HA #7 and #8 Flashcards
The Glasgow Coma Scale is a quantitative tool to assess a client’s level of consciousness. A fully alert client would have a score of?
a. ) 24
b. ) 15
c. ) 7
d. ) 12
b.) 15
The student nurse asks the client to stand with his feet together and arms at his side with his eyes closed. The client starts to sway back and forth and has to move his feet to catch his balance. The student nurse would document this finding as a(n):
a. ) ataxia
b. ) a negative Romberg sign
c. ) a positive Romberg sign.
d. ) loss of coordination
c.) a positive Romberg sign.
What is the expected response when testing the triceps reflex?
a. ) Extension of the forearm.
b. ) Pronation of the hand.
c. ) Flexion of the forearm.
d. ) Flexion of the hand.
a.) Extension of the forearm.
The student nurse is testing superficial reflexes on an adult client. When stroking up the lateral side of the sole and across the ball of the foot, he notices plantar flexion of the toes. How should the student nurse document this finding?
a. ) Plantar relex present.
b. ) A positive Babinski sign
c. ) A plantar reflex of 3+ on a scale of 0-4.
d. ) Plantar reflex abnormal.
a.) Plantar relex present.
With the client’s eyes closed, the nurse places a familiar object in the client’s hand and asks her to identify the object. This assessment is known as ________.
a. ) extinction.
b. ) tactile discrimination.
c. ) stereognosis.
d. ) graphesthesia.
c.) stereognosis.
A very brisk, hyperactive reflex should be documentated as:
a. ) 1+.
b. ) 2+.
c. ) 3+.
d. ) 4+.
d.) 4+.
Which of the following statements is true regarding the internal structures of the breast? The breast is:
- ) Mainly muscle, with very little fibrous tissue.
- ) Composed of fibrous, glandular, and adipose tissue.
- ) Composed mostly of milk ducts, known as lactiferous ducts.
- ) Composed of glandular tissue, which supports the breast by attaching to the chest wall.
2.) Composed of fibrous, glandular, and adipose tissue.
In performing a breast examination, the nurse knows that it is especially important to examine the upper outer quadrant of the breast. The reason for this is that the upper outer quadrant is:
a. ) The largest quadrant of the breast.
b. ) The location of most breast tumors.
c. ) Where most of the suspensory ligaments attach.
d. ) More prone to injury and calcifications than other location in the breast.
b.) The location of most breast tumors.
During an annual physical exam, a 43-year-old patient states that she doesn’t perform monthly breast self-examination (BSE). She tells the nurse that she believes that mammograms “do a much better job than I ever could to find a lump.” The nurse should explain to her that:
a. ) BSEs may detect lumps that appear between mammograms.
b. ) Breast self-examination is unnecessary until the age of 50 years.
c. ) She is correct, mammography is a good replacement for breast self-examination.
d. ) She doesn’t need to perform breast self-examination as long as a physician checks her breasts yearly.
a.) BSEs may detect lumps that appear between mammograms.
During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding?
a. ) Breasts should always be symmetric.
b. ) This finding is probably due to breastfeeding and is nothing to worry about.
c. ) This finding is not unusual, but the nurse should verify that this change is not new.
d. ) This finding is very unusual and means she may have an inflammation or growth.
c.) This finding is not unusual, but the nurse should verify that this change is not new.
The nurse is palpating a female patient’s breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation?
a. ) Supine with arms raised over her head
b. ) Sitting with arms relaxed at the sides
c. ) Supine with arms relaxed at the sides
d. ) Sitting with arms flexed and fingertips touching shoulders
a.) Supine with arms raised over her head
The nurse is aware that which of these statements is true regarding the incidence of testicular cancer?
a. ) Testicular cancer is the most common cancer in men aged 30 to 50 years.
b. ) The early symptoms of testicular cancer are pain and induration.
c. ) Men with a history of cryptorchidism are at greatest risk for development of testicular cancer.
d. ) The cure rate for testicular cancer is low.
c.) Men with a history of cryptorchidism are at greatest risk for development of testicular cancer.
The nurse is describing how to perform a testicular self-examination to a patient. Which of these statements is most appropriate?
a. ) “A good time to examine your testicles is just before you take a shower.”
b. ) “If you notice an enlarged testicle or a painless lump, call your health care provider.”
c. ) “The testicle is egg shaped and movable. It feels firm and has a lumpy consistency.”
d. ) “Perform a testicular exam at least once a week to detect the early stages of testicular cancer.”
b.) “If you notice an enlarged testicle or a painless lump, call your health care provider.”
The external male genital structures include the:
a. ) Testis.
b. ) Scrotum.
c. ) Epididymis.
d. ) Vas deferens.
b.) Scrotum.
The nurse is providing patient teaching about an erectile dysfunction drug. One of the drug’s potential side effects is prolonged, painful erection of the penis without sexual stimulation, which is known as:
a. ) Orchitis.
b. ) Stricture.
c. ) Phimosis.
d. ) Priapism.
d.) Priapism.
