaterally 2. Discharge from the penis when the glans is compressed 3. Foreskin that lies loosely over the penis 4. Glans a light skin tone than the rest of penis

2. Discharge from the penis when the glans is compressed

A male patient indicates that he has sex with multiple partners and that he does not use protection. The most appropriate response is: "Are your partners using birth control?" "You should avoid sex until you are married." "How well do you know your partners?" "Many men use condoms to protect themselves from disease and pregnancy."

"Many men use condoms to protect themselves from disease and pregnancy."

A 58-year-old woman asks how often a mammogram is recommended. The best response by the examiner is: "every year." "every 3 years." "every 5 years." "every 3 to 5 years if you have a family history."

"every year."

A 22-year-old white male comes to the emergency department with a concern about a mass in his testicle. In addition to his age and race, which fact is a known risk factor for testicular cancer? 1. He had an undescended testicle at birth 2. His mother had breast cancer 3. He was treated for gonorrhea 18 months ago 4. He had hydrocele during infancy

1. He had an undescended testicle at birth

Which finding is expected during a rectal exam? 1. The rectal wall is smooth 2. Severe pain is reported when the finger is introduced through the anus 3. Hard stool is present in the rectum 4. The anus is surround by white flat lesions

1. The rectal wall is smooth

A patient has a herpes lesion on her vulva. While examining her, the nurse should take which measures? 1. wear examination gloves while in contact with the genitalia 2. place the patient in an isolation room 3. wash the genitalia with alcohol or providone-iodine (Betadine) before the examination 4. inspect the genitalia only; reschedule the patient for a full examination after the lesion had healed

1. wear examination gloves while in contact with the genitalia

While take the health history of a 23-year-old female patient, the nurse considers risk factors for STD. Which date from the patient suggest a need for patient education? 1. She has been in a monogamous sexual relationship for 2 years; she uses a condom to prevent pregnancy 2. She has been sexually involved with one man for the last 2 weeks; she uses spermicidal gal to prevent pregnancy. 3. She has a pap test each year and the results have been negative 4. She uses oral contraceptives to prevent pregnancy

2. She has been sexually involved with one man for the last 2 weeks; she uses spermicidal gal to prevent pregnancy.

During an examination the nurse palpates the Skene's glands. Which technique best describes the process? 1. Exerting pressure over the clitoris, slide the finger downward toward the vaginal opening 2. Palpate the fourchette and slide the finger forward toward the vaginal opening 3. Exert pressure on the anterior vaginal wall and slide the finger outward toward the vaginal opening 4. Grasp the labia majora between the index finger and thumb and milk the labia outward

3. Exert pressure on the anterior vaginal wall and slide the finger outward toward the vaginal opening

To inspect the glans penis of the uncircumcised male, the nurse retracts the foreskin. After inspection she is unable to replace the foreskin over the glans. The nurse recognizes that this situation could potentially lead to which complication? 1. Decreased sperm production 2. Urinary tract infection 3. Tissue necrosis 4. Testicular cancer

3. Tissue necrosis

The nurse recognizes which symptom as commonly associated with prostate enlargement? 1. Constipation 2. Rectal bleeding 3. Weak urinary stream 4. Penile discharge

3. Weak urinary stream

Which data collected from the history of a 32-year-old female patient should patient should be followed with a symptom analysis? 1. Has never had a mammogram 2. Experiences light to moderate bleeding during menstrual cycle 3. Periods began at age 12; has never been pregnant 4. Has pelvic pain and vaginal discharge

4. Has pelvic pain and vaginal discharge

The nurse assesses that an older male has gynecomastia. The nurse suspects which cause? A decrease in physical activity An increase in lactiferous duct glands Lymphatic engorgement A decrease in testosterone

A decrease in testosterone

What is candida vaginitis?

A fungal (yeast) infection

How are DCIS and LCIS diagnosed?

A mammogram

What type of nipple discharge would make the nurse suspect that the patient has an infection in the breast? A purulent discharge A bloody discharge A milky discharge A watery discharge

A purulent discharge

The nurse suspects that a male patient has syphilis. Which finding suggests this diagnosis? A syphilis lesion on the skin in the pubic hair A syphilis lesion on the shaft of the penis near the base A syphilis lesion on the glans penis A syphilis lesion on the underside of the scrotal sac

A syphilis lesion on the glans penis

Which finding is considered abnormal when conducting an examination on a 68-year-old woman? A. Dark pink areola B. Pendulous breasts C. Serous nipple drainage D. Granular texture

C. Serous nipple drainage

Which questions regarding reproductive function should the nurse ask a patient as part of the personal/social history related to the male genitalia? (Select all) A. Are you sexually active? B. How often do you ejaculate? C. How many children do you have? D. How many siblings do you have? E. Are you experiencing any pain when you ejaculate?

A. Are you sexually active? B. How often do you ejaculate? C. How many children do you have?

Which question should the nurse ask when obtaining a personal/social history from a breastfeeding patient? A. Do you drink alcohol? B. Have you had any pain? C. Do you have other children? D. Have you had breast enlargement?

A. Do you drink alcohol?

Which personal/social history question should the nurse ask an older woman to find out more about overall breast health? (Select all that apply) A. Do you drink alcohol? B. When did you menses end? C. Are you receiving hormonal therapy? D. Did you have a child after the age of 30? E. Have you had an abnormal mammogram?

A. Do you drink alcohol? C. Are you receiving hormonal therapy?

Which question regarding sexual behavior should the nurse ask a patient as part of the personal/social history related to the prostate? (select all) A. Do you have sex with other males B. Do you eat a diet high in animal fat C. How many children did your parents have D. Have you been diagnosed with erectile dysfunction in the past E. Do you have any symptoms of a sexually transmitted infections

A. Do you have sex with other males B. Do you eat a diet high in animal fat

Which personal/social history questions would the nurse ask a pregnant patient experiencing difficultly breastfeeding? (select all that apply) A. Do you use both breasts for feedings? B. Have you had multiple pregnancies? C. How much milk do you get when pumping? D. How long does your baby feed on each breast? E. Have you had a menstrual cycle since your baby was born?

A. Do you use both breasts for feedings? C. How much milk do you get when pumping? D. How long does your baby feed on each breast?

Which questions should the nurse ask regarding the character of the stool as part of the history of present illness related to the male genitalia and prostate? (Select all) A. Number B. Color C. Laxative use D. Consistency E. Presence of blood

A. Number B. Color D. Consistency E. Presence of blood

The nurse should ask a patient who is concerned with infertility about which lifestyle factors? (select all) A. Tight clothing B. Type exercise C. Prolonged sitting D. Extensive outdoor work E. Extended time in hot temperature

A. Tight clothing C. Prolonged sitting D. Extensive outdoor work E. Extended time in hot temperature

Which questions should the nurse ask a patient presenting with difficulty ejaculating as part of the history of present illness? (Select all) A. What color is the ejaculate B. Have you had a prolonged erection C. What medications do you take daily D. Do you have pain with urination E. Does the ejaculate typically have an odor

A. What color is the ejaculate C. What medications do you take daily E. Does the ejaculate typically have an odor

A 58-year-old man seeks treatment for "recent breast enlargement." On examination the nurse notes bilateral enlargement of the breast. Which question asked by the nurse is most appropriate based on this finding? A. What medications are you currently taking? B. Have you recently been lifting weights? C. Did your mother have large breasts? D. Have you every had cancer?

A. What medications are you currently taking?

Risk factors for Ovarian cancer

Family history Personal history BRCA1 and BRCA2 gene mutations PID and lynch syndrome Nulliparity Obesity Estrogen use Increasing age

What is the second most common STI?

Gonorrhea

Risk factors for cervical cancer

HPV infections Sex at an early age & multiple partners Suppressed immune system cigarette smoker multiple childbirths long-term oral contraceptive use

Risk factors for testicular cancer

Age 20-34 Cryptorchidism (undescended testicle at birth) Family history History of testicular cancer in other testicle Being white

Which questions should the nurse ask a patient regarding personal/social history related to the prostate? A. Do you perform testicular self-examination B. Are you vaccinated against HPV C. Have you been able to have children D. Have you traveled outside the U.S.

B. Are you vaccinated against HPV

A 19-year-old college student comes to the student health center because she discovered a small, nontender, firm, rubbery lump in her right breast. What is the most common cause of breast lumps in women her age? A. Breast cancer B. Fibroadenoma C. Ductal ectasia D. Breast abscess

B. Fibroadenoma

Which medical/surgical history questions would the nurse ask to determine a patient's risk factors for breast cancer? (Select all) A. Do you drink any alcohol? B. Have you ever had a biopsy of your breast? C. Have you every had radiation treatments on your chest? D. Have you been tested for BRCA1 or BRCA2 mutations? E. Has your mom been tested for BRCA1 or BRCA2?

B. Have you ever had a biopsy of your breast? C. Have you every had radiation treatments on your chest? D. Have you been tested for BRCA1 or BRCA2 mutations?

The nurse is reinforcing the need to perform breast self-examinations. Which statement regarding breast self-examination (BSE) is true? BSE is an effective method to prevent breast cancer. BSE reduces mortality rates associated with breast cancer. BSE is useful for the early detection of abnormalities of the breast. BSE is more sensitive than a mammogram in detection of a breast mass.

BSE is useful for the early detection of abnormalities of the breast.

What is ductal ectasia?

Benign breast disease with inflammation and dilation of one or multiple subareolar ducts

What is fibroadenoma?

Benign breast tumor that consists of glandular and fibrous tissue

S/S of intraductal papilloma?

Bloody discharge from nipple

What does Benign Breast Disease consist of?

Breast Pain Swelling Lumps Discharge Inflammation

Which follow-up questions would the nurse ask a female patient with a breast lump in order to gather information for the history of present illness? (Select all that apply) A. Have you had a history of breast cancer B. Has your mother had any breast lumps? C. Does the lump occur during your menses? D. Is there any dimpling around the breast lump? E. Have you had surgery on this breast in the past?

C. Does the lump occur during your menses? D. Is there any dimpling around the breast lump?

Which questions should the nurse ask regarding past medical/surgical history of male genitalia? A. How long have you experienced your symptoms? B. Does your father suffer from penile cancer? C. Have you been diagnosed with penile cancer? D. Do you have any pain associated with ejaculation? E. Do you engage in high-impact sport where there is danger pf penile trauma?

C. Have you been diagnosed with penile cancer?

Which questions should the nurse ask a patient who is concerned with infertility as part of the history of present illness? (select all) A. Have you ever had a vasectomy B. Do you often wear tight clothing C. How long have you been trying to conceive D.Which medications are you currently taking E. Did you parents have trouble conceiving

C. How long have you been trying to conceive D.Which medications are you currently taking

What is the reason for palpating axillary lymph nodes during a clinical breast examination> A. Axillary nodes fluctuate during the month in response to the menstrual cycle B. Axillary node tenderness is the most common initial symptom of breast cancer C. The lymph network in the breast primarily drains toward the axillary lymph nodes D. This is a matter of convenience because of the close proximity of the axillae to the breasts

C. The lymph network in the breast primarily drains toward the axillary lymph nodes

If a female patient has a breast lump, which question would provide information about a change in the lump? (Select all that apply) A. When was your last mammogram? B. Are you taking any new medications? C. Where did you first feel the lump? D. Was the lump hard or soft when you felt it? E. Is the lump larger than it was 2 days ago?

C. Where did you first feel the lump? D. Was the lump hard or soft when you felt it? E. Is the lump larger than it was 2 days ago?

What is the most common STI?

Chlamydia

The nurse is explaining the prostate exam to a male patient. The nurse explains that the ______________________ surface is palpated during the examination. anterior rectal surface anorectal junction anterior prostate surface deep external sphincter surface

anterior rectal surface

A 58-year-old woman has found a small lump in her breast. Which data from her history are risk factors for breast cancer? A. Her husband's mother died from breast cancer at age 43 B. She drinks a glass of wine each night with dinner C. Menarche occurred at age 14; menopause occurred at ager 46 D. She underwent radiation treatment for Hodgkin disease at age 17.

D. She underwent radiation treatment for Hodgkin disease at age 17.

Which statement is true regarding the examination of a patient who had a right-sided mastectomy 2 years ago? Swelling and small lumps at the mastectomy site are normal findings. Inspect the mastectomy scar, but do not palpate it because of pain. If a malignancy recurs, it may occur in the scar. There is no need to examine the right breast at all.

If a malignancy recurs, it may occur in the scar.

Risk factors for prostate cancer

Increasing age Being African American Family history High fat, dairy, and calcium intake Genetics

What is Mastitis?

Inflammation of the breast caused by a bacterial infection

Who is affected by Mastitis?

Lactating women

What does LMP stand for?

Last menstrual period (first day of your last menstrual period)

What is gynecomastia?

Male breast tissue enlargement

Which risks are associated with testicular cancer? (Select all that apply.) Multiple sex partners Men age 60 and over Men age 20 to 34 Family history of testicular cancer Cryptorchidism Caucasian men

Men age 20 to 34 Family history of testicular cancer Cryptorchidism Caucasian men

The nurse knows that these are risk factors for breast cancer. (Select all that apply.) Menarche at age 14 Menopause after age 50 Giving birth to a first child at age 38 A first-degree relative with breast cancer Menopause at age 48

Menopause after age 50 Giving birth to a first child at age 38 A first-degree relative with breast cancer

The nurse assesses small raised bumps observed on the nipples of a patient. These are known as: Montgomery's tubercles. Cooper's ligaments. lactiferous ducts. lymph nodes

Montgomery's tubercles.

What does Gravida mean?

Number of pregnancies

What does para mean?

Number of pregnancies that reached 20 weeks or more

The nurse believes a male patient has a sexually transmitted disease. Which symptom is commonly associated with STDs? Penile discharge Difficulty maintaining an erection Difficulty initiating a urine stream A heavy feeling in the scrotum

Penile discharge

When gathering history about breasts and axillae, the nurse should ask about?

Previous breast disease Menstrual history Medications Menopause Pregnancy Radiation Surgery Family history

The nurse is preparing the patient for an axilla exam. Before the nurse palpates the axilla, it is ideal to place the patient in which position? Sitting with her hands over her head Sitting with her arms at her sides Supine with her arms on her hips Lateral with her arms at her sides

Sitting with her arms at her sides

What is intraductal papilloma?

Small, benign, wartlike tumor in major ducts usually within the areolar edge.

S/S of ductal ectasia?

Sticky dark green or black nipple discharge Burn/itching edema of areolar

The nurse is assessing the risks of colorectal cancer for a group of patients. Which patient has a known risk factor for colorectal cancer? Steven, a 21-year-old college student who is a vegetarian Marie, a 22-year-old mother who has multiple hemorrhoids Susan, a 38-year-old female with a 15-year history of ulcerative colitis Jack, a 40-year-old man with frequent constipation

Susan, a 38-year-old female with a 15-year history of ulcerative colitis

What is Thelarche?

The development of breasts in preadolescence

What is invasive malignancy?

The most common breast cancer

What causes infant's to have enlarged breasts?

The mother's hormones

The nurse observes a supernumerary nipple on a newborn. What significance does this have? This infant has a significant risk for breast cancer. This infant may have infertility problems later in life. This infant will develop three breasts at puberty. This is considered a normal variation.

This is considered a normal variation.

True or False. Does the amount of caffeine or chocolate consumed increase fibrocystic changes in the breast?

True

True or False. Postmenopausal women are at a higher risk for developing breast cancer as they age

True

True or False? Onset of menarche before 11 is a risk factor for endometrial cancer?

True

True or False? Women who have endometriosis are at an increased risk for ovarian cancer

True

What ages are affected by intraductal papilloma?

Women from 40-60

The nurse explains that a Pap test involves the provider taking a sample of: vaginal discharge. endocervical cells. cervical tissue. uterine tissue.

endocervical cells.

What is Lobular Carcinoma in Situ (LCIS)?

a risk factor for development of breast cancer

S/S of PID?

fever chills abnormal vaginal discharge can cause infertility

What is pelvic inflammatory disease (PID)?

caused by untreated gonococcal and chlamydia infections

The nurse is counseling an adolescent on preventing sexually transmitted diseases (STDs). The patient understands this when he states, "The most common STD in the United States is___________________." gonorrhea syphilis chlamydia trichomoniasis

chlamydia

S/S of epididymitis?

dull, unilateral scrotal pain Scrotal erythema and edema fever dysuria hydrocele seen with transillumination

The nurse is teaching patient BSE and emphasizes the need to check________, where tumors are commonly found. around the nipple and areola in the lower third of the breast in the upper and lower inner (medial) quadrants in the upper outer quadrant and the tail of Spence

in the upper outer quadrant and the tail of Spence

What is Galactorrhea?

inappropriate lactation caused by endocrine-related disorders, systemic disease, or side effects of medications

What is Epididymitis?

inflammation of the epididymis and vas deferens caused by STIs

What is Ductal Carcinoma in Situ (DCIS)?

precursor to invasive ductal carcinoma

The patient tells the nurse that she has clay-colored stools. Stool of this color results from: intestinal tract bleeding. lack of bile pigment. excessive dietary beef. insufficient fluid intake.

lack of bile pigment.

The nurse is reading a report from the patient's chart and sees a note stating the prostate is hard and irregular. The nurse suspects: prostate cancer. benign prostate hypertrophy (BPH). prostatitis. rectal cancer.

prostate cancer.

S/S of invasive malignancy?

solitary, unilateral, non-tender lump or mass serosanguineous or clear nipple discharge Crusting around nipple Palpable lymph nodes in axilla inverted nipples

What is menarche?

start of menstruation