test 4

Which questions should the nurse include when counseling a client about minimizing modifiable risk factors for breast cancer? Select all that apply.

"Are you aware that alcohol use increases the risk of breast cancer?" "Do you engage in some form of regular exercise?" "What type of menopausal hormone therapy (MRT) are you taking?"

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

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

The nurse is assessing the neurologic system of an adult client. To test the client's use of memory to learn new information, the nurse should ask the client

"can you repeat brown, chair, textbook, tomato?"

When the nurse is assessing a client's mental status as part of the neurological examination, which question would be most appropriate to ask?

"can you tell me where you are right now?"

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

"do you experience mood swings or bloating"

A middle-aged female tells the nurse that she is concerned because her breasts are not as firm as they used to be. What is an appropriate response by the nurse?

"firmness of the breasts decrease with lower estrogen levels"

while conducting a breast health history, a patient states that there is -nothing to say about the breasts and then makes a comment about not realizing that it would take so many months for the milk to stop flowing in the breasts after having a baby. what should the nurse respond to the patient*

"in which breast does this occur"

A patient is concerned about a right breast lump. what can the nurse ask the patient to assess associated manifestations of this mass* (select all that apply.)

"is there pain with the lump" "is there any discharge from the lump" "are you menstruating when the lump is present"

The client tells the nurse that she has benign breast disease and so she is not worried about any lumps or nodules in her breasts. How would the nurse best respond?

"it is important to performm self breast examinations as there could be changes or additional lumps in your breasts that would need further examination

The parents of a newborn appear anxious and express concern upon seeing the pediatrician palpate and gently express a small amount of whitish, milk-like liquid from the baby's nipples. What is the nurse's best response?

"nothing is wrong with your baby. this liquid will clear up spontaneously"

A 17-year-old male client expresses concern about feeling lumps on his testicles. What response by the nurse would best address the client's concerns?

"the normal testicle contains internal structures that cause lumps on the surface"

A 57-year-old woman calls the clinic reporting painful intercourse followed by spotting. She tells the nurse that she hasn't had a period in 2 years. What should the nurse tell her?

"these findingins are common in postmenopausal women"

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

"walk accross the room and back"

The client tells the nurse "I am so glad I had a mastectomy and I will never have breast cancer again." How should the nurse best respond?

"we need to continue to perform examination, breast cancer can reoccur

during the health history of the nervous system' a patient tells the nurse about being diagnosed with grand mal seizures. What should the nurse ask the patient to determine characteristic symptoms of the seizures?

"what occurs after the seizure"

which statement by the nurse would be most appropriate for a woman who seems tense and is wringing her hands prior to having a clinical breast exam performed?

"you seem to be anxious. tell me what you are thinking"

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

'if no other signs or symptoms, it is likely a result of normal ovulation"

What care should a nurse take when using a speculum to assess a client's cervix? Select all that apply.

-Encourage the client to take deep breaths and keep her feet in the stirrups -Choose the instrument that is the correct size for the client -Insert the speculum at a 45-degree angle downward

What care should a nurse take when performing the hands-on assessment of the anus, rectum, and prostate? Select all that apply.

-Explain each step of the examination and encourage the client to relax -Use gentle movements with the finger and ensure adequate lubrication -Listen and watch for signs of discomfort and tensing muscles

A nurse assesses a 30-year-old client who has never had a Pap test. Which factors should the nurse explain to the client are a risk for cervical cancer? Select all that apply.

-diet low in fruits -multiple pregnancies -history of chlamydia infection

Prostate cancer is the leading cancer diagnosed in men in the United States. To increase knowledge of risk factors, the nurse would teach men that (Select all that apply.)

-each decade after age 50 increases the risk -it occurs earlier and is more advanced in African American men -15% have an affected first-degree relative

How many pairs of cranial nerves and how many pairs of spinal nerves are found in the peripheral nervous system?

12 cranial 31 spinal

While testing the patient's muscle strength, the nurse finds that the patient can flex the arms when no resistance is applied but is unable to flex when the nurse applies light resistance. The nurse should documents the patient's muscle strength as level a. 1. b. 2. c. 3. d. 4.

3

A 35-year-old client tells the nurse that she is concerned that she may be already starting menopause. The nurse should explain that the normal range of years for menopause to occur is which of the following?

40-58 years old

When should a woman conduct self breast examination with respect to her menses?

5-7 days

A patient recovering from a stroke has no eye or verbal response and withdraws from painful stimuli. how would the nurse score these responses using the glasgow coma Scale?

6

Which client should a nurse recognize has the highest risk to develop prostate cancer?

65-year-old Caucasian male whose father had prostate cancer at age 55

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

8

When counseling an older patient about ways to prevent fractures, which information will the nurse include?

Buying shoes that provide good support and are comfortable to wear is recommended.

during assessment of the musculoskeletal system of a 74yearold woman, the nurse notes that the paent has lost 1 inch in height since the previous visit two years ago. %he nurse will plan to teach the paent abou

DEXA

cremasteric reflex

Lumbar 1, 2

plantar responses

Lumbar 5, Sacral 1

anal reflex

Sacral 2, 3, 4

what are the two tests for the 5th cranial nerve

TMJ jaw clench and sensation of the skin the head

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

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

Which client would the nurse identify as being at highest risk for the development of testicular cancer?

a 25 year old man with a history of cryptorchidism

A patient being prepared for a nervous system examination is observed sitting quietly; however' the thumb and index finger of the left hand are moving in a circular motion. the nurse identifies this hand activity as being

a resting tremor

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

a sign of early prostate cancer

when the health care provider tells a paent that the pain in the paent's knee is caused by bursitis, the paent asks the nurse to explain just what bursitis is. %he nurse's best response would be to tell the paent bursitis is an infammation of

a small fluid filled sac found at many joints

A male patient tells the nurse about experiencing problems with urination. what should the nurse assess in this patient? (Select all that apply.)

a) The number of times the patient voids during the day b) if there is any blood or semen in the urine c) if there is any difficulty starting the urine stream d) if there is any pain at the base of the penis

Cutaneous stimulation reflexes

abdominal-upper, lower, cremasteric, plantar, anal

cn 6

abducens, lateral deviation of the eye, motor

Following an amputation, the advantage to the client for an immediate prosthesis fitting is:

ability to ambulate sooner

What should the nurse assess to test the function of the occipital lobe?

ability to read

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

absence of symmetry of the inguinal areas w straining

A female client presents to the clinic with chills and fever for 3 days. She also complains of sores in her genital region. The nurse should prepare to give which instructions to this client?

abstinence should be practiced while sores are weeping

cn 8

acoustic, hearing and balance, sensory

After teaching the client about risk factors for rheumatoid arthritis, which of the following,if stated by the client as a risk factor, would indicate to the nurse that the client needs additional teaching?

adults between the ages of 60-75 years

When evaluating the crutch-walking technique of a patient with a right-leg long-leg cast and no weight bearing on the right leg, the nurse determines that the patient is prepared to ambulate independently with the crutches on observing that the patient

advances the right leg and both crutches together and then advances the left leg

What ethnic group has a significantly higher incidence rate of prostate cancer?

african americans

The nurse is preparing an instructional session for male clients about preventing penile cancer. Which non-modifiable risk factor should the nurse include in the teaching?

age 60 years or older

A patient has an injury that affects the posterior sensory nerve columns of the spinal cord.What will the nurse most likely assess in this patient? (Select all that apply.)

alteration in the perception of position changes in the perception of vibration

which client should the nurse assess for possible primary amenorrhea

an 18 year old who has never started menses

deep tendon reflexes

ankle (achilles), knee (patellar), supinatory (brachioradialis), biceps, triceps

there are four axillary nodes, what are they

anterior, posterior, lateral, central

the nurse asks the patient to sit with the arms at both sides when beginning the clinical breast examination. with this position the nurse will assess: (select all that apply)

appearance of the skin size and symmetry of the breasts characteristics of the nipples contour of the breasts

Which information will the nurse include when teaching range-of-motion exercises to a patient with an exacerbation of rheumatoid arthritis?

application of cold packs before exercise may decrease joint pain

how do you test cn 7

ask for facial expressions

A nurse is testing a client's corneal reflex but notices that the reflex appears to be reduced. The client is otherwise alert and oriented with no signs of neurological degeneration. What is an appropriate action by the nurse?

ask the client about the presence of a contact lense

The nurse is assessing the neurologic system of an adult client. To test the client's motor function of the facial nerve, the nurse should

ask the client to purse their lips

Following the application of a hip spica cast for a patient with a fracture of the proximal third of the left femur, an appropriate nursing intervention is to

ask the patient about any abdominal discomfort or nausea

While working at a summer camp, the nurse notices a circular lesion with a red border and clear center on the arm of a patient who is in the camp clinic complaining of chills and muscle aches. Which action should the nurse take next?

ask the patient about recent outdoor activities

A nurse is preparing to assess the cranial nerves of a client. The nurse is about to test cranial nerve I. Which of the following would the nurse do?

ask the patient to identify scents

A client who recently received breast implants asks for recommendations on performing breast self-examination (BSE). Which of the following should the nurse mention? Select all that apply.

ask the surgeon to help her distinguish the implant from the breast tissue press firmly inward at the edges of the breast implants to feel the ribs beneath

The nurse has completed a Glasgow Coma Scale assessment and assigns the client a score of three. Which is the best way for the nurse to assess pain in this client?

assess for nonverbal signs

A 27-year-old female client complains of amenorrhea and severe right-sided pelvic pain. What is the nurse's priority action?

assess the clients vital signs

A patient who has rheumatoid arthritis is seen in the outpatient clinic and the nurse notes that rheumatoid nodules are present on the patient's elbows. Which action will the nurse take?

assess the nodules for skin breakdown and infection

When getting a patient from the bed into the chair for the first time since having an ORIF of a hip fracture, the nurse should

assist the patient to use a walker with partial weight bearing to assist in transfer to the chair

The nurse instructs the client to lean forward so she can inspect the breasts. What might this position reveal that is not visible in another position?

asymmetry of the breast or nipple

A client has been ordered a physical examination of the genitalia. Which information should a nurse give a client scheduled for her first Pap test to improve the accuracy of the test?

avoid douching 48 hours before the examination

An adult woman presents at the clinic with a grayish vaginal discharge. What should the nurse suspect?

bacterial vaginosis

A nurse is preparing to assess a client's cerebellar function. Which of the following would the nurse expect to test?

balance

A client is visiting the health care facility for follow-up care for a stroke. Today he has increased muscle tone, some involuntary movements, an abnormal gait, and a slowness of response in movements. He most likely has involvement of which of the following?

basal ganglia

During assessment of the inguinal regions for herniating masses, the nurse instructs the standing male client do which of the following?

bear down

The nurse is planning to inspect the anal area of an adult female client. To assess for any bulges or lesions, the nurse should ask the client to

bear down

A 72-year-old male presents at a local clinic and states: "I have to urinate all the time, and I never feel like my bladder is emptied. It really bothers me at night." What condition might the nurse suspect related to this chief complaint?

benign prostatic hyperplasia

A patient has undergone a digital rectal examination. This assessment will allow the clinician to diagnose which of the following?

benign prostatic hyperplasia

Which population should be the primary target for breast cancer screening?

black women over the age of 60

The nurse suspects that a male client may have a hernia. The nurse should further assess the client for

bowel sounds at the buldge

While palpating a client's nipples, the nurse notes a clear discharge from one breast. This unilateral discharge could best be explained by which of the following? Select all that apply.

cancer of the breast fibrocystic disease benign intraductal papiloma

Which type of yeast infection is manifested by white, cottage cheese-like discharge?

candidiasis

The nurse working in the emergency department is assessing an intoxicated driver involved in a motor vehicle crash when the client insists on ambulating to the bathroom. The nurse escorts the client and calls for help while anticipating which abnormal gait in this client that places him at risk for falls?

cerebellar ataxia

While assessing the neurologic system of a confused older adult, the nurse observes that the client is unable to recall past events. The nurse suspects that the client may be exhibiting signs of

cerebral cortex disorder

biceps reflex

cervical 5, 6

supinator (brachioradialis) reflex

cervical 5,6

triceps reflex

cervical 6, 7

When examining the genitalia of a client, a nurse observes cauliflower-like growth on the client's cervix. The nurse recognizes this finding as indicative of what condition?

cervical cancer

the nurse is explaining a pap smear to a client, the nurse would include information about being obtained from which area

cervix

After falling down the basement steps in his house, a client is brought to the emergency room. His physician confirms that his leg is fractured. Following application of a leg cast, the nurse will first check the client's toes for:

change in color

Following a motor-vehicle accident, a patient arrives in the emergency department with massive right lower-leg swelling. Which action will the nurse take first?

check leg pulses and sensaiton

A patient is admitted to the emergency department with possible fractures of the bones of the left lower extremity. The initial action by the nurse should be to

check the popliteal, dorsalis pedis, and posterior tibial pulses.

The nurse is separating the labia of a female patient during a reproductive physical examination. The structures that the nurse will inspect include' (select all that apply.)

clitoris urethral meatus vaginal opening labia minora

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

clockwise then counterclockwise

If there is a drooping eye lid on your patient what cranial nerve is most likely damaged?

cn 3, 4, 6`

what is the function of the frontal lobe

communication, emotions, intellect, reasoning, behavior, judgement

A patient in the emergency department is diagnosed with a patellar dislocation. The initial patient teaching by the nurse will focus on the need for

conscious sedation

The nurse is examining the breast of a clinic client and palpates a lump. What would the nurse be sure to document about this lump? Select all that apply.

consistency distinctness mobility

A 35-year-old client has a Pap test with a normal test result. The client has had two previous tests with normal results. Which information is correct for the nurse tell this client with regard to future screening for cervical cancer?

continue exams every 2-3 years

what are the functions of the medulla oblongata

controls respiratory rate, heart rate and force and blood pressure.

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

cryptochidism

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

cryptochidism

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

cystocele

Which of the following is a downward displacement of the bladder toward the vaginal orifice?

cystocele

A client with fracture develops compartment syndrome. When caring for the client, the nurse would be alert for which of the following signs of possible organ failure?

dark, scanty urine

When assessing deep tendon reflexes in an elderly client what finding would the nurse anticipate?

decreased reaction time

During an admission assessment, the nurse notes that the client has diabetes with peripheral neuropathy. What finding would the nurse expect to find?

decreased sensation in the feet

An older adult client visits the clinic complaining of urinary incontinence. The nurse should explain to the client that this is often due to

decreased urethral elasticity

The nurse performing an admission assessment on an older adult. What would be an expected finding?

decreased vision

A client visits the clinic and tells the nurse that he has not been feeling very well. The nurse observes that the client's speech is slow, the client has a disheveled appearance, and he maintains poor eye contact with the nurse. The nurse should further assess the client for

depression

A client sustains an injury to the brain stem. What is the most important assessment parameter that the nurse should perform for this client?

depth of respiration

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

detect cervical cancer

Which of the following are types of diabetic neuropathies? (Select all that apply.)

diabetic amyotrophy autonomic dysfunction monoeuritis multiplex

A client has a disorder of the hypothalamus. The nurse recognizes that this structure is found in which area of the brain?

diencephalon

Which of the following would the nurse expect to be done to assess the size of the prostate?

digital rectal exam

An elderly client has sustained intertrochanteric fracture of the hip and has just returnedfrom surgery where a nail plate was inserted for internal fixation. The client has been instructed that she should not flex her hip. The best explanation of why this movement would be harmful is:

displacement can occur with flexion

A client has had a recent mastectomy and visits the clinic for postoperative evaluation. The client tells the nurse that she has been depressed and feels as if she is less of a woman. The most appropriate nursing diagnosis for this client is

disturbed body image related to mastectomy

An older woman had a left total hip arthroplasty yesterday afternoon mom which precautions will the nurse teach before helping the client transfer from the bed to the chair? (Select all)

do not hyper flex your hips when sitting avoid twisting your body when moving use your cane to help move into the chair

the nurse is assessing the passive range of motion of a patent's shoulder. the patient complains of pain during circumduction when the nurse moves the arm behind the patient. which question should the nurse ask

do you have difficulty putting on a jacket

The nurse is present during a pelvic examination of a female client. The healthcare provider states that the multiparous client has several small nodules at the cervix that look like yellow pustules. The nurse should prepare for which action?

document the findings

The nurse performs a neurological assessment and determines the Glasgow Coma Scale (GCS) score is 15. What is the nurse's best action?

document the findings

All of the following symptoms are potential indicators of testicular disorders except:

dull ache in the lower abdomen

A nurse is conducting a health history with a client who has recently had a stroke. The nurse notes the client has slurred speech, although language is intact. Which disorder of speech is the nurse observing in this client?

dysarthria

Nursing students are doing a class presentation on stroke. What is the term they would use for deficits in speech articulation?

dysarthria

On a visit to the clinic, a client reports the onset of early symptoms of rheumatoidarthritis. Which of the following would be the nurse most likely to asses:

early morning stiffness

An adolescent male client is diagnosed with testicular torsion. The nurse should prepare the client for which treatment?

emergency surgery

What assessment findings would be expected for a woman that is 3 months pregnant? Select all that apply.

enlarged breast darkened nipples nodular feeling breasts

8. To prevent foot drop in a client with Buck's traction, the nurse should:

ensure proper body positioning

While reviewing the medical record before examining a male clinic patient, the nurse notes that the urinary meatus is located on the top of the glans of the penis. The nurse understands the correct term for this congenital defect is

epispadias

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

estrogen

Which of the following statements is true of prostate cancer?

ethnicity is a risk factor

How often should you get your breasts examined by a doctor?

every three years for women the ages of 20-39

what if you are over 40 years old, how often should you have a mammogram

every year

A nurse is planning care for a client who has been diagnosed with restless leg syndrome. Which intervention is the most effective for temporary relief of the symptoms?

exercising the legs

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

external hemorrhoid

cn 3, 4, 6

extraocular movements

cn 7

facial movements, sensory and motor

During assessment, the nurse notes the client has limited movement of his lower extremities and sways when standing with feet together. The nurse identifies that the client is at risk for what?

falls

The nurse practitioner is examining a client and notes an axillary lymph node approximately 1.5 cm in size, tender, and movable. The nurse practitioner also notes an erythematous 3-cm abrasion on the client's upper arm. The client tells the nurse practitioner that she fell in the garden while fertilizing her plants. What nursing diagnosis would the nurse practitioner include in the plan of care?

fear related to possible diagnosis of breast cancer

A male in college presents to the health clinic with complaints of fever, malaise, and swelling of the sides of the neck. A blood test confirms the presence of mumps. The nurse should educate the client to report which changes of his genitalia to the health care provider?

feelings of heaviness and pain in the scrotum

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

femoral

if benign lumps are present what are they called

fibrocystic breast disease

Which characteristic would support the determination that a client is at high risk for breast cancer?

first degree relative with a history of either BRCA1 or BRCA2 mutation

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

flow may include clots

Based on the nurse's understanding of the physiology of bone and carlage, the injury that the nurse would expect to heal most rapidly is a

fracture of the midhumerus

A client presents to the health care clinic with reports of black stool. The client denies the ingestion of iron supplements or taking Pepto-Bismol. The nurse recognizes that the black stools could be an indication of what disease process?

gastrointestinal bleeding

female breasts consists of three types of tissue

glandular, fibrous, fatty (adipose)

The visible portion of the clitoris is termed the

glans

The cranial nerve that has sensory fibers for taste and fibers that result in the "gag reflex" is the

glossopharyngeal

cn 9

glossopharyngeal, motor-pharynx sensory-posterior portion of the eardrum, ear canal, pharynx, posterior portion of the tongue for salty, sweet, sour, and bitter, both

A male client is complaining of pain with urination, rectal pain and urethral discharge. The nurse suspects this is what?

gonorrhea

A patient hospitalized with multiple fractures has a long-arm plaster cast applied for immobilization of a fractured left radius. Until the cast has completely dried, the nurse should

handle the cast with the palms of the hands

During assessment of an adult client, which of the following lifestyle practices would indicate to the nurse that the client may be at high risk for HIV/AIDS? A client who

has anal intercourse with other males

A patient with a comminuted fracture of the right femur has Buck's traction in place while waiting for surgery. To assess for pressure areas on the patient's back and sacral area and to provide skin care, the nurse should

have the patient lift the buttocks by bending and pushing with the left leg

The nurse has discussed the risks for breast cancer with a group of high school seniors. The nurse determines that one of the students needs further instructions when the student says that one risk factor is

having a baby before the age of 20

a nurse assesses a 22 year old client who has never had a pap test. which factor should the nurse explain to the client as being a risk factor for cervical cancer

having multiple sexual partners

An ambulance brings an older adult client to the ED. The client's daughter found the client on the floor of the house; the client is almost unresponsive. It is unknown how long the client was on the floor. When performing an acute assessment on the client, which of the following may the health care team omit?

health history

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

hemorrhoids

A male client has a distinctive bulge in the right inguinal area when standing. What should the nurse suspect is occurring with this client?

hernia

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

herpes infection

the prenatal patient presents to the clinic with complains of flu like symptoms, the nurse notes scattered vesicles on the labia and inguinal lymphadenopathy. what condition does the nurse suspect the patient has

herpes simplex type 2

When assessing the breast and lymphatics of the axillae, where would the nurse locate the central axillary nodes?

high in the axillae at the top of the ribs

A 68-year-old man comes to the clinic reporting that he is having difficulty obtaining an erection. When reviewing the patient's history what might the nurse note that contributes to impotence?

history of hypertension

cn 12

hypoglossal, tongue symmetry and position

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

hypospadias

Which part of the brain regulates water balance, appetite, vital signs, sleep cycles , pain perception and emotional status?

hypothalamus

A patient has a short-arm plaster cast applied at the outpatient center for a wrist fracture. An understanding of discharge teaching is apparent when the patient says,

i can apply an ice pack to the cast over the fracture site for the 24 hours

What should the nurse assess to test the function of the temporal lobe?

impulses from the ear

A nurse assesses a client who presents to the health care clinic with suspected Bell's palsy. What finding should the nurse anticipate on examination?

inability to wrinkle forehead

A nurse is reviewing a client's health record while interviewing her. The nurse sees in the patient's record a score of 3+ on the biceps reflex test from her previous visit. The nurse understands that this finding indicates which of the following?

increased or brisk, but not pathologic

A nurse inspects the genitalia of an elderly client and notices the mucosa is dry and atrophied. The nurse should educate the client about her increased risk of what condition?

infection

While assessing the cervix of an adult client, the nurse observes a yellowish discharge from the cervix. The nurse should further assess the client for a/an

infection

The nurse assesses the motor system as part of the full neurological examination. In order to effectively assess this system, which of the following instructions should be given to the client?

instruct the client to flex and extend the right elbow

1.During the examination of the breasts, a young adult patient's nipples becomes erect and the areolas pucker. The nurse explains to the patient that these findings indicate

intact tactile stimualtion of the area

A nurse is performing a test of cranial nerve XII (hypoglossal) on an elderly client. When the client protrudes her tongue for the test, the tongue moves in and out uncontrollably. Which of the following should the nurse most suspect?

interior tremor

what is dystonia

involuntary / sustained muscle movements that cause twisting and repeat movements

Which characteristics are present in a cancerous breast lesion? Select all that apply.

irregular in shape usually nontender may cause retraction of the nipple

Describe some of the characteristics of a malignant tumor in the breast?

irregular/poorly delineated border, hard and nontender, fixed to underlying tissue

A patient with a fractured radius asks when the cast can be removed. The nurse will instruct the patient that the cast can be removed only after the bone

is strong enought to stand mild stress

An adolescent is brought to the clinic by her mother because of abnormal uterine bleeding. What should the nurse explain about this bleeding?

it is common in adolescents and woman approaching menopause

The nurse instructs a female client on breast self-examination. Why does the nurse recommend the pattern shown for the client to use? (going up and down in vertical strips)

it is the best technique to detect masses

After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse interprets these findings as indicating which of the following?

joint dislocation

What is the level of the spinal cord associated with the knee (patellar) deep tendon reflex?

l2 to l4

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

labia minora

what is the name for the opening of the nipple

lactiferous ducts

posterior columns

large neurons and heavily myelinated axons, peripheral large fiber projection of the dorsal root that transmit sensation of vibration, proprioception, kinesthesia, pressure, and fine touch from skin and joint position receptors

The nurse is instructing a patient on conducting breast self-examination. What should the nurse include in these instructions? (Select all that apply.)

lie down and place one arm behind the head use the finger pads of the three middle fingers of the hand

When examining the breasts of a client, the nurse finds a collection of fatty tissue that appears as a lump. The nurse knows that this is which of the following conditions?

lipoma

Which position is it most logical for the nurse to place the female client in for the anus and rectum examination?

lithotomy

When completing the history and physical examination of a client diagnosed with osteoarthritis, which of the following would the nurse assess

local joint pain

when assessing an adolescent female the nurse documents tanners stage 2 of maturation in the health record, which assessment finding best describe tanners stage 2

long, slightly pigmented, downy hair that is straight or only slighly curled along the labia

Your patient is noted to have thickening of the skin and unusually prominent pores on her right breast. What might you suspect?

lymphatic obstruction

A patient asks $hat can be done to reduce the risk of developing breast cancer. what should the nurse instruct this patient* (select all that apply.

maintain a normal body weight limit alcohol use

A recently retracted nipple that was previously everted suggests what?

malignancy (maybe a tumor)

A client presents to the health care clinic with a 3-day history of fever, chills, neck pain and stiffness, and headache. The nurse observes an elevated temperature of 102.5°F and pain with rotation of the head side to the side and decreased ability to flex the head forward. The nurse recognizes these findings as most likely the onset of what infectious process?

meningitis

During the reproductive system health history, a patient tells the nurse about having excessive menstrual flow. The nurse would document this information as'

menorhagia polymenorrhea-intervals fewer than 21 days oligomenorrhea-infrequent bleeding metrorrhagia-intermenstrual bleeding

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

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

What three parts make up the brain stem

midbrain, pons, medulla oblongata

What if the patient has some prominent venous patterns on her breasts?

might indicate a malignancy causing increased circulation

the nurse asks a patient to flex and extend the right elbow as part of which screening neurologic examination?

motor system

What task should a nurse ask a client to perform to assess the function of cranial nerve XII?

move tongue from side to side

a nurse is performing a musculoskeletal assessment on an older adult. what physiologic changes of aging with the nurse expect (select all)

muscle atrophy, slowed movement

The nurse is concerned that a client who had an open reduction, internal fixation of his tibia and fibula is at risk for complex regional pain syndrome. What assessment findings at the affected area are common when a client has this complication? (select all)

muscle spasms skin discoloration paresis edema

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

nabothian cysts

.A patient has had two breast biopsies within 10 years. both of these biopsies were to drain cysts. The nurse should instruct the patient that these procedures will have which impact on the future development of breast cancer*

no increased risk

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

nocturia

A nurse recognizes that which finding is normal upon palpation of the prostate?

nontender and rubbery

The nurse identifies a cheesy white material that has accumulated under a male patients foreskin of the penis. what does this finding suggest to the nurse

normal finding of smegma

A patient with comminuted fractures of the tibia and fibula is treated with open reduction and application of an external fixator. The next day, the patient complains of severe pain in the leg, which is unrelieved by ordered analgesics. The patient's toes are pink, but the patient complains of numbness and tingling. The most appropriate action by the nurse is to

notify the patient health care provider

The nurse is performing teaching on breast health at a community center. The nurse would identify what risk factors related to breast cancer? Select all that apply.

obesity and physical inactivity

when assessing the musculoskeletal system the nurses intitial action will usually be to

observe the patients body build and muscle configuration

When working with a patient whose job involves many hours of word processing, the nurse will teach the patient about the need to

obtain a keyboard pad to support the wrist while word processing

Palpation of a male client's urethra produces a yellowish-white discharge. What is the nurse's best action?

obtain a sample of discharge for culture

cn 3

oculomotor

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

offers permanent birth control

At the completion of a reproductive health history, a female patient tells the nurse about having pain with penetration during intercourse. what should the nurse assess at this time+ (select all that apply.)

onset of problem severity of the problem what makes it better or worse

What are some more medications involved with clear discharge?

oral contraceptives, phenothiazines, steroids, diuretics

Which of the following unexpected findings of the testes is most likely to result in painful palpation of the testes?

orchitis

fter falling at home, a patient is admitted to the emergency department, where x-rays confirm the presence of an extracapsular fracture of the femur. When assessing the patient, the nurse would expect to find

outward pointing toes on the left leg

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

ovarian cyst

The nurse is testing for Brudzinski's sign in a newly admitted client. What would indicate meningeal inflammation?

pain and flexion of the hips and knees

When testing sensory function of the trigeminal nerve (CN V), which of the following sensations would the nurse assess?

pain and light touch

Which finding will the nurse expect when assessing a 60-year-old patient who has osteoarthritis (OA) of the left knee?

pain upon joint movement

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

palpable and tortuous veins

During palpation of the male genitalia, which of the following is an expected finding?

palpable spermatic cord

A nurse is examining the breasts of a woman who has had a mastectomy. Which of the following should the nurse do?

palpate the scar for redness, lesions, lumps, swelling, or tenderness

After completing the physical examination of the genitalia for an uncircumcised client, the nurse observes that the foreskin is too tight to be returned to cover the glans of the penis. How should the nurse document this condition?

paraphimosis

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

pediculosis pubis

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

persistent hpv infection

Included in the subjective assessment of the breast are the client's statements about what? (Mark all that apply.)

personal history surgeries nipple changes

An uncircumcised, 78 year-old male has presented at the clinic complaining that he cannot retract his foreskin over his glans. On examination it is noted that the foreskin is very constricted. What is this condition called?

phimosis

The nurse is repositioning the client who has returned to the nursing unit following internal fixation of a fractured right hip. The nurse uses a:

pillow to keep the right leg abducted during turning

A nurse inspects the cervix of a 33-year-old, nonpregnant client during a routine assessment. Which coloration of the cervix would indicate normal health in this client?

pink red=inflamed

A patient with a fractured pelvis is initially treated with bed rest with no turning from side to side permitted. The second day after admission, the patient develops chest pain, tachypnea, and tachycardia. The nurse determines that the patient's symptoms are most likely related to fat embolism when assessment of the patient reveals

pinpoint red areas of the upper chest

While assessing the anus of an adult client, the nurse detects the presence of small nodules. The nurse should refer the client to a physician for possible

polyps

When developing the teaching plan for the client with rheumatoid arthritis to promote rest, which of the following would the nurse expect to instruct the client to avoid during the rest periods?

positions of flexion

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

prepuce

ankle relfex

primarily sacral 1

The nurse notes that a client has a small red papule that is clean, smooth, and glistening on the penis. What should the nurse suspect is causing this lesion?

primary syphilis

at puberty, the female breasts enlarge in response to estrogen and

progesterone

A patient with severe osteoarthritis of the left knee has undergone left-knee arthroplasty with replacement of the total knee joint with a plastic prosthesis. Postoperatively, the nurse expects care of the leg to include

progressive leg exercises to obtain 90-degree flexion.

A nurse is assisting a healthcare provider perform a digital rectal examination of a 65-year-old African American client. This test, along with the PSA blood test is used as an early detection of what disease?

prostate cancer

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

prostate cancer

During assessment of an elderly male client, the client tells the nurse that he has had difficulty urinating for the past few weeks. The nurse should refer the client to the physician for possible

prostate enlargement

Mr. Jackson, 50 years old, has had discomfort between his scrotum and anus. He also has had some fevers and dysuria. Rectal examination is halted by tenderness anteriorly, but no frank mass is palpable. What is the most likely diagnosis?

prostatitis

cn 2, 3

pupillary retraction

What instruction should the nurse provide to a client to assess for dimpling or retraction of breast tissue?

raise the arm over head

What is fasciculation?

rapid twitching of resting muscles, seen in lower motor neuron disease or fatigue

when assessing the axillae of the patient during the breast examination, the nurse should:

reach high towards the apex of the axilla

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

receives the fertilized ovum and provides housing and nourishment for the fetus

The major rationale for the use of acetylsalicylic acid (aspirin) in the treatment of rheumatoid arthritis is to

reduce the inflammation of the joints

A male client tells the nurse that he has received a diagnosis of hernia. He visits the clinic because he is nauseated and has extreme tenderness on the left side. The nurse should

refer the client to an emergency room

What functions are attributed to sensory impulses? (Select all that apply.)

regulation of internal autonomic functions body position in space conscious sensation

A checkout clerk in a grocery store has muscle and tendon tears that have become inflamed, causing pain and weakness in the left hand and elbow. The nurse identifies these symptoms as related to

repetitive strain injury

The nurse is preparing to care for a patient who has myasthenia gravis. The nurse will be alert to symptoms affecting which body system in this patient?

respiratory system and facial muscles

What if the breast takes on a pigskin-like orange-peel appearance what does this mean?

results from edema, peau d'orange

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

retroverted

A patients patellar reflex is normal for the right side but diminished on the left. how will the nurse document this finding

right knee +2; left knee +1

A patient hospitalized with polymyositis has joint pain, an erythematosus facial rash with eyelid edema, and a weak, hoarse voice. The priority nursing diagnosis for the patient is

risk for aspiration related to dysphagia

In developing a care plan for a patient with an open reduction and internal fixation (ORIF) of an open, displaced fracture of the tibia, the priority nursing diagnosis is

risk for infection related to disruption of skin integrity

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

risk of urge incontinence

During the physical examination, a nurse palpates the breasts of a client for masses. The nurse knows that if the client has benign breast disease, masses with which characteristics will be present? (Select all that apply.)

rubbery and mobile well-demarcated borders

While inspecting a client's vagina, the nurse notes transverse folds in the outer layer of pink squamous epithelium. These folds are known as which of the following?

rugae

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

scrotal

a client is 1 day postoperative after a total hip replacement. the client should be placed in which of the following positions

semi fowlers

A client says that an object placed in the hand is a pair of scissors when the object is a paper clip. Which aspect of the client's neurologic system should the nurse identify as being compromised?

sensory

To best secure accurate assessment information, the nurse should complete which part of the reproductive history last?

sexual

during the inspection of a patients reproductive system, the nurse identifies small lacerations and bruises of the labia majora and minora. what does this finding suggest to the nurse+

sexual abuse

A female client tells the nurse that she has pain while urinating. Besides obtaining a urinalysis, the nurse should assess the client for

sexually transmitted disease

Which of the following would the nurse assess in a client with an intracapsular hipfracture?

shortening of the affected leg

What task should a nurse ask a client to perform to assess the function of cranial nerve XI?

shrug shoulders against resistance

During a physical examination, the nurse inspects the eternal genitalia of a male client. Which of the following would the nurse identify as an abnormality?

skin lesions

A nurse is examining the breasts of a 75-year-old woman. Which of the following are normal findings in the breasts of an older adult?

smaller, flatter nipples nipples that are less erectile on stimulation pendulous breasts

cn 1

smell, sensory

The nurse is planning a presentation to a group of adults on the topic of strokes. Which of the following should the nurse plan to include in the teaching plan?

smoking and high cholesterol are risk factors for stroke

What information would the nurse include when educating a client concerning magnetic resonance imaging (MRI) as a screening for breast cancer?

specificity is such that false positive readings can occur

cn 11

spinal accessory-the sternomastoid and upper portion of the trapezius ie shoulder and neck movements-motor

Where do the cell bodies of the lower motor neurons lie?

spinal cord

Sensations of temperature, pain, and crude and light touch are carried by way of the

spinothalamic tract

The nurse is preparing to perform the Romberg test on an adult male client. The nurse should instruct the client to

stand erect with arms at the sides and feet together

A nurse is instructing a client who has recently experienced a transient ischemic attack (TIA) on warning signs of a stroke that the client should be aware of in case they occur and she needs to call 911. Which of the following should the nurse mention? Select all that apply.

sudden: numbness or weakness of the face confusion, trouble speaking or understanding speech trouble seeing in one or both eyes trouble walking, dizziness, loss of balance or coordination severe headache w no known cause

When caring for a patient with a new diagnosis of rheumatoid arthritis, which action will the nurse include in the plan of care?

suggest that the patient take a nap in the afternoon

When palpating the internal female genitalia, the nurse separates the client's labia and asks her to strain down to assess which of the following?

support of the vaginal walls

the testes in the male scrotum are

suspended by the spermatic cord

cn 9, 10

swallowing and rise of the palate, gag reflex

while conducting a complete bed bath for a male patient, the nurse inspects the scrotum for' (select all that apply.)

swelling lumps veins

When the individual walks with a spastic hemiparesis gait, what does it look like?

swinging a single foot in a semi circle movement

A nurse is preparing to offer a community education session on anxiety. Which part of the nervous system should the nurse include in the discussion?

sympathetic nervous system

A nurse is working with a client who is victim of a gun shooting. The client has an increased pulse rate and pupil dilation and is clearly in stress. The nurse recognizes the "fight-or-flight" response in this client and understands that this represents an activation of which of the following?

sympathetic nervous system

during a physical examination of a female patients reproductive system, the nurse detects a thick white discharge from the labia. The patients vulva appears inflamed. how should the nurse document this finding+

symptoms of candidal vaginitis

What should the nurse assess to test the function of the parietal lobe?

tactile stimulation

A female client with rheumatoid arthritis has been on aspirin grain TID and prednisone 10mg BID for the last two years. The most important assessment question for the nurse to ask related to the client's drug therapy is whether she ha

tarry stools

A 35-year-old patient with three school-age children who has recently been diagnosed with rheumatoid arthritis (RA) tells the nurse that the inability to be involved in many family activities is causing stress at home. Which response by the nurse is most appropriate?

tell me more about the situations that are causing stress

The nurse observes the client's pupils as shown.Which is one dilated the other normal. What should the nurse suspect is occuring with the client?

temporal lobe herniation

The diencephalon of the brain consists of the

thalamus and hypothalamus

when taking a paent history during assessment of the musculoskeletal system, the nurse iden0es an increased risk for the paent who reports

that a parent became much shorter with aging

A client presents in the emergency department after falling from a roof. A fracture of the femoral neck is suspected. Which of these assessments best support this diagnosis.

the affected extremity is shortened. adducted, and externally rotated

When admitting a client with a fractured extremity, the nurse would focus the assessment on which of the following first?

the area distal to the fracture

The health care provider initially orders bed rest for a patient with an open-book pelvic fracture. Which assessment data obtained by the nurse are most important to report to the health care provider?

the bowel tones are absent

After a nervous system examination' the nurse determines that patient is at risk for a stroke. What should the nurse instruct the patient at this time? (Select all that apply.)

the importance of smoking cessation taking prescribed antihypertensive medication the warning signs of a stroke control blood glucose levels in diabetes

A 57-year-old woman has come to the OB/GYN clinic for her annual physical. She tells the nurse that it has been 14 months since her last period. What should the nurse further assess?

the patient is postmenopausal

Motor impulses are conducted to the muscles by two descending neural pathways, what are they?

the pyramidal (corticospinal tract) and the extrapyramidal tract

Sensory impulses travel to the brain by way of two ascending neural pathways, what are they?

the spinothalamic tract and the posterior columns

When assessing the plantar reflex, what is a positive Babinski response?

the toes will fan out

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

the woman has been pregnant three times and has delivered two live children

Lymph nodes are present in both male and female breasts, what function do they serve?

these structures drain lymph from the breasts to filter out microorganisms and return water and protein to the blood

what is an accurate description of scaling?

think flakes of keratinized epithelium

abdominal reflex lower

thoracic 10, 11, 12

Abdominal upper reflex

thoracic 8, 9, 10

An adult male client comes to the clinic for his annual physical examination. During the nursing assessment, the nurse asks, "Do you have any current or chronic illnesses such as diabetes, hypertension, respiratory problems, or cardiovascular disease?" Why does the nurse ask this question?

to assess risk for erectile dysfunction

A 24-year-old delivers a healthy female infant. Incidentally, the patient had used diethylstilbestrol (DES) during her pregnancy. It is important that the nurse stress frequent gynecological examinations of patient's daughter when she reaches a certain age due to which of the following?

to prevent the onset of vaginal carcinoma in the patients daughter

The nurse is planning to test position sensation in an adult female client. To perform this procedure, the nurse should ask the client to close her eyes while the nurse moves the client's

toes up or down

A nurse is preparing a client for a Pap smear. The nurse knows that the area where 90% of the neoplasms of the lower genital track originate and the area from which cells will be obtained for the Pap smear is which of the following?

transformational zone

The client with an above the knee amputation is to use crutches until the prosthesis is being adjusted. In which of the following exercises would the nurse instruct the client to best prepare him for using crutches?

triceps stretching exercises

An older patient with a change in mental status is clenching the jaw closed to avoid taking a prescribed oral medication. the patient is demonstrating the motor function of which cranial nerve?

trigeminal

The nurse is admitting a client new to the clinic who states, "My face feels funny." When the nurse assesses the client she finds isolated facial sensory loss to pain and no neurologic deficits in his extremities. What diagnosis would the nurse expect for this client?

trigeminal neuralgia

cn 5

trigeminal, corneal relexes, facial sensation, jaw movements sensory and motor

cn 4

trochlear-downward, internal rotation of the eye-motor

After assessing the breasts of a female client, the nurse should explain to the client that most breast tumors occur in the

upper outer quadrant

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

urethritis

following x-rays of an injured wrist, the patient is informed that it is badly sprained. In teaching the patient to care for the injury, the nurse tells the patient to

use pillows to keep the arm elevated above the heart

Which action by a nurse demonstrates the correct technique to use the reflex hammer?

use rapid wrist movement and strike the tendon

cn 10

vagus, motor-palate, pharynx, larynx sensory-pharynx and larynx both

The nurse is caring for a 17-year-old girl who is 16 weeks pregnant. The patient's history shows infection with multiple STIs. What should the nurse do?

verify that prior STIs were treated according to protocol

when conducting the clinical breast examination of a patient, the pattern that nurse should folow would be:

vertical strip

The skin folds of the labia majora and the labia minora form a boat-shaped area termed the

vestibule

during an assessment of the cranial nerves' a patient tells the nurse of not being able to taste sweet or salty foods. the nurse should focus additional assessment on which cranial nerve?

vii (seven-facial)

the nurse is preparing to assess a patients cranial nerves using a screening neurologic examination. what will be included in this assessesment (select all that applY)

visual acuity eye movements hearing facial strength

cn 2

visual acuity, visual fields, ocular fundi sensory

cn 5, 7, 10, 12

voice and speech

A patient is seen at the urgent care center after falling on the right arm and shoulder. It will be most important for the nurse to determine

whether the right arm is shorter than the left

A patient with an intracapsular fracture of the left femur is placed in Buck's traction before surgery for a hip replacement. The patient asks why traction is necessary when surgery is planned. The nurse's response to the patient is based on the knowledge that traction

will decrease the incidence of painful muscle spasms

Which assessment procedure should a nurse institute to test a client for stereognosis?

with eyes closed, ask the client to identify a familiar object that is placed in their hand

A patient arrives in the emergency department with ankle swelling and severe pain after twisting the ankle playing soccer. All of the following orders are written by the health care provider. Which one will the nurse act on first?

wrap the ankle and apply an ice pack

A 20-year-old baseball pitcher has an arthroscopic repair of a rotator cuff injury performed in same-day surgery. When the nurse plans postoperative teaching for the patient, which information will be included?

you have an app with a physical therapist tomorrow

A patient with lower-leg fractures has an external fixation device in place and is scheduled for discharge. Which information will the nurse include in the discharge teaching?

you will need to assess and clean the pin insertion sites daily