Test 4 questions

The prenatal client presents to the clinic with complaints of flu-like symptoms. The nurse notes scattered vesicles on the labia and inguinal lymphadenopathy. What condition does the nurse suspect the client has? Condyloma acuminatum Gonorrhea Herpes simplex type 2 Trichomoniasis

Herpes simplex type 2

A woman who has undergone a total hysterectomy asks a nurse about follow-up pap smears. Which statement by the nurse is correct? a. "Cervical screening is not necessary once a total hysterectomy is performed" b. "If you had 3 or more pap smears that were normal, you can stop the screening" c. "If you are still sexually active, a pap smear is recommended every 5 years" d. "You should continue to have pap smears every 2-3 years"

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

A nurse is providing care to a 1-year-old female client. The parents ask the nurse about having female circumcision performed, saying that it is a part of their culture. What is the best response of the nurse? a. "Female circumcision is against the law in the United state." b. "I will check with my supervisor" c. "You will have to travel to another country for that procedure" d. "Let me ask the health care provider."

a. "Female circumcision is against the law in the United state."

Which of the following male clients is most in need of immediate medical treatment? a. A 15-year-old boy who has been brought in by his mother for assessment of his severely painful testes that are retracted upward b. A 22-year-old student who has presented with a cluster of painful lesions on the shaft of his penis c, A 30-year-old who presents with palpable nodules in his left testis d. A 70-year-old retiree whose intestines are palpable in his scrotum

a. A 15-year-old boy who has been brought in by his mother for assessment of his severely painful testes that are retracted upward

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

a. Bartholin's gland infection

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? a. Continue exams every 2-3 years b, Length of time between exams can be lengthened to every 5 years c. Option to stop screening can be considered d. Because of the client's age exams should be done every year

a. Continue exams every 2-3 years

A 70-year-old retired auto mechanic comes to the office because his neighbor is concerned about the client's memory. The client admits to misplacing his keys more often and forgetting what he is supposed to buy from the grocery store and where he has parked the car. He denies getting lost in familiar places. Upon further questioning, he states that his wife of 40 years died 8 months ago; his three children live in three different provinces; and he has limited his activities because the people he interacted with were "his wife's friends, not his." He drinks a six-pack of beer daily; he does not smoke or use illicit drugs. The nurse performs a mini-mental state examination and obtains a total score of 24 out of 28. Based on this information, what is the most likely diagnosis? a. Depression b. Meningitis c. Dementia d. Benign forgetfulness

a. Depression

A son brings his 80-year-old father into the clinic. The son is concerned because he feels as if his father is growing weak, losing interest in things he used to care about, and no longer coming to dinner on Sundays. The nurse would know that the father is at risk for what? a. Depression b. Decreased mobility c. Malnutrition d. Dementia

a. Depression

A client visits the clinic because she has missed one period and suspects she is pregnant. While assessing the client, the nurse detects a solid, mobile, tender, unilateral adnexal mass. The client's cervix is soft. The nurse suspects that the client may be experiencing a. Ectopic pregnancy b. Endometriosis c. Normal pregnancy d. Pelvic inflammatory

a. Ectopic pregnancy

What type of assessment would the nurse perform when assessing pain after medicating? a. Focused b. Urgent c. Shift d. Comprehensive

a. Focused

During a client's genitourinary exam, the nurse notes that the client's scrotum is enlarged and easily transilluminates. What should the nurse suspect? a. Hydrocele b. Tumor c. Varicocele d. Hernia

a. Hydrocele

When collecting a specimen from the cervix for cytology, the nurse does which of the following? a. Label glass slides and treats them immediately with fixative b. Use water-soluble lubricate to ease insertion of the speculum c. Collect specimen from the endocervix, ectocervix and lateral fornices d. Presses firmly on a glass slides with the applicator end

a. Label glass slides and treats them immediately with fixative

A nurse observes a thick, white, cheesy discharge at the vaginal opening, with irritation and swelling of the labia. The nurse recognizes this finding as most likely indicating what type vaginal infection? a. Moniliasis b. Chlamydia c. Vaginosis d. Trichomoniasis

a. Moniliasis

When testing sensory function of the trigeminal nerve (CN V), which of the following sensations would the nurse assess? a. Pain and light touch b. Dull touch and vibration c. Proprioception and extinction d. Vibration and stereognosis

a. Pain and light touch

An older adult client has received a diagnosis of stress incontinence, and the nurse is planning the client's subsequent care. What health education is most relevant to this client's needs? a. Pelvic floor strength training and activity management b. Appropriate use of incontinence pads and dietary modifications c. Aseptic technique for intermittent catheterization and fluid restriction d. Management of fluid and electrolyte intake

a. Pelvic floor strength training and activity management

A 41-year-old real estate agent comes to the office saying that he feels like his face is paralyzed on the left. He states that last week he felt his left eyelid was drowsy; as the day progressed he could not close his eyelid all the way. Later he felt like his smile became affected also. He denies any recent injuries but had an upper respiratory viral infection last month. Past medical history is unremarkable. He is divorced with one child. He smokes one pack of cigarettes a day, occasionally drinks alcohol, and denies any illegal drug use. His mother has high blood pressure and his father has sarcoidosis. On examination the nurse asks the client to close his eyes. He cannot close his left eye. The nurse asks him to open his eyes and raise his eyebrows. His right forehead furrows but his left remains flat. The nurse then asks the client to give a big smile. The right corner of his mouth raises but the left side of his mouth remains the same. What type of facial paralysis does he have? a. Peripheral CN VII paralysis b. Central CN VII paralysis

a. Peripheral CN VII paralysis

A 20-year-old comatose high school student arrives at the emergency room. His friends have accompanied him and report that they have been shooting up heroin tonight and think their friend may have had too much. The client is unconscious and cannot protect his airway so he is intubated. His heart rate is 60 and he is breathing through the ventilator. He is not posturing and he does not respond to a sternal rub. On neurological examination with a penlight, what type of pupils is the examiner likely to see in this comatose client? a. Pinpoint b. Large c. Irregularly shaped d. Asymmetrical

a. Pinpoint

The nurse is doing a neurologic screening examination. The nurse should include some aspect of which areas? Select all that apply. a. Reflexes b. Cranial nerves c. Motor system d. Sensory system e. Cardiovascular system f. Mental status

a. Reflexes b. Cranial nerves c. Motor system d. Sensory system f. Mental status

A 77-year-old retired school superintendent comes to the office with a report of unsteady hands. He says that for the past 6 months when his hands are resting in his lap they shake uncontrollably. He says that when he holds them out in front of his body or uses his hands, the shaking improves. He also complains of some difficulty getting up out of his chair and walking around. He denies any recent illnesses or injuries. His past medical history is significant for high blood pressure and coronary artery disease, requiring a stent in the past. He has been married for more than 50 years and has five children and 12 grandchildren. He denies any tobacco, alcohol, or drug use. His mother died of a stroke in her 70s and his father died of a heart attack in his 60s. He has a younger sister with arthritis. His children are all essentially healthy. Examination reveals a fine pill-rolling tremor of his left hand. His right shows less movement. His cranial nerve examination is normal. He has some difficulty rising from his chair, his gait is slow, and it takes him time to turn around to walk back towards the examiner. He has almost no "arm swing" with his gait. What type of tremor is most likely? a. Resting b. Intention c. Postural

a. Resting

A client's patellar reflex is normal for the right side but diminished on the left. Using the scale for grading reflexes, how should the nurse document this finding? a. Right knee +2; Left knee +1 b. Right knee +4; Left knee +3 c. Right knee +3; Left knee +2 d. Right knee +1; Left knee 0

a. Right knee +2; Left knee +1

A client is admitted to the health care facility with new onset of right-sided paralysis, slurred speech, and lethargy. A nurse obtains in the history that the client has uncontrolled hypertension and smokes 2 packs of cigarettes a day. Which nursing diagnosis is priority for the client upon admission? a. Risk for Aspiration b. Impaired Verbal Communication c. Unilateral Neglect d. Risk for Altered Skin Integrity

a. Risk for Aspiration

While performing a neurological assessment on a 56-year-old male, the nurse identifies the client may be experiencing a stroke. What symptoms would the nurse identified? Select all that apply. a. Slurred speech b. Impaired vision c. Difficulty following instructions d. Orientation x 3 e. Hypotension

a. Slurred speech b. Impaired vision c. Difficulty following instructions

The nurse is providing discharge teaching to a client who underwent a hip fracture repair. The nurse should instruct the client to report which findings that indicate surgical site infection? (Select all that apply.) a. Surgical site warm to touch b. Redness over hip area c. Pain at incision site d. Tenderness at incision site e. Diffuse hives over body

a. Surgical site warm to touch b. Redness over hip area c. Pain at incision site d. Tenderness at incision site

A nurse performs an integrated head-to-toe assessment on a client who is admitted with exacerbation of heart failure. What signs and symptoms would the nurse expect? Select all that apply. a. Swelling of lower extremities b. Weight gain c. Green, yellow sputum d. SOB e. Expiratory wheezing

a. Swelling of lower extremities b. Weight gain d. SOB

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? a. The client is postmenopausal. b. The client has possibly developed cervical cancer. c. The client is premenopausal. d. The client is perimenopausal.

a. The client is postmenopausal.

A female client tells the nurse that she may be experiencing premenstrual syndrome. An appropriate question for the nurse to ask the client is a. "Are you experiencing regular menstrual cycles?" b. "Do you experience mood swings or bloating?" c. "How old were you when you began to menstruate?" d. "How often are your menstrual periods?"

b. "Do you experience mood swings or bloating?"

Which of the following male clients is most in need of immediate medical treatment? a. A 22-year-old student who has presented with a cluster of painful lesions on the shaft of his penis b. A 15-year-old boy who has been brought in by his mother for assessment of his severely painful testes that are retracted upward c. A 30-year-old who presents with palpable nodules in his left testis d. A 70-year-old retiree whose intestines are palpable in his scrotum

b. A 15-year-old boy who has been brought in by his mother for assessment of his severely painful testes that are retracted upward

An elderly client is complaining of weakness and fatigue. The nurse suspects the client may be experiencing what? a. Signs of cancer b. Anemia c. Normal aging process d. Depression

b. Anemia

The nurse is examining a client who has an exacerbation of hip pain when in a sitting position. Which body system can the nurse examine with the client lying down? a. Spinal motion b. Anterior thorax c. Balance d. Posterior thorax

b. Anterior thorax

When integrating the total physical examination the nurse should a. Assess cranial nerve I (olfactory) with the other 11 cranial nerves at the same time. b. Assess peripheral vascular status when examining the lower extremities. c. Perform the Mental Status Exam after examining all other body systems. d. Integrate the rectal examination with the abdominal examination.

b. Assess peripheral vascular status when examining the lower extremities.

The nurse is palpating the prostate of a 55-year-old client and finds it to be enlarged, smooth, firm, and slightly elastic, without a median sulcus. Which condition should the nurse most suspect? a. Acute prostatitis b. Benign prostatic hypertrophy c. Prostate cancer d. Hydrocele

b. Benign prostatic hypertrophy

The nurse notes thick white secretions, erythema, and excoriation of the vulvovaginal area of a client who complains of pruritus and dyspareunia. Which condition does the nurse suspect the client has? a. Pediculosis b. Candidiasis c. Trichomoniasis d. Gonorrhea

b. Candidiasis

A 28-year-old married clothing sales clerk comes to the clinic for her annual examination. She requests a refill on her birth control pills. Her only complaint is painless bleeding after intercourse. She denies any other symptoms. Her past medical history consists of two spontaneous vaginal births. Her past six Pap smears have all been normal. She is married with two children. Her mother is in good health, and her father has high blood pressure. Examination shows a young woman appearing healthy and relaxed. Her vital signs are unremarkable, and her head, eyes, ears, throat, neck, cardiac, lung, and abdominal examinations are normal. Visualization of the perineum shows no lesions or masses. Speculum examination shows a red mass at the os. On taking a Pap smear the mass bleeds easily. Bimanual examination shows no cervical motion tenderness. Both ovaries are palpated and nontender. What is the most likely diagnosis related to the abnormality of her cervix? a. Carcinoma of the cervix b. Cervical polyp c. Retention cyst d. Mucopurulent cervicitis

b. Cervical polyp

The nurse notes that it takes an older client 45 seconds to complete the "get up and go" test. Which activities of daily living should the nurse plan to assist the client with completing? Select all that apply. a. Using the telephone b. Climbing stairs c. Getting in and out of bed d. Managing finances e. Bathing

b. Climbing stairs c. Getting in and out of bed e. Bathing

When assessing a client's coordination by asking the client to touch the nose with the finger, what should a nurse keep in mind about a client's movements? a. Uncoordinated movements can be expected in the elderly b. Dominant side will be more coordinated than nondominant side c. Most clients will hesitate before touching the nose to check their position d. As the client repeats the maneuver, movements will be less accurate

b. Dominant side will be more coordinated than nondominant side

A nurse performs a neurologic examination on a client who sustained an injury to the spinal cord. What finding should the nurse expect when stroking the bottom of the client's feet? a. Flexion of the toes b. Dorsiflexion of the great toe and fanning of all toes c. Dorsiflexion of the foot d. Plantar flexion

b. Dorsiflexion of the great toe and fanning of all toes

A client complains of scrotal pain, and the nurse elicits a positive Prehn sign. The nurse would refer the client for treatment of what condition? a. Scrotal mass b. Epididymitis c. Tortuous varicocele d. Strangulated hernia

b. Epididymitis

Some symptoms are common in elderly clients. Which of the following is less likely to be a common problem in old age? a. Confusion. b. Fever. c. Falls. d. Weakness.

b. Fever.

A 68-year-old man comes to the clinic reporting that he is having difficulty obtaining an erection. When reviewing the client's history what might the nurse note that contributes to impotence? a. Use of multivitamins b. History of hypertension c. Past history of infection d. Lack of exercise

b. History of hypertension

A nurse assesses a client for pupillary response of the eyes and finds a unilateral dilated pupil that is unresponsive to light or accommodation. The nurse recognizes that which cranial nerve is responsible for the damage of pupillary response? a. V b. III c. I d. II

b. III

During assessment of the vaginal area of an adult client, the client tells the nurse that she has had pain in her vaginal area. The nurse should further assess the client for a. Cancer b. Infection c. Trauma d. Pregnancy

b. Infection

During the assessment of a female client, which physical examination techniques should the nurse use to assess the vagina? a. Transillumination b. Inspection c. Deep palpation d. Light palpation

b. Inspection

A nurse is assessing the risk factors of the male reproductive system in a client. Of the following questions, which are pertinent in assessing the risk factors? Select all that apply. a. Is there a family history of genital warts? b. Is there infertility in siblings? c. Is there a history of penile cancer in your family? d. Do you have any current or chronic illnesses such as diabetes or hypertension? e. Is there a history of hernia in your family? f. Is there a family history of testicular torsion?

b. Is there infertility in siblings? c. Is there a history of penile cancer in your family? d. Do you have any current or chronic illnesses such as diabetes or hypertension? e. Is there a history of hernia in your family?

The nurse is interviewing an 82-year-old client who is accompanied by her daughter. The daughter states that her mother is "unable to hold her urine," and the client attests that this is true. What question should the nurse prioritize when assessing the client's urinary incontinence? a. Have you been prone to urinary tract infections in the past? b. Is this something that has begun to happen just recently? c. Have you noticed any change in your bowel function? d. Did you deliver your children vaginally or by cesarean section?

b. Is this something that has begun to happen just recently?

A nurse is working with an 88-year-old client who has developed stress incontinence. In this case, as in all cases, the nurse should understand that which of the following is the key to recognizing pathology and illness in the very old? a. Knowing the client's family history b. Knowing the person's baseline functional status and recognizing deviations from it c. Knowing the client's mental status d. Knowing the statistical occurrence of the condition among people the same age

b. Knowing the person's baseline functional status and recognizing deviations from it

While conducting a complete bed bath for a male client, the nurse inspects the scrotum for: Select all that apply. a. Wrinkled skin b. Lumps c. Veins d. Swelling e. Discharge

b. Lumps c. Veins d. Swelling

The nurse wants to ensure that a thorough medication history has been completed with the older adult client. Which checks need to be included? Select all that apply. a. Sleep log b. Medication frequency c. Medication name d. Client's understanding for the need for the medication e. Medication dose

b. Medication frequency c. Medication name d. Client's understanding for the need for the medication e. Medication dose

Half way through a shift, a nurse reassesses an elderly client who was admitted with uncontrolled hypertension the day before. On reassessment, the nurse has difficulty palpating the client's right pedal pulse, which had been palpable and equal to the left pedal pulse at the start of the shift. What is the priority action of the nurse? a. Reassess the pulses in 4 hours b. Notify the health care provider c. Ask the client if their right foot is usually cooler than the left d. Document the findings

b. Notify the health care provider

A client with which of the following cancers is prone to developing phimosis? a. Leukemia b. Penile c. Prostate d. Testicular

b. Penile

A nurse is a preparing to assess a male client's anus and rectum. How should the nurse best prepare the client for this assessment? a. Ask the client if he is feeling anxious or fearful about the exam. b. Position the client in a left side-lying position. c. Administer a dose of analgesia 15 minutes before the exam. d. Assist the client into the supine position.

b. Position the client in a left side-lying position.

A simple test that a nurse can perform to assess an elderly client's activity tolerance is to ask the client to perform what task while monitoring the heart rate? a. Swing the arms overhead several times b. Rise from a chair to a standing position c. Perform 4 to 5 slow, deep knee bends d. Walk around the room and observe gait

b. Rise from a chair to a standing position

During a physical examination of a female client's reproductive system, the nurse detects a thick white discharge from the labia. The client's vulva appears inflamed. How should the nurse document this finding? a. Symptoms of primary syphilis b. Symptoms of candidal vaginitis c. Symptoms of trichomonal vaginitis d. Symptoms of bacterial vaginosis

b. Symptoms of candidal vaginitis

When preparing to do a comprehensive health assessment, the nurse obtains the client's permission based on an understanding of which of the following? a. It ensures that the client will answer personal questions b. The client has the right to refuse c. Permission maintains the client's confidentiality d. The client's level of comfort will be increased

b. The client has the right to refuse

A 15-year-old high school football player comes to the office with his mother. He complains of severe testicular pain since 8:00 this morning. He denies any sexual activity and states that it hurts so bad he can't even urinate. He is nauseated and vomiting. He denies any recent illness or fever. Past medical history is unremarkable. He denies any tobacco, alcohol, or drug use. His parents are both in good health. Examination shows a young teenager lying on the bed with an emesis basin. He is very uncomfortable and keeps shifting his position. Blood pressure is 150/100, pulse is 110, and respirations are 24. On visualization of the penis he is circumcised; there are no lesions or discharge from the meatus. Scrotal skin is tense and red. Palpation of the left testicle causes severe pain and causes the client to cry. His prostate examination is unremarkable. His cremasteric reflex on the left is absent but normal on the right. Catheterization is necessary to get a urine sample, the analysis of which is unremarkable. The boy is admitted to the emergency department of a nearby hospital for further workup. What is the most likely cause of this young man's symptoms? a. Acute epididymitis b. Torsion of the spermatic cord c. Acute orchitis d. Prostatitis

b. Torsion of the spermatic cord

The nurse is providing care for a client admitted with new onset chest pain. What is a priority question the nurse should ask this client? a. "What were you doing when the pain occurred?" b. "Do cardiac problems run in your family?" c. "How would you rate your pain on a scale of 1 to 10, with 10 being the worst?" d. "What makes the pain better or worse?"

c. "How would you rate your pain on a scale of 1 to 10, with 10 being the worst?"

While inspecting the labia minora, a nurse notices that they are asymmetric. Which of the following does this finding most likely point to? a. Cervical cancer b. Candidal vaginitis c. Abscess d. Urinary tract infection

c. Abscess

A nurse is palpating the prostate of a client and finds it to be swollen, tender, firm, and warm to the touch. Which condition should the nurse most suspect? a. Hydrocele b. Benign prostatic hypertrophy c. Acute prostatitis d. Prostate cancer

c. Acute prostatitis

Which of the following would the nurse most likely document when noting a small opening in the skin surrounding the anal opening? a. Repetitive trauma b. Perianal abscess c. Anorectal fistula d. Pinworm infection

c. Anorectal fistula

A hospitalized client has been in bed and not able to ambulate for 3 days. When assessing the right leg, the nurse observes edema and erythema. The calf is warm to touch and the client complains of pain in the calf area. What is the nurse's best action? a. Dorsiflex the foot and ask about increased pain b. Apply sequential compression device c. Assess for SOB d. Suspend the leg lower than the heart

c. Assess for SOB

An older adult client has come to the clinic with new complaints of fatigue, constipation, and cold intolerance. The nurse would refer the client for what type of testing? a. Liver function testing b. Lung function testing c. Assessment of thyroid function d. Cognitive testing

c. Assessment of thyroid function

A 30-year-old paralegal analyst comes to the clinic reporting a bad-smelling vaginal discharge with some mild itching, present for about 3 weeks. Douching did not help. She has had no pain with urination or with sexual intercourse. She has noticed that the smell increases after intercourse and during her period last week. She denies any upper respiratory, gastrointestinal, cardiac, or pulmonary symptoms. Past medical history consists of one spontaneous vaginal birth. She is married with one child. She denies tobacco, alcohol, or drug use. Her mother has high blood pressure, and her father died from heart disease. On examination she appears healthy and has unremarkable vital signs. On examination of the perineum no lesions are noted. On palpation of the inguinal nodes there is no lymphadenopathy. On speculum examination a thin gray-white discharge is seen in the vault. The pH of the discharge is over 4.5, and there is a fishy odor when potassium hydroxide KOH is applied to the vaginal secretions on the slide. Wet prep shows epithelial cells with stippled borders (clue cells). What type of vaginitis best describes her findings? a. Candida vaginitis b. Atrophic vaginitis c. Bacterial vaginosis d. Trichomonas vaginitis

c. Bacterial vaginosis

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? a. Scissors movement b. Sensory ataxia c. Cerebellar ataxia d. Spastic Hemiparesis

c. Cerebellar ataxia

The nurse is examining a child with severe cerebral palsy. On sudden movement of the child's foot dorsally, a sustained "beating" of the foot against the nurse's hand ensues. What does this represent? a. A focal seizure b. Extinction c. Clonus d. Reinforcement

c. Clonus

A 37-year-old comatose woman arrives at the emergency room. Paramedics say her husband found her unconscious at home. Her past medical history consists of type 1 diabetes for which she takes insulin. In the ambulance the paramedics obtained a glucose check and determined she was severely hypoglycemic. They began a dextrose saline infusion and intubated her to protect her airway. Despite their efforts she is posturing in the emergency room with her arms straight at her side and her jaw clenched. Her legs are also straight and her feet are plantar flexed. What type of posturing is she showing? a. Decorticate rigidity b. Hemiplegia c. Decerebrate rigidity d. Chorea

c. Decerebrate rigidity

The nurse is assessing the biceps tendon reflex of a client. Place the following steps in the order the nurse should perform them. a. With the wrist relaxed, strike the tendon briskly using a rapid wrist movement. b. Compare the response of one side to another c. Encourage the pt to reflex, then position the limb properly and symmetrically d. Note the speed, force, and amplitude of the reflex response and grade the response e. Hold the reflex hammer loosely between the thumb and index finger so that it swings freely in an arc within the limits set by the palm and other fingers

c. Encourage the pt to reflex, then position the limb properly and symmetrically e. Hold the reflex hammer loosely between the thumb and index finger so that it swings freely in an arc within the limits set by the palm and other fingers a. With the wrist relaxed, strike the tendon briskly using a rapid wrist movement. d. Note the speed, force, and amplitude of the reflex response and grade the response b. Compare the response of one side to another

The nurse is assessing the genitalia of an adult male client when he tells the nurse that his testes are swollen and painful. The nurse should refer the client to a physician for possible a. Cancer b. Hematocele c. Epididymitis d. Hydrocele

c. Epididymitis

The nurse is preparing a client for an assessment of her genitalia and rectum. What action should the nurse perform when preparing the client? a. Assist the client into a prone position b. Obtain written, informed consent for the examination c. Explain the rationale for using foot stirrups d. Reassure the client that no one other than the nurse will be in the room

c. Explain the rationale for using foot stirrups

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 for cervical cancer? a. Lack of exercise b. Having the human papilomavirus (HPV) vaccination c. Having multiple sexual partners d. Smoking

c. Having multiple sexual partners

The nurse notes the client has weak pulses bilaterally. The nurse understands that this could indicate the client is experiencing what? a. Occlusion b. Hypervolemia c. Hypovolemia d. Constriction

c. Hypovolemia

The client has a Glasgow Coma Score of 7. The nurse understands this client is considered to be what? a. To have minimal impairments b. To have no impairments c. In coma d. Is in a deep coma

c. In coma

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? a. Incontinence b. Vaginal Bleeding c. Infection d. Straining to urinate

c. Infection

A client presents to the health care clinic with reports of clay-colored stool. The nurse recognizes that this finding is most likely a result of which of the following? a. Increased fat content b. Cancer of the colon c. Lack of bile pigment d. Gastrointestinal bleeding

c. Lack of bile pigment

A nurse has been asked to provide an educational event for the families of clients of a nursing home. What would the nurse teach during this educational event? a. People older than 80 years experience fewer consequences of traumatic brain injury. b. People older than 70 years have a rate of traumatic brain injury-related hospitalization and death comparable to that of children. c. People older than 75 years experience more consequences of traumatic brain injury. d. Risks of traumatic brain injury-related hospitalization and death decrease with age.

c. People older than 75 years experience more consequences of traumatic brain injury.

A nurse who works on a day-surgery unit conducts a thorough, head to toe assessment of each client prior to the client's scheduled surgery. The nurse would document an unexpected finding if unable to palpate a client's: a. Liver b. Thyroid gland c. Peripheral pulses d. Lymph nodes

c. Peripheral pulses

Which of the following assessment findings should the nurse interpret as increasing a client's risk for falls? a. New onset of localized infection b. Obesity c. Recent decline in cognitive status d. Persistent fatigue

c. Recent decline in cognitive status

Upon assessment, the nurse finds the client's systolic blood pressure to be 88; heart rate of 121 and a lactate level of 2.3. The nurse recognizes the client is experiencing what? a. Increased intracranial pressure b. Cardiac dysrhythmias c. Severe sepsis d. Surgical site infection

c. Severe sepsis

On inspection of a client's penis, the nurse observes a small, silvery-white papule. Which of the following conditions should the nurse suspect in this client? a. Herpes progenitalis b. Hypospadias c. Syphilitic chancre d. Cancer of the glans penis

c. Syphilitic chancre

The nurse is completing an abbreviated head-to-toe assessment of a client. What would the nurse perform when assessing the client's eyes? a. Test the client's visual fields b. Perform the cover test c. Test the client's pupillary response to light d. Test the client's vision

c. Test the client's pupillary response to light

During a gynecologic examination, the nurse observes that the client has a yellow-green frothy vaginal discharge. The nurse should plan to test the client for possible a. Atrophic vaginitis b. Bacterial vaginosis c. Trichomonas vaginalis infection d. Chlamydia trachomatis infection

c. Trichomonas vaginalis infection

When examining the genitalia of a client, a nurse observes a yellow-green, frothy, and foul-smelling discharge from the vagina. The nurse recognizes this finding as indicative of what condition? a. Mucopurulent cervicitis b. Cancer of the cervix c. Trichomonas vaginitis d. Exposure to diethylstilbestrol (DES)

c. Trichomonas vaginitis

In an interview with an elderly female client, the nurse learns that the client often has involuntary loss of urine associated with an abrupt and strong desire to void. What type of incontinence should the nurse document in the client's record? a. Stress b. Functional c. Urge d. Overflow

c. Urge

When conducting a Romberg test, why does the nurse ask the client to stand feet together with eyes open and then closed? a. Client feels safer after testing with eyes open b. Vestibular defects become evident with eye closed c. Vision can compensate for loss of position sense d. Repetition affects position sense

c. Vision can compensate for loss of position sense

When documenting a comprehensive assessment, which statement would the nurse record as the reason for seeking health care? a. "I try not to let the pain affect my life." b. "I had my appendix removed when I was 14 years old" c. "I have an aunt who had breast cancer." d. "I haven't had a checkup in over 5 years."

d. "I haven't had a checkup in over 5 years."

The nurse is assessing a 12-year-old boy and finds the following: sparse growth of pubic hair, beginning penile enlargement, and beginning textural changes on the scrotum. The nurse would document which Tanner stage? a. 4 b. 1 c. 3 d. 2

d. 2

A client has been assigned a nursing diagnosis of fatigue related to anemia as evidenced by pale skin, statements of tiredness, and low hematocrit and hemoglobin values. What would be an appropriate nursing intervention for this client? a. Evaluate adequacy of exercise b. Have the client explain an energy-conservation plan to offset the effects of fatigue c. Evaluate urinary patterns d. Collaborate with physician to treat anemia

d. Collaborate with physician to treat anemia

The nurse notes dull lung percussion along the lower right lobe of an adult client. Which intervention should the nurse initiate right away for this client? a. Order chest x-ray b. Begin antibiotic therapy through intravenous route c. Administer a nebulizer treatment d. Encourage turning, coughing, deep breathing

d. Encourage turning, coughing, deep breathing

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? a. Level of consciouness b. Glasglow coma scale d. Health history d. Papillary reaction

d. Health history

Which of the following would lead the nurse to suspect a problem with the ovaries during palpation? a. Slight tenderness b. Walnut sized c. Smooth d. Immobile

d. Immobile

The nurse has placed her hands behind the client's head and flexed the client's neck forward as far as the client can tolerate. During the test, the client experiences leg pain and bends his knees. This assessment finding is suggestive of what health problem? a. Ischemic stroke b. Bell's palsy c. Brain stem lesion d. Meningitis

d. Meningitis

The client presents at the clinic with a complaint of weakness that is made worse with repeated effort and improves with rest. The client's complaint is consistent with what health problem? a. Parkinson disease b. Ischemic stroke c. Lyme disease d. Myasthenia gravis

d. Myasthenia gravis

Which cranial nerve controls pupillary constriction? a. Trochlear b. Trigeminal c. Optic d. Occulomotor

d. Occulomotor

A nurse is caring for a client who uses a hearing aid for amplifying sound. During the Rinne test for checking the bone conduction of the sound, where should the nurse place the stem of the vibrating tuning fork? a. Center of the head b. Near the ear canal c. Behind the client's head d. On the mastoid area

d. On the mastoid area

The nurse suspects that a client is experiencing meningitis. Which assessment finding caused the nurse to make this clinical determination? a. Neck flexes to the chest b. Pain behind the knees when fully extended c. Hips and knees relaxed d. Pain and hip flexion when the neck is flexed

d. Pain and hip flexion when the neck is flexed

When performing the physical assessment of a client, the nurse notes the presence of a small cyst that contains hair, which is located midline in the sacrococcygeal area and has a palpable sinus tract. How should the nurse document this finding? a. External hemorrhoid b. Perianal abscess c. Anal fissure d. Pilonidal cyst

d. Pilonidal cyst

A nurse is a preparing to assess a male client's anus and rectum. How should the nurse best prepare the client for this assessment? a. Assist the client into the supine position. b. Ask the client if he is feeling anxious or fearful about the exam. c. Administer a dose of analgesia 15 minutes before the exam. d. Position the client in a left side-lying position.

d. Position the client in a left side-lying position.

The emergency department nurse's rapid assessment of a young adult client admitted unresponsive reveals fixed, constricted pupils bilaterally. The nurse should consider what possible cause for this assessment finding? a. Hemorrhagic stroke b. Recent seizure activity c. Cerebellar lesion d. Recent narcotic use

d. Recent narcotic use

The nurse has assessed the thorax and lungs of an elderly client, as well as reviewing the results of lung function testing. What finding should the nurse attribute to possible pathology rather than expected, age-related changes? a. Decreased vital capacity b. Increased residual volume c. Presence of a slight barrel chest d. Respiratory rate of 30 breaths per minute

d. Respiratory rate of 30 breaths per minute

The nurse assesses an older adult using the short from of the Geriatric Depression Scale. The total score obtained is 11. Which interpretation by the nurse is correct? a. The client is not depressed b. Further evaluation is needed to make a diagnosis c. The score suggests depression may be a problem d. The client is mostly likely depressed

d. The client is mostly likely depressed

A client with congestive heart failure presents to the emergency department with soreness from swelling of the ankles. When conducting the physical examination of this client, the nurse would require a stethoscope for which reason? a. To assess jugular venous pressure b. To assess pedal pulses c. To check the radial pulses d. To auscultate the lungs

d. To auscultate the lungs

Which placement of the hands demonstrates proper technique by a nurse for palpating the thyroid gland? a. Standing in front of the client, hook the fingers into the clavicle and press firmly and deeply b. Standing in front of the client, place the fingers just below and under the mandible c. Standing behind the client, place fingers at the base of the ears and palpate along the sternomastoid muscle on either side d. standing behind the client, place fingers on either side of the trachea below the cricoid cartilage

d. standing behind the client, place fingers on either side of the trachea below the cricoid cartilage