Exam IV questions
During a physical assessment, using the handle of the reflex hammer, you gently stroke the inner left thigh of the patient, which causes the ipsilateral testicle to rise. What superficial reflex is demonstrated?
Cremasteric Reflux
The nurse is admitting a 75-year-old man with a 50-year history of smoking 1 pack of cigarettes per day. Among the patient's concerns is his chronic shortness of breath. One nail finding that demonstrates chronic hypoxia is
Clubbing
A 22-year-old patient presents to the clinic with a large firm mass on her left earlobe. She had her ears pierced approximately 3 weeks ago. The mass began as a small bump and progressively enlarged to its current size of approximately 2.5 cm (1 in.) in diameter. It is not tender, reddened, or seeping any drainage. What is the term used to describe this secondary skin lesion?
Keloid
A 26-year-old man was in a motor vehicle accident and suffered a complete spinal cord injury to L3. The nurse assesses the patient for loss of motor function in the:
Legs
The chart states that a 62-year-old woman has had a stroke in the right parietal area of the brain. The nurse expects to note which of the following?
Weakness in the left arm
ACBDEs of melanoma
+Asymmetry +Border Irregularity +Color +Diameter of more than 6mm +Evolution of the lesion over time
The nurse is inspecting the urethra and the Skene glands. She knows these are a part of what area?
Vestibule
Of the following changes, which is the earliest sign of progressing brain herniation that originates in the cerebral hemispheres?
Altered mentation
When examining the scrotum of an adult Hispanic male, a normal finding is
Asymmetrical sac with left side lower than right side
If the great toe extends upward and the other toes fan out in response to stroking the lateral aspect of the sole of the foot, this is documented as which of the following?
Babinski Sign
A 70-year-old man presents with the following symptoms: straining to void, nocturia, dribbling, and hesitancy when voiding. These signs are consistent with what condition?
Benign prostatic hypertrophy (BPH) Rationale: As men age, fibromuscular structures of the prostate gland atrophy and are gradually replaced by collagen, which enlarges the gland. Consequences include nocturia, dribbling, and hesitancy when voiding
The ABCDEs of melanoma identification do not include
Birthmark: Cafe au last spot that does not fade
While the nurse performs formal patient assessment, assistive personnel often observe changes when obtaining vital signs or assisting patients with ADLs. When discussing care for a patient with back pain, the nurse should particularly alert the assistant to watch for:
Bowel/Bladder incontinence
One of the guests at a health promotion fair asks the nurse, "What is the greatest killer of women?" The nurse knows by current evidence that it is
CVD
A Pap smear is recommended to screen for what condition?
Cervical Cancer
Which of the following organisms is associated with salpingitis?
Chlamydia trachomatis.
The patient with a head injury and increasing ICP is likely to have which assessment findings?
Decreased LOC and sluggish pupil
The nurse is taking a menstrual history. What would be an appropriate question to ask?
Do you ever skip periods?
What is one difference between testicular torsion and epididymitis that indicates testicular torsion?
Elevation of affected testicle does not lessen pain
A fair-skinned, blonde, 18-year-old woman is at the clinic for a skin examination. She reports that she always turns red within 10 minutes of going outside. She is planning a trip to Mexico and wants to avoid getting sunburned. Which of the following would be included in the teaching? (Select all that apply)
Excessive exposure to UVA and UVB rays increases risk of sunburn and skin cancer B. Apply a sunscreen or sunblock at least 15 to 30 minutes before sun exposure C. Avoid sun exposure between 10 AM and 4 PM to reduce UVA and UVB exposure
T/F Men who have sex with women are at higher risk for herpes then men who have sex with men
False Men who has sex with men are at higher risk for genital herpes and HIV
Which sexually transmitted infection presents with painful red superficial vesicles along the penis or on the glans?
Herpes simplex virus 2 (HSV-2). Rationale: Herpes presents with painful vesicles along the penis or on the glans
All of the following skin lesions may be papular except
Herpes zoster
The nurse performs BP screening at the local community center. As part of the health promotion intervention, the nurse also discusses the following risk factors for stroke:
High BP, diet high in fat, and smoking
A nurse observes a skin lesion with well-defined borders on the upper left thigh. It is 1.5 cm in diameter, flat, hypopigmented, and nonpalpable. What is the correct terminology for this lesion?
Patch
A 20-year-old Caucasian man complains of a mass in his left testicle. In addition to his age and race, what else is a risk factor for testicular cancer?
Personal history of cryptorchidism. Rationale: Cryptorchidism (undescended testicle at birth) is a risk factor for testicular cancer.
When assessing hydration, the nurse will
Pinch a fold of skin just below the midpoint of one of the clavicles and allow the skin to recoil to normal (Skin turgor)
A patient has several red, inflamed, superficial, palpable lesions containing a thickened yellowish substance. How would the nurse document this lesion?
Pustule
A patient in a nursing home was admitted with a diagnosis of dementia. He started a fire because he was cooking at home and forgot that he left a pan on the stove. The nursing diagnosis that is highest priority is:
Risk for Injury
A 24-year-old patient reports an itchy red rash under her breasts. Examination reveals large, reddened, moist patches under both breasts in the skin folds. Several smaller, raised, red lesions surround the edges of the larger patch. What is the correct terminology for the distribution pattern of these smaller lesions?
Satellite
The nurse is preparing the patient for her genital examination. What position will the nurse assist the patient into for a comfortable genital examination?
Semi-Lithotomy
The practitioner has decided to place a patient on isotretinoin for her acne problems. The nurse is preparing to counsel the patient. What is the most important information she needs to tell the patient?
She needs to use two forms of birth control or abstain from sex 1 month before, during, and 1 month after taking this medication
You are inspecting the groin of an older adult man who lives in a long-term care facility. Which of the following is an expected finding that you will document?
Smegma under the foreskin. Smegma is a thin, white, cheesy substance that may normally be present under the foreskin
The correct position in which to place a healthy adult male client to examine the rectum and prostate is
Standing and leaning over the examination table, chest and shoulders resting on the table. Rationale: Standing is preferred because it allows for visualization of the anus and palpation of the rectum. If the patient cannot stand, the Sims position (A) is used
A young male presents for a sports physical examination. In addition to examining for hernias, it would be appropriate for you to do which of the following?
Teach testicular self-examination. Rationale: This age group is at high risk for testicular cancer; prostate cancer usually occurs later in life
A 20-year-old male patient presents with scrotal pain. A suspected diagnosis that requires immediate referral is
Testicular torsion. Rationale: Testicular torsion requires immediate surgical intervention to prevent strangulation of the testicle
An 83-year-old woman is undergoing a routine physical examination. Which of the following assessment findings would the nurse consider an expected age-related variation?
Thinning of the skin
A patient presents to the clinic with erythematous vesicles on the face and chest. Some vesicles have broken open, revealing a moist, shallow, ulcerated surface; some have scabbed over. Which of the following infectious illnesses does the nurse suspect?
Varicella
A patient complains of a soft, irregular mass on the left side of the scrotum he noticed while walking. The nurse palpates a mass that feels like "a bag of worms." These findings are consistent with which condition?
Varicocele Rationale: Varicocele is a condition caused by abnormal dilation and tortuosity of the veins along the spermatic cord, often on the left side. Upon palpation, the varicocele feels like a bag of worms
Use of the GCS provides relatively objective assessment of LOC. The three functions assessed are:
Verbal response, eye opening, and motor response
Which of the following would you recognize as an unexpected finding while examining the male genitalia?
You note an impulse at the tip of your finger during hernia examination Rationale: Indirect inguinal hernia presents with an impulse at the tip of the nurse's finger during hernia examination. All other answers represent normal findings
A 47-year-old woman states she is having vertigo and some difficulty with balance. The nurse should assess:
balance and equilibrium are associated with cranial nerve VIII
The nurse practitioner is assessing a patient with frequent candidiasis. The test that the nurse will order for this patient is
blood test for glucose
Upon inspection, the nurse sees flesh-colored lesions surrounding the anal area. These lesions most likely indicate
condyloma acuminatum infection
After completing a history on a 45-year-old patient, the nurse suspects the patient may have uterine fibroids. What information might have led her to this conclusion?
heavier than usual menstraul period
