EXAM #3 (Review for Final)
Bouchards nodes
osteoarthritis PIP joint
Chelitis
angular stomatitis which manifests as tissue inflammation at the corners of the mouth.
CNVII
anterior two thirds of tongue
Men with a history of _________ are at greatest risk for development of testicular cancer.
cryptorchidism
Cataracts
An opacity in the lens reducing lens clarity ; usually occurs in aging.
Aspirin can cause ________ in the ears
ringing
Menarche before the age of _____ or menopause after the age of ____ increase the risk for breast cancer.
12 50
A 32-week-pregnant client is upset and is concerned about breast disease because she has been experiencing a thick, yellowish discharge coming from her breasts. How should the nurse respond to this client?
"This is normal toward the end of pregnancy and is called colostrum."
The patient asks the nurse, 'why is it so important to examine the upper outer quadrant of the breast?" What is the nurse's best response?
"This the location of most breast tumors."
Periorbital edema
Swollen, puffy lids; occurs with crying, infection, trauma, and systemic problems including kidney failure, heart failure and allergy.
Instruct susceptible populations that have a risk for developing glaucoma to have a check every ____________ years after the age of _______, especially if they have high blood pressure.
1-2 years 35
Physical assessment of the eyes follows an organized pattern Place in order: ophthalmoscopic examination Visual fields external eye structures visual acuity muscle function
1st visual acuity 2nd visual fields 3rd muscle function 4th external eye structures 5th ophthalmoscopic examination
A new mom is concerned that her breast will sag after breast feeding. Regarding age related changes, what is the nurses' best response? 1. 'Breast become less fibrous.' 2. 'Muscle mass and tone decrease.' 3. 'Adipose tissue decreases.' 4. 'Glandular tissue increases.'
2
A client has been diagnosed with a kidney stone, lodged within the medulla of the right kidney. The nurse understands that this stone will most likely affect: a. the collection of urine b. the filtration of blood c. lymphatic circulation in the kidney d. the clearance of toxins
A
The nurse places a pillow between the legs of a client who has just undergone hip replacement surgery in order to position the operative hip in a position of: a. abduction b. adduction c. pronation d. flexion
A
The nurse is assessing the sinuses of a client. Normal findings include: Hint: Techniques and Normal Findings, Nose and Sinuses a. no tenderness to palpation or percussion of the sinuses b. mild swelling over the frontal sinuses c. Absence of a red glow with transillumination of the maxillary sinuses d. pink, moist mucous membranes with no lesions
A Normal findings of the frontal and maxillary sinuses are no tenderness to palpation or percussion. Swelling should not be present. With transillumination of the maxillary sinuses, a red glow should be present under the eyes. The mucous membranes of the sinuses are not directly visible and are unable to be assessed.
When examining an uncircumcised client, the nurse attempts to retract the foreskin. The foreskin is so tight that it cannot be retracted. The nurse documents the presence of: Hint: Assessment Techniques and Findings; Inspect the Penis a. phimosis b. paraphimosis c. epispadias d. hypospadias
A Phimosis is a condition in which the foreskin is so tight that it cannot be retracted. Paraphimosis describes a condition in which the foreskin, once retracted, becomes so tight that it cannot be moved back over the glans. Epispadias is the condition in which the urinary meatus is located on the dorsal side of the glans. Hypospadias is the condition in which the urinary meatus is located on the ventral side of the glans.
An older adult reports that she is incontinent of urine when she coughs or sneezes. The nurse realizes this client is describing: Hint: Changes in Urinary Elimination a. stress incontinence b. reflex incontinence c. urge incontinence d. functional incontinence
A Stress incontinence, involuntary urination, occurs when intra-abdominal pressure is increased during coughing, sneezing, or straining. Changes related to aging may also contribute to stress incontinence. Reflex incontinence occurs when urine is involuntarily lost in clients with spinal cord damage. Urge incontinence may be caused by consuming a significant volume of fluids over a short period of time, or it may be due to diminished bladder capacity. Functional incontinence occurs when the client is unable to reach the toilet in time because of environmental, psychosocial, or physical factors.
A young adult female client asks what she can do to reduce her risk for breast cancer. Which statements should the nurse include in responding to this client's question and concern? Select all that apply. a. "Regular exercise can help to decrease your risk for breast cancer." b. "You should begin to have yearly mammograms between the ages of 40 and 50." c. "Try to keep your weight within a normal range." d. "If you choose to breastfeed, you should limit it to less than 3 months." e. "You should not have any breast enhancement surgery."
A C Physical activity in the form of exercise has been found to decrease a woman's risk for breast cancer. Obesity has been linked with breast cancer; thus, maintaining a healthy weight can reduce a woman's risk for breast cancer. Mammography is used for early detection of breast cancer, not prevention. Breastfeeding (especially 1½-2 years) has been shown to decrease a woman's risk for breast cancer; therefore, a woman should be encouraged and supported, not limited. Breast enhancement surgery does not increase a woman's risk for breast cancer; however, implants can make reading mammograms more difficult to interpret.
The nurse is palpating the breasts of an adult female. Normal findings include: Select all that apply. a. smooth, elastic breast tissue b. unilateral nipple discharge c. peau d'orange d. thickening of the skin e. wrinkled skin over areola
A E Peau d'orange, orange peel skin, occurs in advanced stages of cancer from blocked lymphatic drainage
When performing a prostate examination, the nurse knows that normal findings include: Select all that apply. Hint: Palpate the Bulbourethral Gland and Prostate Gland a. smooth surface b. firm consistency c. The gland extends about 2 centimeters into the rectal area. d. moderate tenderness to palpation e. small, discrete nodules
A B The normal prostate gland extends out no more than 1 centimeter into the rectal area. The prostate should be nontender to palpation. The surface is smooth. Nodules are characteristic of prostate cancer.
The nurse is educating a group of young women on risk factors for cervical cancer. What should the nurse include that increase a woman's risk for development of cervical cancer? Select all that apply. a. A previous history of human papillomavirus (HPV) b. Multiple sexual partners c. Gardasil vaccine d. Onset of sexual activity before the age of 25 e. Obesity
A B Onset of sexual activity before the age of 18 increases a woman's risk for the development of cervical cancer. Obesity is a risk factor for the development of uterine cancer
When inspecting the mouth and throat of a client, the nurse considers normal findings to be: Select all that apply. a. symmetrical rise of the soft palate and uvula when the client says, "aah" b. the tonsils are red with white exudates present c. salivary ducts are moist without redness or swelling d. the dorsal surface of the tongue is moist with papillae e. smooth, pink nodules on the lateral sides of the tongue
A C D
When assessing the genitals of a male client, the nurse notes normal findings that include: Select all that apply. a. The left testicle hangs lower than the right. b. The skin on the scrotum is shiny and smooth. c. The scrotum is a darker color than the general skin color. d. The testes move closer to the body in response to cooler temperatures. e. The urethral meatus is positioned on the ventral surface of the penis.
A C D •The left testicle hangs lower than the right. The scrotum is visibly asymmetrical with the left side extending lower than the right because the spermatic cord is longer. •The scrotum is darkly pigmented, wrinkled, and has a scant amount of pubic hair. •The testes move closer to the body in response to cooler temperatures and stimulation. •The urethral meatus should be positioned in the midline.
Which statements should the nurse include when providing client education regarding testicular self-examination? Select all that apply. a. "The testicle should feel smooth, rounded, and firm." b. "Apply gentle pressure with your thumb, index, and middle fingers. Your testicle should hurt when you feel it." c. "The best time to perform the exam is in the shower or bath." d. "If your testicle has any lumps or is enlarged, call your healthcare provider." e. "It is normal to feel the epididymis on top of and behind each testicle."
A C D E
The nurse is planning an educational session on cancers of the male reproductive system. Which statements should the nurse include? Select all that apply. Hint: Cultural and Environmental Considerations a. Penile cancer is rare in the United States. b. Prostate cancer occurs more frequently in Caucasians than in African Americans. c. Testicular cancer occurs more frequently in Caucasians than in any other ethnic group. d. The rates for sexually transmitted infections (STIs) are higher in Caucasians than in other ethnic groups. e. Bladder cancer is more common in Caucasians.
A C E • Penile cancer is rare in the United States; however, it accounts for almost 10% of male cancers in Africa and South America. •Prostate cancer occurs more frequently in African Americans than in Caucasians. • The incidence of testicular cancer is higher in Caucasians than in any other ethnic group. • The rates for STIs are higher in African American and Hispanic populations than in Caucasians. •Caucasians are more likely to develop bladder cancer.
The nurse obtains a history from a female client who reports genital irritation. The nurse suspects that factors contributing to this client's problem include: Select all that apply. a. The client douches after intercourse. b. The client bathes daily. c. The client received three doses of Gardasil vaccine at the age of 19. d. The client works in the microelectronics industry. e. The client exercises most weekdays at the gym after work and often runs errands in her gym clothing before going home.
A E Douching is not necessary for cleanliness, and in fact, can contribute to genital irritation, rashes, and infection in some women. The likelihood of irritation can be reduced by changing out of sweaty or wet clothing immediately after exercise or water activities. Daily bathing and changing of underclothing reduces the likelihood of genital irritation. The Gardasil vaccine protects against most cervical cancers related to human papilloma virus (HPV). Cervical cancer does not manifest as genital irritation. Females working in the microelectronic industry may be exposed to substances (i.e., arsenic, lead, radiation, glycol ethers) that place the woman at risk for spontaneous abortions and birth defects. There is no relationship between the microelectronic industry and genital irritation.
Carpal tunnel
A misuse syndrome characterized by frequent repetitive movements that lead to inflammation of the tissues of the wrist putting pressure on the median nerve. A numbness and tingling in the hand and arm caused by a pinched nerve in the wrist. Wrist trauma. Usually from repeated trauma. Worst at night or after activity. Radiates up the ar,. Muscle weakness. Inability to oppose the thumb and little finger.
The nurse is performing an eye assessment on an older adult. Which would be considered normal age-related variations for this client? Select all that apply. a. Presbyopia b. Dryness of the eyes c. Decreased peripheral vision d. Strabismus e. Conjunctivitis
A, B •Presbyopia. By age 45, the lens of the eye loses elasticity and the ciliary muscles become weaker, decreasing the lens's ability to change shape to accommodate for near vision. •Dryness of the eyes. Dryness is usually due to decreased tear production, which occurs with aging. •Decreased peripheral vision. This condition can be caused by glaucoma, which is not a normal condition of aging. •Strabismus. Strabismus is a disparity of the axes of the eyes and is not associated with aging. •Conjunctivitis. Inflammation of the conjunctivae (conjunctivitis) is not a normal finding in any age group.
The nurse is assessing a client's eyes for the accommodation response. What does the nurse expect to observe? Select all that apply. Hint: Testing for accommodation of the pupil response a. Constriction of the pupils with near vision b. Direct and consensual pupil constriction c. Parallel movement of the eyes d. Convergence of the axes of the eyes e. Light reflection at the same spot in both eyes
A, D •Constriction of the pupils with near vision. To assess the accommodation response, the client looks at a distant point then shifts his/her gaze to a near object a few inches away. The expected response is convergence of the eyes and constriction of the pupils to adjust for near vision. •Direct and consensual pupil constriction. This is an expected finding when assessing the pupillary response to light. •Parallel movement of the eyes. The Six Cardinal Fields of Gaze assesses parallel movement of the eyes. •Convergence of the axes of the eyes. The client looks at a distant point, then shifts his/her gaze to a near object a few inches away. The expected response is convergence of the eyes and constriction of the pupils to adjust for near vision.
When examining the eyes of older adults, the nurse knows that which findings are associated with normal aging? Select all that apply. Hint: Special Consideration; The Older Adult a. Xanthelasma b. Pingueculae c. Arcus senilis d. Pterygium e. Diplopia
A,B,C • Xanthelasma—Soft, yellow plaques on the lids and inner canthus are xanthelasmas and considered a normal sign of aging. • Pingueculae—Yellow nodules that are thickened areas of the bulbar conjunctiva caused by prolonged exposure to sun, wind, and dust. They may be on either side of the pupil and cause no problems. • Arcus senilis—A light gray or white ring surrounding the iris at the corneal margin due to the deposition of lipids. This is a common finding in the older adult that does not affect vision. • Pterygium—An opacity of the bulbar conjunctiva that can grow over the cornea and block vision. • Diplopia—Double vision that is not associated with normal changes related to aging.
When performing a genitourinary assessment, the nurse notices that the urethral meatus is positioned ventrally. This finding is:
ANS: called hypospadias. Normally the urethral meatus is positioned just about centrally. Hypospadias is the ventral location of the urethral meatus. The position of the meatus does not change with aging. Phimosis is the inability to retract the foreskin. A stricture is a narrow opening of the meatus.
When performing a genital examination on a 25-year-old man, the nurse notices deeply pigmented, wrinkled scrotal skin with large sebaceous follicles. On the basis of this information the nurse would:
ANS: consider this a normal finding and proceed with the examination.
A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for complaints of burning and pain during urination. He is experiencing:
ANS: dysuria. Dysuria or burning with urination is common with acute cystitis, prostatitis, and urethritis. Nocturia is voiding during the night. Polyuria is voiding in excessive quantities. Hematuria is voiding with blood in the urine.
A 62-year-old man states that his doctor told him that he has an "inguinal hernia." He asks the nurse to explain what a hernia is. The nurse should:
ANS: explain that a hernia is a loop of bowel protruding through a weak spot in the abdominal muscles.
During a physical examination, the nurse finds that a male patient's foreskin is fixed and tight and will not retract over the glans. The nurse recognizes that this condition is:
ANS: phimosis. With phimosis, the foreskin is nonretractable, forming a pointy tip of the penis with a tiny orifice at the end of the glans. The foreskin is advanced and so tight that it is impossible to retract over the glans. This may be congenital or acquired from adhesions related to infection
A thin watery discharge is the result of ________.
Acute rhinitis from either a viral infection or an allergic reaction. there is a genetic link
Presbyopia
Age related condition in which the lens of the eye loses the ability to accommodate. As a result light is focused behind the retina and focus on near objects becomes difficult (it is the gradual decrease in near vision). Common in patients over 45 From practice questions: By middle-age, the lens of the eye loses elasticity, and the ciliary muscles become weaker, resulting in a decreased ability of the lens to change shape to accommodate for near vision (presbyopia). Corneal degeneration doesn't cause problems with near vision or night vision. Decreased peripheral vision can be related to conditions such as glaucoma, not presbyopia. Presbyopia causes difficulty with near, not distance, vision.
epispadias
An epispadias is a rare type of malformation of the penis in which the urethra ends in an opening on the upper aspect (the dorsum) of the penis.
When performing an assessment on an older adult, the nurse notes that the client has kyphosis. What did the nurse observe in this client? Hint: Abnormalities of the Spine a. A lateral curvature of the spine b. An exaggerated inward curvature of the lower spine c. An exaggerated convex curve of the thoracic spine d. Decreased bone density
An exaggerated convex curve of the thoracic spine Kyphosis is an exaggeration of the normal convex curve of the thoracic spine. It may result from congenital abnormality, rheumatic conditions, compression fractures, or other disease processes including syphilis, tuberculosis, and rickets. Scoliosis is a lateral curvature of the spine. Lordosis is an exaggeration of the normal lumbar curve of the spine. Osteoporosis occurs because of decreased bone density. The nurse is not able to observe this during an assessment.
otitis media
An infection of the air-filled space behind the eardrum (the middle ear). fever tympanic membrane feels red
Romberg Test
Assess equilibrium. Have patient stand with feet together and arms at the sides. Have them close their eyes and wait for 20seconds. Normal (might have a little swaying) is denoted a s negative Romberg. If they have trouble it is a problem with cranial nerve VIII
A child is scheduled for a tonsillectomy and adenoidectomy. The nurse understands this surgery will involve the child's: Hint: Anatomy and Physiology Review, Throat a. oropharynx and palate b. nasopharynx and oropharynx c. nasopharynx and laryngopharynx d. oropharynx and laryngopharynx
B
A client asks the nurse, "Why do I need to examine my underarms when I perform breast self-examination?" The most appropriate response by the nurse is: Hint: Anatomy and Physiology Review a. "This is the hardest area to feel for changes." b. "Breast tissue extends into the axilla." c. "This is the least likely area for breast cancer to occur." d. "It is easier to detect abnormalities in this area than in the breast tissue."
B
A client tells the nurse about upper thigh and hip pain when standing too long. What do these symptoms suggest to the nurse? a. The client is experiencing paresthesia. b. The client may have some degenerative disease process within the hip. c. The client may have referred pain from another body region. d. The client may have lumbosacral nerve root irritation.
B
When performing a straight-leg-raise test, the client complains of sharp pain in the lower back with radiation down one leg. The nurse suspects this client may be experiencing: Hint: Techniques and Normal Findings; Hips a. the presence of arthritis in the lumbar spine b. a herniated disk c. inflammation of the hip joint d. the presence of synovitis
B
Where should the nurse place the stethoscope to assess the renal arteries for the presence of bruits? Hint: Techniques and Normal Findings; Auscultate the Right and Left Renal Arteries a. Epigastric region b. Extended midclavicular line c. Hypogastric region d. Costovertebral angle
B Gently place the bell of the stethoscope over the extended midclavicular line, just under the costal angle on either side of the abdominal aorta above the level of the umbilicus to auscultate the renal arteries. There should be no bruits present. A bruit is an abnormal blowing or whooshing sound produced by turbulent blood flow through an artery. The nurse auscultates for bruits of the abdominal aorta in the epigastric area. The bladder and uterus are assessed in the hypogastric region. The costovertebral angle, located posteriorly at the level of the twelfth rib, is where the nurse performs direct percussion, not auscultation, to determine whether there is pain or tenderness, which might indicate inflammation.
What statement should the nurse include when educating an older adult male on prostate health? Hint: Cultural and Environmental Considerations a. "Men your age should have the prostate-specific antigen (PSA) screening every year." b. "You should receive an annual prostate examination." c. "The symptoms of prostate cancer occur early in the disease." d. "Risk factors for prostate cancer include a family history of testicular cancer and a personal history of a vasectomy."
B Signs of prostate cancer are not usually noticeable until the prostatic cancer is advanced. The signs are usually confounding because benign prostatic disease presents with similar symptoms such as dribbling, retention of urine, difficulty initiating the urinary stream, and cystitis. Risk factors include a family history of prostatic cancer and smoking.
An older adult male client reports frequent urination and difficulty starting his urinary stream. He reports he feels well otherwise. The nurse suspects this client may have: Hint: Focused Interview Questions; Questions Related to Symptoms a. urinary tract infection b. enlargement of the prostate gland c. end-stage renal disease d. bladder cancer
B Enlargement of the prostate gland is common in older men causing problems with urinary elimination such as frequency, difficulty starting the urine stream, or urinary retention. Men over the age of 40 should have regular prostate examinations. Females are more susceptible to urinary tract infections because of a shorter urethra. Urinary frequency and difficulty starting the urinary stream are not signs or symptoms of end-stage renal disease. Bladder cancer is often asymptomatic; however, it can present with hematuria, edema in the lower extremities, pelvic mass, or frequent urination.
Identifying and considering risk factors for prostate cancer, which client should the nurse refer to the healthcare provider? Hint: Patient Education; Cultural Considerations a. 40-year-old White uncircumcised male b. 60-year-old Black male with an elevated PSA c. 25-year-old White male with testicular pain d. 65-year-old Hispanic male with difficulty starting and stopping urination
B Prostate cancer occurs more frequently in Black males than in other ethnic groups. The client's age and his race raise his risk for prostate cancer. While an elevated PSA is not specific for prostate cancer, the nurse should refer this client to the healthcare provider for evaluation. The incidence of prostate cancer increases as men age; unless there are increased risk factors, prostate screening typically begins at the age of 50. An uncircumcised male may be at increased risk for penile cancer, not prostate cancer. A 25-year-old White male with a testicular mass is at risk for testicular cancer, not prostate cancer. A 65-year-old Hispanic male with difficulty starting and stopping urination may be experiencing prostatic hypertrophy. As men age, it is common for the prostate gland to enlarge causing urinary symptoms that may include, frequency, urinary retention, difficulty starting and stopping the urinary stream, and dysuria.
During the inspection of a male client's genitalia, the nurse notes a white cheesy substance on the glans penis. The nurse documents this finding as: Hint: Techniques and Normal Findings; Inspect the Penis a. purulent discharge on glans penis b. smegma present c. signs of urethritis present d. potential sexually transmitted infection
B Smegma, a white cheesy substance on the glans penis, may be present and is considered a normal finding. Purulent discharge could be white or yellow in color. There are no other symptoms noted to make the nurse suspect that this is purulent drainage. Signs of urethritis (inflammation of the urethra) include redness and edema around the glans and foreskin, and discharge. The client would likely have pain on urination as well. Gonococcal infection is suspected if the drainage is profuse and thick, purulent, and greenish yellow.
A client is newly diagnosed with osteoarthritis of the spine. The nurse knows that this client has a disease process within the: a. fibrous joints b. cartilaginous joints c. synovial joints d. cervical bursae
B With osteoarthritis the joint cartilage erodes and typically affects the spine, hips, and knees. Bones joined by cartilage, such as the vertebrae, are called cartilaginous joints. Bones joined by fibrous tissue, such as the sutures joining the bones of the skull, are called fibrous joints. Bones separated by a fluid-filled joint cavity are called synovial joints. Synovial joints are reinforced and strengthened by ligaments. Ligaments are protected by small, synovial fluid-filled sacs called bursae. Cervical bones do not have bursae.
During a breast assessment, the nurse notes an inverted right nipple. The nurse knows that this is: a. always indicative of a slow-growing tumor b. a significant finding if it is recent c. a normal finding in most women d. usually found on lactating mothers
B Recent inversion of a nipple, a change in the direction of the nipple, or retraction of the nipple is suggestive of malignancy. Recent nipple inversion is suggestive of malignancy but not always indicative of a slow-growing tumor. This is not a normal finding in most women nor expected during pregnancy.
One of the objectives of Healthy People 2020 is to reduce the rate of new cases of end-stage renal disease. The nurse understands which actions are recommended to achieve this objective? Select all that apply. a. Urine screening b. Early identification of people at risk c. Control of diabetes and hypertension d. Education related to diet and exercise e. Routine glucose screening
B Early identification of people at risk C Control of diabetes and hypertension D Education related to diet and exercise • Urine screening - Urine screening does not reduce the rate of new cases of renal disease. • Early identification of people at risk - Reducing the rate of new cases of end-stage renal disease is focused on prevention, which would include the early identification of individuals at risk for development of the disease, such as those with diabetes and hypertension. • Control of diabetes and hypertension - Control of diabetes and hypertension helps to prevent the development of renal disease. • Education related to diet and exercise - Education regarding diet and exercise is a preventative measure in the development of diabetes and hypertension. • Routine glucose screening - Routine glucose screening does not reduce the rate of new cases of renal disease.
The nurse is assessing a client with carpal tunnel syndrome. When the nurse percusses lightly over the median nerve, the client feels numbness, tingling, and pain along the median nerve. The nurse documents: Hint: Techniques and Normal Findings; Wrists and Hands a. positive Phalen's test b. positive Tinel's sign c. positive Dupuytren's contracture d. positive thenar atrophy
B Tinel's Sign A positive Phalen's test is performed in individuals with carpal tunnel syndrome. The wrists are bent downward, pressing the backs of both hands together causing the flexion of the wrists to 90 degrees. Normally clients experience no symptoms with this maneuver. In individuals with carpal tunnel syndrome, this maneuver produces pain, tingling, and numbness that radiates to the arm, shoulder, or neck.
Which findings might the nurse note when performing an assessment on a client with long-standing renal disease? Select all that apply. a. A distended bladder b. The client appears fatigued c. Peripheral edema d. Indications of pruritus e. Crackles at the bases of the lungs
B,C,D,E • A distended bladder - Is not a finding specifically associated with renal disease. It may be seen in individuals who need to void and perhaps are unable to do so. • The client appears fatigued - Clients with chronic kidney disorders frequently look tired and experience fatigue. • Peripheral edema - Individuals with kidney disease may exhibit signs of circulatory overload (pulmonary edema) or peripheral edema (puffy face, fingers, lower extremities) • Indications of pruritus - Itching is present in individuals with kidney disease as well as mental confusion from elevated nitrogenous wastes. • Crackles at the bases of the lungs - Signs of circulatory overload such as crackles in the lung fields or pulmonary edema may be present in individuals with kidney disease.
An older adult tells the nurse, "Since I stopped having menstrual periods a year or so ago, I have noticed a leakage of urine." The nurse explains to this client: Hint: Special Considerations; The Older Adult a. "Changes in progesterone levels after menopause often cause urinary leakage." b. "After menopause, the uterus loses elasticity and enlarges, which can cause pressure on the bladder and leakage of urine." c. "There is a decrease in estrogen after menopause, which affects the strength of the pubic muscles and can lead to urine leakage." d. "The decrease in estrogen after menopause can cause spasm of the bladder and leakage of urine."
C Postmenopausal females experience a decrease in estrogen, which affects the strength of the pubic muscles and may lead to leakage of urine, reduced acidity in the lower urinary tract, and the development of urinary tract infections. Alterations in progesterone levels do not have an effect on urinary leakage. The uterus doesn't enlarge after menopause. Sexual organs atrophy after menopause. A decreased amount of estrogen does not cause bladder spasms.
During palpation of a client's vaginal walls, the nurse feels a bulging along the posterior wall. This finding suggests: a. a prolapsed uterus b. a cystocele c. a rectocele d. a rectal prolapse
C A rectocele is a hernia that is formed when the rectum pushes into the posterior vaginal wall. A prolapsed uterus may protrude right at the vaginal wall with straining, or it may hang outside the vaginal wall without straining. A cystocele is a hernia that is formed when the urinary bladder is pushed into the anterior vaginal wall. Rectal prolapse is seen when rectal tissue protrudes through the anal opening.
When performing an assessment of the genital and anal region of a male, the nurse notes the presence of tears around the anal opening. The client states that he has been more constipated than usual. The nurse documents the finding as: Hint: Abnormalities of the Perianal Area a. pilonidal cyst b. perianal or perirectal abscess c. anal fissures d. prolapse of the rectum
C Anal fissures are tears in the anal mucosa and are most frequently associated with passage of hard stools. Rectal prolapse occurs when the rectal mucosa protrudes through the anus. A round or oval pink protrusion is seen outside the anus.
During the assessment of a middle-aged client, the nurse sees yellow-white fatty material around the client's corneas. This finding suggests to the nurse: a. the client has hypercholesterolemia b. this may cause a change in the size of the pupils c. this is a normal finding for this age d. this may affect vision
C Arcus senilis is a deposition of fat around the cornea. It looks like yellow-white material and is considered normal after age 45 to 50. The presence of arcus senilis is not associated with hypercholesterolemia. As individuals age, their pupils may become smaller in size; however, this is not related to the presence of arcus senilis. This condition has no effect on vision.
When gathering breast history information on a client, the client states that she has noticed a few drops of clear discharge from her nipples over the past few months. The nurse should: a. notify the health-care provider b. document the presence of the discharge c. ask additional history questions about the discharge and medications she is currently taking d. refer the client for a mammogram
C Nipple discharge from medications is usually clear. This discharge is bilateral. Unilateral nipple discharge would be of more concern and perhaps be caused by an intraductal papilloma or cancer.
A nurse is providing education to a client with a history of renal calculi. What should the nurse include in this teaching session? Hint: Patient Education; Environmental Considerations a. Discuss that renal calculi are usually caused by bacteria. b. Discuss the importance of taking all of the antibiotic medication, even when symptoms subside. c. Drink enough fluid in a 24-hour period to produce 2 quarts of urine. d. Recommend calling the healthcare provider if a fever develops.
C Renal calculi (stones) are usually composed of calcium, struvite, or a combination of magnesium, ammonium, phosphate, and uric acid. Pain is the primary symptom. Other symptoms include nausea, dysuria, frequency and urgency of urination, and hematuria. Individuals should have adequate fluid intake to produce 2 quarts of urine in a 24-hour period to reduce the development of renal calculi. Calculi are not caused by bacteria as seen in urinary tract infections. Antibiotics are prescribed for urinary tract infections but are not the routine treatment for renal calculi. The presence of a fever is seen with infection.
Rinne Test
Compares air and bone conduction. Normal: AC 30 seconds BC 15 seconds
The mother of a young child tells the nurse that the child has speech problems and was diagnosed with ankyloglossia. She states that she doesn't understand what this condition is. What can the nurse explain to the mother about this condition? Hint: Overview of Disorders of the Mouth and Throat a. "Your child's tongue is slightly larger than normal and may be causing speech problems." b. "The aphthous ulcers your child has are related to this condition." c. "Your child's nosebleed is caused by a perforated septum." d. "The piece of tissue from the tip of the tongue to the floor of the mouth is shortened and is likely causing your child's speech difficulties."
D
When examining the genitalia of an older woman, the nurse notes that which is considered a normal finding? a. Hypertrophy of the mons pubis b. Increased secretions in the vagina c. The vaginal orifice is not visible. d. Thin, sparse pubic hair
D As the female ages, her sexual organs atrophy. The pubic hair becomes thin and sparse. The mons pubis may atrophy. Vaginal secretions are not as plentiful, and she may experience pain during intercourse. The clitoris may also become smaller. The vaginal orifice is still visible.
An older adult female who has had normal Pap tests for over 10 years asks the nurse when she will no longer need Pap testing. An appropriate response for the nurse to make to this client would be: Hint: Client Education a. "Pap tests are recommended annually for life." b. "every 2 to 3 years" c. "at least once a year" d. "You may discontinue Pap tests."
D At 70 years, females with three or more normal Pap tests may discontinue having them done. Pap tests are not recommended annually for life if a woman is 70 years or older and has had three or more normal Pap tests. At age 30, Pap testing may occur every 2 to 3 years in females who have had three normal tests. Pap testing is not recommended more often than every year, unless the woman has had abnormal results.
When inspecting the external genitalia of a female client, the nurse notes the presence of a red rash with weeping and crusting lesions. The nurse suspects that the most likely cause of this condition is: Hint: Inspect the Labia Majora a. genital warts b. yeast infection c. gonococcal infection d. contact dermatitis
D Contact dermatitis appears as a red rash with associated lesions that are weepy and crusty. There are often scratches due to intense itching. Genital warts are raised, moist, cauliflower-shaped papules. Yeast infections are the most common female genital infection and can produce redness, pruritus, and a cheese-like discharge. Gonococcal infections present with a foul-smelling green discharge that may spread to the abdominal cavity and cause pelvic inflammatory disease.
A young adult female with benign breast disease says she has increased breast pain and tenderness with menses. In response to this client's concerns, the nurse should: Hint: Abnormal Findings, Benign Breast Disease a. discuss the relationship of benign breast disease to breast cancer b. explain that a breast biopsy may be indicated c. tell the client that this condition will soon go away d. recommend an over-the-counter analgesic and reducing salt intake
D Decreasing salt intake and taking a mild analgesic may help with the breast pain. There is no direct link between benign breast disease and the incidence of cancer. The discomfort associated with this disease is cyclical, occurring in the days prior to menstruation, and does not indicate that a biopsy is needed. The condition occurs during the woman's reproductive years, typically during the 20s. \
During the musculoskeletal assessment of a client, the client reports pain as the nurse palpates the muscles and soft tissue around the head, neck, shoulders, and hips. The nurse understands these findings are suggestive of: a. osteoarthritis b. systemic lupus erythematosus c. gout d. fibromyalgia
D Fibromyalgia, classified as a rheumatic disease, is characterized by pain in the muscles and soft tissues that support and surround joints. Pain is experienced in tender points of the head, neck, shoulders, and hips. With osteoarthritis, the joint cartilage erodes, resulting in pain and stiffness primarily in the spine, knees, and hips. Systemic lupus erythematosus (SLE) is an autoimmune disease that causes inflammation in joints and other body organs. Gout is a type of arthritis caused by uric acid crystal deposits in the joints. The deposits cause inflammation, pain, and swelling in the joints, especially the great toe.
The nurse is assessing the corneal light reflex on an adult client. The nurse would expect to note: a. blinking when a wisp of cotton is brushed across the cornea b. consensual constriction of the pupils in response to bright light c. a steady, fixed gaze d. reflection of light at the same spot in both eyes
D The nurse assesses the corneal light reflex by shining a light into eyes from a distance of 12 inches away. The expected response is that the light will be reflected at the same spot in both eyes. Asymmetry of the light reflection indicates that there could be a weakness in the extraocular muscles. Blinking when a wisp of cotton is brushed across the eye is the expected response when the corneal reflex is assessed. Consensual constriction of the pupils is the normal pupillary light response. A steady, fixed gaze is the expected response for the cover-uncover test.
Vitamin _____ may reduce symptoms of breast edema and tenderness.
E
Children or nonenglish speaking patients can use which chart for visual acuity?
E chart
The Six ADLs
Eating Bathing Dressing Toileting Transferring (walking) Continence
Benign Prostate Hypertrophy
Enlargement of the prostate It is a common cause of urinary retention and obstruction in men. Results in frequent overflow voiding, especially during the night.
Hyperopia
Farsightedness eye is shorter than normal and light rays focus behind the retina
Miosis
Fixed and constricted pupils; may occur with the use of narcotics, with damage to the pons or as a result of treatment for glaucoma
Which Cranial Nerve deals mainly with swallowing
Glossopharyngeal IX
Presbycusis
Gradual hearing loss with aging
_________, thin foul odor with bacterial vaginosis.
Gray or white
Corneal Light Reflex
Hold penlight 12inches from eye and you should see a "twinkle" in the same spot on both pupils
During an examination of an aging male, the nurse recognizes that normal changes to expect would be:
In the aging male the amount of pubic hair decreases, the penis size decreases, and there is a decrease in the rugae over the scrotal sac. The scrotal sac does not enlarge.
Stye
Infection of the hair follicle
Gingivitus
Initial stage of gum disease a common and mild form of gum disease (periodontal disease) that causes irritation, redness and swelling (inflammation) of your gums. Gingivitis can lead to much more serious gum disease (periodontitis) and eventual tooth loss.
Weber Test
Uses bone conduction to assess hearing in a person who hears better in one ear than the other Normal finding "no lateralization"
Osteoporosis
Kyphosis, back pain, balance problems, asymptomatic, loss of height, pathological fractures, loss of bone density, decreased bones strength, Factors: lack of exercise, steroids, ETOH, smoking, immonility, post menopausal women. A loss in height can indicate osteoporosis. 500 mg of calcium is all your body will absorb at one time.
An enlarged tongue can be due to ___________ or __________.
Mental retardation hypothyroidism
Muscle strength rating
Muscle strength is rated on a 0-5 scale (no muscle contraction-normal muscle strength). A rating of 5/5 is considered normal muscle strength, meaning that the client has full range of motion against gravity with full resistance. 1/5 Palpable muscle contraction but no movement 2/5 muscle strength is full range of motion without gravity (passive motion). A rating of 3/5 muscle strength is considered fair and means the client has full range of motion with gravity, but not against resistance. 4/5 muscle strength is documented if the client has full range of motion against gravity with moderate resistance.
Myopia
Nearsightedness light rays focus in the front of the retina From practice questions In myopia (nearsightedness) the client experiences difficulty with distance vision. Difficulty with near vision is hyperopia (farsightedness). The light rays are focused in front of the retina with myopia and behind the retina with hyperopia. Myopia does not cause alterations in peripheral vision.
The nurse is inspecting the breasts of a female client. Which finding should trigger a prompt referral to the woman's healthcare provider? a. Left breast is slightly larger than her right b. Skin is marked with linear striae c. Faint, healed scarring bilaterally d. Nipples are pointing in different directions
Nipples are pointing in different directions Nipples should point in the same direction outward and slightly upward. A change in the direction of point of the nipple is suggestive of an abnormality. It is normal for a woman to have one breast slightly larger than the other unless this is a recent change. The presence of striae (stretch marks) is also considered within normal limits. Well-healed bilateral scarring should trigger additional questions if the nurse has not asked about breast surgery but should not trigger an immediate referral.
The nurse notes that a client has a smooth, red, shiny tongue with no lesions. Which of the following is the most appropriate in this situation? Hint: Overview of Disorders of the Mouth and Throat a. Ask whether the client has a history of halitosis. b. Obtain a dietary history on this client. c. Review the client's medical record for a history of leukoplakia. d. Continue with assessment as this is a normal finding for the tongue.
Obtain a dietary history on this client. A smooth tongue is a condition resulting from vitamin B and iron deficiency. The surface of the tongue is smooth and red with a shiny appearance. Halitosis is the presence of bad breath and not applicable in this situation. Leukoplakia is a whitish thickening of the mucous membrane in the mouth or tongue and is often a precancerous lesion. A smooth, shiny, red tongue is not a normal finding.
Odynophagia
Painful swallowing
Paraphimosis
Paraphimosis is an uncommon medical condition in which the foreskin of an uncircumcised penis becomes trapped behind the glans penis, and cannot be reduced (pulled back to its normal flaccid position covering the glans).
A 45-year-old mother of two children is seen at the clinic for complaints of "losing my urine when I sneeze." The nurse documents that she is experiencing:
Stress incontinence is involuntary urine loss with physical strain, sneezing, or coughing that occurs due to weakness of the pelvic floor. Urge incontinence is involuntary urine loss from overactive detrusor muscle in the bladder. It contracts, causing an urgent need to void.
Swan Neck Deformity
Swan neck deformity is a deformed position of the finger, in which the joint closest to the fingertip is permanently bent toward the palm while the nearest joint to the palm is bent away from it. Seen in rheumatoid arthritis
orchitis
Swollen painful testes
Rosenbaum
Tests for near vision pt. is seated and chart is held 12-14 inches normal is 14/14
Katz Index
The Index ranks adequacy of performance in the six functions of bathing, dressing, toileting, transferring, continence, and feeding. Clients are scored yes/no for independence in each of the six functional categories.
During the focused musculoskeletal interview, the nurse learns that a client developed osteomyelitis after hip replacement surgery. What does this information suggest to the nurse? a. The client may be more prone to develop osteomalacia. b. The client is more likely to develop osteoarthritis. c. The client is at risk for future episodes of bone infections. d. The client is at risk for the development of fractures.
The client is at risk for future episodes of bone infections. Osteomyelitis, an infection of the bone, frequently recurs in clients with a history of previous infections. Individuals with osteomalacia (adult vitamin D deficiency) are more prone to develop multiple fractures of the bone. The development of osteoarthritis is not related to osteomyelitis. A previous history of osteomyelitis is not a risk factor for the development of fractures.
What two facial areas are best for assessing symmetry of facial features?
The palpebral fissure and the nasolabial folds
Candidiasis
Thrush from Candida Albicans results in immunosuppressed individuals and those on antibiotic treatment
T/F If the patient notices a firm painless lump, a hard area, or an overall enlarged testicle, he should call his health care provider for further evaluation.
True The testicle normally feels rubbery with a smooth surface. A good time to examine the testicles is during the shower or bath, when one's hands are warm and soapy, and the scrotum is warm. It should be performed once a month
T/F Ear Canals should never be cleaned
True cerumen moves towards the outside naturally Use of cotton-tipped applicators to remove cerumen can cause trauma to the tympanic membrane and cause cerumen impaction. Ear canals should never be cleaned. Cerumen moves to the outside of the canal naturally. Commercial cerumen removal products should be used with the guidance of a healthcare provider. Use of cotton-tipped applicators does not predispose the individual to a middle ear infection.
Cracks or erythema in the corner of the lips could be due to a __________ deficiency.
Vitamin B
_________ vaginal discharge is seen with a yeast infection.
White curd-like
Which CN is responsible for symmetrical movement of the uvula
X (IX)
What cranial nerve si responsible for the turning of the head and shruging the shoulders
XI
Kaposi's Sarcoma
a cancer that causes patches of abnormal tissue to grow under the skin, in the lining of the mouth, nose, and throat or in other organs. The patches are usually red or purple and are made of cancer cells and blood cells. The red and purple patches often cause no symptoms, though they may be painful. If the cancer spreads to the digestive tract or lungs, bleeding can result. Lung tumors can make breathing hard. HIV/AIDS
E chart for distant vision
a chart to test visual acuity (distant vision) Have patient point in the direction that the E is facing
Snellen chart
a chart to test visual acuity (distant vision) provide 20 ft and chart should be at eye level The numerator indicates the distance from the chart (20ft) The denominator indicates the distance at which a person with normal vision can read the last line If the patient is unable to read more than 1/2 of the letters on the line, record the number of the line above.
When performing a breast examination, the nurse notes the presence of Montgomery's tubercles, soft tissue bilaterally, palpable infraclavicular lymph nodes, and slight tenderness to deep palpation bilaterally. Which of the findings does the nurse consider a deviation from normal?
a. Palpable infraclavicular lymph nodes Normal lymph nodes should not be palpable. The presence of Montgomery's tubercles, which are tiny sebaceous glands on the areolae, is normal. The tissue of the breast should be soft. Tenderness to deep palpation is not as concerning as palpable lymph nodes in the breast assessment.
in older women glandular tissue is replaced with ______ tissue
adipose
Opaque Card
aka eye cover the patient must be instructed not to close or apply pressure to the covered eye.
Serous drainage from the ear may indicate
allergic reaction Clear drainage could be cerebrospinal fluid from trauma
Visual acuity require _______ lighting while the room is darkened to assess ______ responses and the internal eye
bright pupillary
Night blindness is associated with
cataracts
Rheumatoid Arthritis
chronic inflammatory disease of the connective tissues, pain and joint stiffness greater than 30mins, Bilateral movement, spongey soft feeling joints, deformity. Can run a low grade fever, fatigue, weakness, ulnar deviations, swan neck. Boutonniere deformity (nodules).
the lens is what color
clear
Children ear examination. Pull earlobe _______ and _______
down and back
Mydriasis
fixed and dilated pupils; may occur with sympathetic nerve stimulation, glaucoma, CNS damage or deep anesthesia
And a yellow or green discharge with _______.
gonorrhea
Acute Sinusitus
infection within the sinuses
Air conduction
is the transmission of sound through the tympanic membrane to the cochlea and auditory nerve
Macular degeneration
loss of central vision. A degenerative condition of the macula, the central retina, causing the gradual loss of central vision while peripheral vision remains intact. Risk factors are hypertension and cigarette smoking. older adults
Lesions
may include warts, rashes, ulcers or vesicles. Lesions may also be related to STDs or a cancer or a systemic problem
Ptosis
one eyelid drooping. can be caused by cranial nerve III (oculomotor). Can also be due to systemic neuromuscular weakness
Changes in vision should be referred to an
opthalmologist
Heberden's nodes
osteoarthritis distal metacarpal joint
Bloody or purulent ear drainage could indicate
otitis media or infection of the middle ear
Ophthalmoscopic examination the ______ reflex is visible
red The red reflex is an expected, normal finding, which is the reflection of the light off the retina. When there is an opacity of the lens as seen in cataracts, the red reflex is not present.
When inspecting the eye, eyelid and eyebrow look for size ______ and ______
shape symmetry
The nurse is inspecting the breasts of a female client. Which position will accentuate the presence of dimpling? The nurse asks the client to: a. sit with arms relaxed at the sides b. lean forward with arms in front of the client c. sit with arms raised over the head d. lie on her back with arms elevated
sit with arms raised over the head Dimpling of the skin over a mass is usually a visible sign of breast cancer. Dimpling is accentuated with the client's arms raised over the head, which tightens the pectoral muscles. Sitting with arms relaxed at the sides gives the examiner a general impression of the breasts. Leaning forward with arms in front of the client demonstrates whether the breasts fall freely from the chest wall. Lying flat or supine with the arm extended over the head is the position for palpation of the breast.
Tophi
small white nodules on the helix or antihelix of the ear that contain uric acid crystals and are a sign of gout.
Xanthelasma
soft yellow plaques on the lids at the inner canthus. sometimes associated with cholesterolemia, usually have no pathological significance.
otitis externa
swimmer's ear caused by contaminated water left in the ear
CN IX
taste posterior one third of tongue and swallowing.
Bone Conduction
transmission of sounds through the bones of the skill to the cochlea and auditory nerve
A female client reports an odorless, frothy, yellow-green discharge. The nurse suspects this client may have: a. trichomoniasis b. candidiasis c. chlamydia d. gonorrhea
trichomoniasis Trichomoniasis infection produces a frothy, yellow-green discharge. Candidiasis (yeast infection) produces a white, curd-like discharge. Green discharge that has a foul odor is seen in conditions of gonorrhea. Chlamydia infection often has no symptoms or a purulent yellow discharge.
T/F cartilage formation continues through life
true
Bell's Palsy
unilateral (stoke can be bilateral) Transient or permanent Cranial nerve VII
what color is the sclera
white
Breast cancer ethnicity considerations.
¥ Ashkenazi Jews greater incidence ¥ White women higher than non-white women ¥ African American women lower survival rates ¥ African American men greater risk than white men
Risk Factors for Testicular Cancer
¥ Cryptorchidism ¥ Age 20-40 ¥ Family history ¥ Mumps orchitis ¥ Inguinal hernia during childhood Signs --Hard, fixed non-tender mass --Scrotal swelling --Scrotal heaviness
