weekly quiz qestions

Question 1

How should the nurse document mild, slight non-pitting edema present at the ankles of a pregnant patient?

Answer 1

1+ on a 0-4+ scale

Question 2

A patient is having difficulty in swallowing medications and food. The nurse would document that this patient has?

Answer 2

dysphagia

Question 3

The nurse is reviewing an assessment of a patient’s peripheral pulses and notices that the documentation states that the radial pulses are “2+.” The nurse recognizes that this reading indicates what type of pulse?

A) Bounding
B) Normal
C) Weak
D) Absent

Answer 3

B) Normal

Pages: 506-507. When documenting the force, or amplitude, of pulses, 3+ indicates an increased, full, or bounding pulse, 2+ indicates a normal pulse, 1+ indicates a weak pulse, and 0 indicates an absent pulse.

Question 4

The nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment? The nurse should:

Answer 4

examine the tender area last

Question 5

Just before going home, a new mother asks the nurse about the infant’s umbilical cord. Which statements is correct?

Answer 5

It should fall off by 10-14 days

Question 6

The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to:

Answer 6

hyperactive bowel sounds

Question 7

The nurse is performing a peripheral vascular assessment on a bedridden patient and notices the following findings in the right leg: increased warmth, swelling, tenderness, tenderness to palpation, and a positive Homan’s sign. The nurse should:

Answer 7

seek emergency referral because of the risk of pulmonary embolism

Question 8

The nurse notices that the patient has had a black, tarry stool and recalls that a possible cause would be:

Answer 8

gastrointestinal bleeding

Question 9

A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:

A) diarrhea.
B) peritonitis.
C) laxative use.
D) gastroenteritis.

Answer 9

B) peritonitis.

Page: 561. Diminished or absent bowel sounds signal decreased motility from inflammation as seen with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction.

Question 10

A patient’s abdomen is bulging and stretched in appearance. The nurse should describe this finding as:

Answer 10

protuberant

Question 11

When auscultating over a patient’s femoral arteries the nurse notices the presence of a bruit on the left side. The nurse knows that:

Answer 11

bruits occur with turbulent blood flow, indicating partial occlusion.

Question 12

During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient’s abdomen. Before reporting this finding as “silent bowel sounds” the nurse should listen for at least:

A) 1 minute.
B) 5 minutes.
C) 10 minutes.
D) 2 minutes in each quadrant.

Answer 12

B) 5 minutes.

Pages: 539-540. Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding bowel sounds are completely absent.

Question 13

During an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing:

Answer 13

Raynaud’s disease/phenomenom

Question 14

A nurse notices that a patient has ascites, which indicates the presence of:
A) fluid.
B) feces.
C) flatus.
D) fibroid tumors.

Answer 14

A) fluid

Ascites is free fluid in the peritoneal cavity, and occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.

Question 15

A patients has a positive Homen’s sign. The nurse knows that a positive Homen’s sign may indicate:

Answer 15

deep vein thrombosis

Question 16

A 67-year old patient states that he recently began to have pain in his left calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for about 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing:

Answer 16

claudication

Question 17

The nurse is watching a new graduate nurse perform auscultation of a patient’s abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?
A) “We need to determine areas of tenderness before using percussion and palpation.”
B) “It prevents distortion of bowel sounds that might occur after percussion and palpation.”
C) “It allows the patient more time to relax and therefore be more comfortable with the physical examination.”
D) “This prevents distortion of vascular sounds such as bruits and hums that might occur after percussion and palpation.”

Answer 17

B) “It prevents distortion of bowel sounds that might occur after percussion and palpation.”

Auscultation is performed first (after inspection) because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.

Question 18

During an abdominal assessment, the nurse elicits tenderness on light palpation in the lower right quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures?

Answer 18

appendix

Question 19

The nurse is reviewing risk factors for venous disease. Which of these situations best describes a person at highest risk for development of venous disease?
A) Woman in her second month of pregnancy
B) Person who has been on bed rest for 4 days
C) Person with a 30-year, 1 pack per day smoking history
D) Elderly person taking anticoagulant medication

Answer 19

B) person who has been on bed rest for 4 days

At risk for venous disease are people who undergo prolonged standing, sitting, or bed rest. Hypercoagulable (not anticoagulated) states and vein wall trauma also place the person at risk for venous disease. Obesity and pregnancy are also risk factors, but not the early months of pregnancy.

Question 20

During an assessment, the nurse notices that a patient’s left arm is swollen from the shoulder down to the fingers, with non-pitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem?

Answer 20

lymphedema

Question 21

During an assessment of a 26 year old at the clinic for a “spot on my lip I think is cancer” the nurse notices a group of clear vesicles with an erythematous base around them located at the lip/skin border. The patient mentions that she just returned form Hawaii. What would be the most appropriate response from the nurse?

Answer 21

Tell the patient it is most likely herpes simplex 1 and will heal in 4 to 10 days.

Question 22

A patient visits the clinic because he has recently noticed that the left side of his mouth is paralyzed. He states that he cannot raise his eyebrow or whistle. The nurse suspects that he has?

Answer 22

Bell’s Palsy

Question 23

A 19 yr old college student is brought tho the ED with a severe headache he describes as “like nothing I have ever had before” Hie temp 104 F and he has a stiff neck. The nurse looks for other signs and symptoms of what?

Answer 23

meningitis

Question 24

During an assessment of an infant, the nurse notes that the fontanels are depressed and sunken. The nurse suspects what?

A) Rickets
B) Dehydration
C) Mental retardation
D) Increased intracranial pressure

Answer 24

B. dehydration

Depressed and sunken fontanels occur with dehydration or malnutrition. Mental retardation and rickets have no effect on fontanels. Increased intracranial pressure would cause tense or bulging, and possibly pulsating fontanels.

Question 25

A patient's lab data reveal an elevated thyroxine level. The nurse would proceed to examine what gland?

Answer 25

thyroid

Question 26

The nurse suspects that a patient has hyperthyroidism and laboratory data indicate that the patient's thyroxine and tri-iodothyronine hormone levels are elevated. Which of these findings would the nurse most likely find on examination? A) Tachycardia B) Constipation C) Rapid dyspnea D) Atrophied nodular thyroid

Answer 26

A) Tachycardia Thyroxine and tri-iodothyronine are thyroid hormones that stimulate the rate of cellular metabolism, resulting in tachycardia. With an enlarged thyroid as in hyperthyroidism, the nurse might expect to find diffuse enlargement (goiter) or a nodular lump, but not an atrophied gland. Dyspnea and constipation are not findings associated with hyperthyroidism.

Question 27

Nurse is palpating sinus areas. If they are normal the patient will report what sensation?

Answer 27

firm pressure

Question 28

Patient presents with excruciating headache on one side of head, around his eye, forehead and cheek. They last 1/2 - 2 hours and happen once or twice a day. The nurse suspects what?

Answer 28

cluster headaches

Question 29

A woman comes to the clinic and states, "I've been sick for so long! My eyes have gotten so puffy, and my eyebrows and hair have become coarse and dry." The nurse will assess for other signs and symptoms of: A) cachexia. B) Parkinson's syndrome. C) myxedema. D) scleroderma.

Answer 29

C) myxedema. Pages: 276-277. Myxedema (hypothyroidism) is a deficiency of thyroid hormone that, when severe, causes a nonpitting edema or myxedema. The patient will have a puffy edematous face especially around eyes (periorbital edema), coarse facial features, dry skin, and dry, coarse hair and eyebrows. See Table 13-4, Abnormal Facial Appearances with Chronic Illnesses, for descriptions of the other responses.

Question 30

A male patient with a history of AIDS has come in for an examination and states, "I think that I have the mumps." The nurse would begin by examing what?

Answer 30

parotid gland

Question 31

A 92 yr old patient has had a stroke. The right side of his face is drooping. The nurse might also suspect which of these assessment findings?

Answer 31

dysphagia

Question 32

The nurse is assessing a patient in the hospital who has received numerous antibiotics and notices that his tongue appears to be black and hairy. In response to his concern what would the nurse say?

Answer 32

This is a fungal infection caused by all the antibiotics you've received.

Question 33

During an examination of a female patient, the nurse notes lymphadenopathy and suspects and acute infection. Acutely infected lymph nodes would feel how?

Answer 33

firm but freely movable

Question 34

A patient has been diagnosed with strep throat. The nurse is aware that without treatment, what complication may occur?

Answer 34

rheumatic fever

Question 35

During an admission assessment, the nurse notices that a male patient has an enlarged and rather thick skull. The nurse suspects acromegaly and would further assess for what?

Answer 35

coarse facial features

Question 36

A patient presents with complete paralysis to the right side of her face. She states that she cannot wrinkle her forehead, raise eyebrow, close eye, whistle, or show teeth. The nurse suspects Bell's palsy and knows that it indicates what?

Answer 36

paralysis of cranial nerve VII

Question 37

A patient complains that while studying for an examination he began to notice a severe headache in the frontotemporal area of his head that is throbbing and is somewhat relieved when he lies down. He tells the nurse that his mother also had these headaches. The nurse suspects that he may be suffering from what?

Answer 37

migraine headaches

Question 38

During a check up, a 22 yr old woman tells the nurse that she uses an over the counter nasal spray because of her allergies. She also states that it does not work as well as it used to when she started using it. The best response by the nurse would be what?

Answer 38

"Using these nasal medications irritates the lining of the nose and may cause rebound swelling"

Question 39

During a well baby check, the nurse notices that a 1 week old infant's face looks small compared with his cranium, which seems enlarged. On further examination, the nurse also notices dilated scalp veins and down cast "setting sun" eyes. What condition does the nurse suspect?

Answer 39

hydrocephaly

Question 40

During an assessment of a 20 yr old patient with a 3 day history of nausea and vomiting, the nurse notices dry mucosa and deep vertical fissures in the tongue. These findings are reflective of what?

Answer 40

dehydration

Question 41

A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain would the nurse be concerned about with these findings?

Answer 41

Cerebellum

Question 42

A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination on him. During the tests of cognitive function the nurse would expect that he:

Answer 42

will be oriented to place and person but may not be certain of the date

Question 43

During a mental status examination, the nurse wants to assess a patient's affect. The nurse should ask the patient which question? A) "How do you feel today?" B) "Would you please repeat the following words?" C) "Have these medications had any effect on your pain?" D) "Has this pain affected your ability to get dressed by yourself?"

Answer 43

A) "How do you feel today?" Page: 74. Judge mood and affect by body language and facial expression and by asking directly, "How do you feel today?" or "How do you usually feel?" The mood should be appropriate to the person's place and condition and should change appropriately with topics.

Question 44

During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This is an example of:

Answer 44

compulsive disorder

Question 45

The nurse is testing the function of cranial nerve XI. Which of these best describes the response the nurse should expect if the nerve is intact? The patient:

Answer 45

moves the head and shoulders against resistance with equal strength

Question 46

The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to:

Answer 46

give him the Four Unrelated Words Test

Question 47

The nurse is reviewing a patient’s medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?

Answer 47

6

Question 48

When the nurse asks a 68-year-old patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as a(n): A) ataxia. B) lack of coordination. C) negative Homans' sign. D) positive Romberg sign.

Answer 48

D) positive Romberg sign. Page: 638. Abnormal findings for Romberg test include swaying, falling, and widening base of feet to avoid falling. Positive Romberg sign is loss of balance that is increased by closing of the eyes. Ataxia is uncoordinated or unsteady gait. Homans' sign is used to test the legs for deep vein thrombosis.

Question 49

During an examination, the nurse can assess mental status by which activity? A) Examining the patient's electroencephalogram B) Observing the patient as he or she performs an IQ test C) Observing the patient and inferring health or dysfunction D) Examining the patient's response to a specific set of questions

Answer 49

C) Observing the patient and inferring health or dysfunction Page: 71. Mental status cannot be scrutinized directly like the characteristics of skin or heart sounds. Its functioning is inferred through assessment of an individual's behaviors, such as consciousness, language, mood and affect, and other aspects.

Question 50

A patient drifts off to sleep when she is not being stimulated. The nurse can arouse her easily when calling her name, but she remains drowsy during the conversation. The best description of this

Answer 50

patient’s level of consciousness would be: | lethargic

Question 51

A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not _____ four unrelated words _____.

Answer 51

recall; after a 30-minute delay

Question 52

The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented?

Answer 52

“I know that my name is John. I am at the hospital in Spokane. I couldn’t tell you what date it is, but I know that it is February of a new year—2010

Question 53

The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status? A) Mental status assessment diagnoses specific psychiatric disorders. B) Mental disorders occur in response to everyday life stressors. C) Mental status functioning is inferred through assessment of an individual's behaviors. D) Mental status can be assessed directly, just like other systems of the body (e.g., cardiac and breath sounds).

Answer 53

C) Mental status functioning is inferred through assessment of an individual's behaviors. Page: 71. Mental status functioning is inferred through assessment of an individual's behaviors. It cannot be assessed directly like characteristics of the skin or heart sounds.

Question 54

A patient describes feeling an unreasonable, irrational fear of snakes. It is so persistent that he can no longer comfortably even look at pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. The nurse recognizes that he:

Answer 54

has a snake phobia

Question 55

During the history, a patient tells the nurse that “it feels like the room is spinning around me.” The nurse would document this as:

Answer 55

vertigo

Question 56

The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment? A) Cranial nerves, motor function, and sensory function B) Deep tendon reflexes, vital signs, and coordinated movements C) Level of consciousness, motor function, pupillary response, and vital signs D) Mental status, deep tendon reflexes, sensory function, and pupillary response

Answer 56

C) Level of consciousness, motor function, pupillary response, and vital signs Pages: 660-661. Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be monitored closely for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure. The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.

Question 57

Which of these individuals would the nurse consider at highest risk for a suicide attempt?

Answer 57

Elderly man who tells the nurse that he is going to “join his wife in heaven” tomorrow and plans to use a gun

Question 58

During a mental status assessment, which question by the nurse would best assess a person's judgment? A) "Do you feel that you are being watched, followed, or controlled?" B) "Tell me about what you plan to do once you are discharged from the hospital." C) "What does the statement, 'People in glass houses shouldn't throw stones,' mean to you?" D) "What would you do if you found a stamped, addressed envelope lying on the sidewalk?"

Answer 58

B) "Tell me about what you plan to do once you are discharged from the hospital." Pages: 76-77. A person exercises judgment when he or she can compare and evaluate the alternatives in a situation and reach an appropriate course of action. Rather than testing the person's response to a hypothetical situation (as illustrated in the option with the envelope), the nurse should be more interested in the person's judgment about daily or long-term goals, the likelihood of acting in response to delusions or hallucinations and the capacity for violent or suicidal behavior.

Question 59

During an assessment of a 22-year-old woman who has a head injury from a car accident 4 hours ago, the nurse notices the following change: pupils were equal, but now the right pupil is fully dilated and nonreactive, left pupil is 4 mm and reacts to light. What does finding this suggest? A) Injury to the right eye B) Increased intracranial pressure C) Test was not performed accurately D) Normal response after a head injury

Answer 59

B) Increased intracranial pressure Pages: 662-663. In a brain-injured person, a sudden, unilateral, dilated, and nonreactive pupil is ominous. Cranial nerve III runs parallel to the brainstem. When increasing intracranial pressure pushes the brainstem down (uncal herniation), it puts pressure on cranial nerve III, causing pupil dilation. The other responses are incorrect.

Question 60

While obtaining a history of a 3-month-old infant from the mother, the nurse asks about the infant’s ability to suck and grasp the mother’s finger. What is the nurse assessing?

Answer 60

Reflexes

Question 61

A 70-year-old woman tells the nurse that every time she gets up in the morning or after she’s been sitting she gets “really dizzy” and feels like she is going to fall over. The nurse’s best response would be

Answer 61

“You need to get up slowly when you’ve been lying or sitting”

Question 62

During an assessment of the cranial nerves, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these cranial nerves?

Answer 62

Motor component of VII

Question 63

A patient has been diagnosed with a ganglion cyst over the dorsum of his left wrist. He asks the nurse, “What is this thing?” The nurse’s best answer would be,

Answer 63

“It is a common benign tumor”

Question 64

During a neonatal examination, the nurse notices that the newborn infant has six toes. This finding is documented as: During a neonatal examination, the nurse notices that the newborn infant has six toes. This finding is documented as: A) unidactyly. B) syndactyly. C) polydactyly. D) multidactyly.

Answer 64

C) polydactyly

Question 65

The nurse is teaching a class on osteoporosis prevention to a group of postmenopausal woman. A participant shows that she needs more instruction when she states.

Answer 65

“I will start swimming to increase my weight-bearing exercise.”

Question 66

A patient states, “I can hear a crunching or grating sound when I kneel.” She also states that “it is very difficult to get out of bed in the morning because of stiffness and pain in my joints.” The nurse should assess for signs of what problem?

Answer 66

Crepitation

Question 67

The nurse should use which test to check for large amounts of fluid around the patella?

Answer 67

Ballottement

Question 68

An 85-year-old patient comments during his annual physical that he seems to be getting shorter as he ages. The nurse should explain that decreased height occurs with aging because:

Answer 68

of the shortening of the vertebral column

Question 69

The nurse has completed the musculoskeletal examination of a patient’s knee and has found a positive bulge sign. The nurse interprets this finding to indicate:

Answer 69

swelling from fluid in the suprapatellar pouch

Question 70

A 14-year-old boy who has been diagnosed with Osgood-Schlatter disease reports painful swelling just below the knee for the past 5 months. Which response by the nurse is appropriate?

Answer 70

“Your disease is due to repeated stress on the patellar tendon. It is usually self-limited, and your symptoms should resolve with rest.”

Question 71

A patient has been diagnosed with osteoporosis and asks the nurse, “What is osteoporosis?” The nurse explains to the patient that osteoporosis is defined as:

Answer 71

loss of bone density

Question 72

A patient is being assessed for range of joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called:

Answer 72

adduction

Question 73

``` A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform which movement? A) flexion. B) abduction. C) adduction. D) extension. ```

Answer 73

A) flexion. Flexion, or bending a limb at a joint, would be required to move the hand to the mouth. Extension is straightening a limb at a joint. Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body.

Question 74

``` A woman who is 8 months pregnant comments that she has noticed a change in posture and is having lower back pain. The nurse tells her that during pregnancy women have a posture shift to compensate for the enlarging fetus. This shift in posture is known as: A) lordosis. B) scoliosis. C) ankylosis. D) kyphosis. ```

Answer 74

A) lordosis. Lordosis compensates for the enlarging fetus, which would shift the center of balance forward. This shift in balance in turn creates strain on the low back muscles, felt as low back pain during late pregnancy by some women. Scoliosis is lateral curvature of portions of the spine; ankylosis is extreme flexion of the wrist, as seen with severe rheumatoid arthritis; and kyphosis is an enhanced thoracic curvature of the spine.

Question 75

The nurse suspects that a patient has carpal tunnel syndrome and wants to perform the Phalen's test. To perform this test, the nurse should instruct the patient to: A) dorsiflex the foot. B) plantarflex the foot. C) hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. D) hyperextend the wrists with the palmar surface of both hands touching and wait for 60 seconds.

Answer 75

C) hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. For the Phalen's test, the nurse should ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. The Phalen's test reproduces numbness and burning in a person with carpal tunnel syndrome. The other actions are not correct for testing for carpal tunnel syndrome.

Question 76

What statement is true regarding the vertebra prominens? The vertebra prominens is: A. opposite the interior border of the scapula. B. usually not palpable in most individuals. C. located next to the manubrium of the sternum. D. the spinous process of C7.

Answer 76

D. the spinous process of C7.

Question 77

A 40-year-old man has come into the clinic with complaints of “extreme tenderness in my toes.” The nurse notices that his toes are slightly swollen, reddened, and warm to the touch. His complaints would suggest:

Answer 77

acute gout

Question 78

A patient tells the nurse that “all my life I’ve been called ‘knock knees.’” The nurse knows that another term for “knock knees” is:

Answer 78

genu valgum

Question 79

``` A patient who has had rheumatoid arthritis for years comes to the clinic to ask about changes in her fingers. The nurse will assess for signs of what problems? A) Heberden's nodes B) Bouchard's nodules C) Swan neck deformities D) Dupuytren's contractures ```

Answer 79

C) Swan neck deformities

Question 80

A patient is complaining of pain in his joints that is worse in the morning, is better after he has moved around for awhile, and then gets worse again if he sits for long periods of time. The nurse should assess for other signs of what problem? A) Tendinitis B) Osteoarthritis C) Rheumatoid arthritis D) Intermittent claudication

Answer 80

C) Rheumatoid arthritis

Question 81

When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What Grade should the nurse record using a 0 to 5 point scale?

Answer 81

5

Question 82

The nurse is examining a 3-month-old infant. While holding the thumbs on the infant’s inner mid thighs and the fingers outside on the hips, touching the greater trochanter, the nurse adducts the legs until the nurse’s thumbs touch and then abducts the legs until the infant’s knees touch the table. The nurse does not notice any “clunking” sounds and is confident to record a: A) positive Allis test. B) negative Allis test. C) positive Ortolani's sign. D) negative Ortolani's sign.

Answer 82

D. negative Ortolani’s sign

Question 83

Nodule

Answer 83

Solid, elevated, hard or soft, larger than 1 cm. May extend deeper into dermis than papule. Examples: xanthoma, fibroma, intradermal nevi.

Question 84

Keloid

Answer 84

A hypertrophic scar. The resulting skin level is elevated by excess scar tissue, which is invasive beyond the site of original injury. May increase long after healing occurs. Looks smooth, rubbery, and “clawlike” and has a higher incidence among African Americans.

Question 85

Papule

Answer 85

Something you can feel (i.e., solid, elevated, circumscribed, less than 1 cm diameter) caused by superficial thickening in the epidermis. Examples: elevated nevus (mole), lichen planus, molluscum, wart (verruca).

Question 86

Macule

Answer 86

Solely a color change, flat and circumscribed, of less than 1 cm. Examples: freckles, flat nevi, hypopigmentation, petechiae, measles, scarlet fever.

Question 87

Wheal

Answer 87

Superficial, raised, transient and erythematous; slightly irregular shape due to edema (fluid held diffusely in the tissues). Examples: mosquito bite, allergic reaction, dermographism.

Question 88

Zosteriform Shapes/configurations of lesions, examples

Answer 88

linear arrangement along a unilateral nerve route (e.g., herpes zoster)

Question 89

Grouped | Shapes/configuration of lesions, examples

Answer 89

cluster of lesions (e.g., vesicles of contact dermatitis)

Question 90

``` Elevated skin lesions that are greater than 1 cm in diameter are called: A. bullae. B. papules. C. nodules. D. furuncles. ```

Answer 90

C. nodules.

Question 91

``` The nurse notices that a patient has a solid, elevated, circumscribed lesion that is less than 1 cm in diameter. When documenting this finding, the nurse would report this as a: A. nodule. B. bulla. C. papule. D. vesicle. ```

Answer 91

C. papule

Question 92

During the examination of a patient, the nurse notices that the patient has several small, flat macules on the posterior portion of her thorax. These macules are less than 1 cm wide. Another name for these macules is:

Answer 92

freckles.

Question 93

Mr. Shea is a 51-year-old patient who presents with complaints of a skin lesion. On examination, you note a linear skin lesion that runs along a nerve route. Which of the following terms best describes this lesion? A. Zosteriform B. Annular C. Dermatome D. Shingles

Answer 93

A. Zosteriform

Question 94

Confluent | Shapes/configurations of lesions, examples

Answer 94

lesions run together (e.g., urticaria [hives])

Question 95

Target | Shapes/configurations of lesions, examples

Answer 95

(or iris), resembles the iris of an eye, concentric rings of color in the lesions (e.g., erythema multiforme).

Question 96

When performing the corneal light reflex assessment, the nurse notes that the light is reflected at 2 o’clock in each eye. The nurse should: A. consider this a normal finding. B. perform the confrontation test to validate the findings C. document this as an asymmetric light reflex. D. refer the individual for further evaluation.

Answer 96

A. consider this a normal finding. Reflection of the light on the corneas should be in exactly the same spot on each eye, or symmetric. If asymmetry is noted, then the nurse should administer the cover test.

Question 97

``` In a patient who has anisocoria, the nurse would expect to observe: A. dilated pupils. B. excessive tearing. C. pupils of unequal size. D. an uneven curvature of the lens. ```

Answer 97

C. pupils of unequal size. Unequal pupil size is termed anisocoria. It exists normally in 5% of the population but may also be indicative of central nervous system disease.

Question 98

The nurse is assessing a patient who may have hearing loss. Which of these statements is true concerning air conduction? A. It is the normal pathway for hearing. B. It is caused by the vibrations of bones in the skull. C. The amplitude of sound determines the pitch that is heard. D. A loss of air conduction is called a conductive hearing loss.

Answer 98

A. It is the normal pathway for hearing. The normal pathway of hearing is air conduction, which starts when sound waves produce vibrations on the tympanic membrane. Conductive hearing loss results from a mechanical dysfunction of the external or middle ear.

Question 99

The nurse just noted from a patient’s medical record that the patient has a lesion that is confluent in nature. On examination, the nurse would expect to find:

Answer 99

lesions that run together.

Question 100

A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been having trouble with reading the paper, sewing, and even seeing the faces of her grandchildren. On examination, the nurse notes that she has some loss of central vision but her peripheral vision is normal. These findings suggest that: A. she may have macular degeneration. B. her vision is normal for someone her age. C. she has the beginning stages of cataract formation. D. she has increased intraocular pressure or glaucoma

Answer 100

A. she may have macular degeneration. Macular degeneration is the most common cause of blindness. It is characterized by loss of central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most common type of glaucoma, involves a gradual loss of peripheral vision.

Question 101

``` During an otoscopic examination, the nurse notices an area of black and white dots on the tympanic membrane and ear canal wall. What does this finding suggest? A. Malignancy B. Viral infection C. Blood in the middle ear D. Yeast or fungal infection ```

Answer 101

D. Yeast or fungal infection A colony of black or white dots on the drum or canal wall suggests a yeast or fungal infection (otomycosis).

Question 102

A patient’s vision is recorded as 20/30 when the Snellen eye chart is used. The nurse interprets these results to indicate that: A. at 30 feet the patient can read the entire chart. B. the patient can read at 20 feet what a person with normal vision can read at 30 feet. C. the patient can read the chart from 20 feet in the left eye and 30 feet in the right eye. D. the patient can read from 30 feet what a person with normal vision can read from 20 feet.

Answer 102

B. the patient can read at 20 feet what a person with normal vision can read at 30 feet. The top number indicates the distance the person is standing from the chart; the denominator gives the distance at which a normal eye can see.

Question 103

A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates that: A. the eyes converge to focus on the light. B. light is reflected at the same spot in both eyes. C. the eye focuses the image in the center of the pupil. D. constriction of both pupils occurs in response to bright light.

Answer 103

D. constriction of both pupils occurs in response to bright light. The pupillary light reflex is the normal constriction of the pupils when bright light shines on the retina. The other responses are not correct.

Question 104

The nurse is testing a patient’s visual accommodation, which refers to which action? A. Pupillary constriction when looking at a near object B. Pupillary dilation when looking at a far object C. Changes in peripheral vision in response to light D. Involuntary blinking in the presence of bright light

Answer 104

D. Pupillary constriction when looking at a near object The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision, which also results in pupil constriction. The other responses are not correct.

Question 105

``` A patient’s vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean that the patient: A. is presbyopic. B. has normal vision. C. has acute vision. D. has poor vision. ```

Answer 105

D. has poor vision. Normal visual acuity is 20/20 in each eye. The larger the denominator, the poorer the vision.

Question 106

``` During an examination, the patient states he is hearing a buzzing sound and says that it is “driving me crazy!” The nurse recognizes that this symptom indicates: A. vertigo. B. pruritus. C. tinnitus. D. cholesteatoma. ```

Answer 106

C. tinnitus. Tinnitus is a sound that comes from within a person; it can be a ringing, crackling, or buzzing sound. It accompanies some hearing or ear disorders.

Question 107

``` The nurse is reviewing for a class in age-related changes in the eye. Which of these physiological changes is responsible for presbyopia? A. Degeneration of the cornea B. Loss of lens elasticity C. Decreased adaptation to darkness D. Decreased distance vision abilities ```

Answer 107

B. Loss of lens elasticity The lens loses elasticity and decreases its ability to change shape to accommodate for near vision. This condition is called presbyopia.

Question 108

The nurse is performing the diagnostic positions test. Normal findings would be which of these results?

Answer 108

Parallel movement of both eyes A normal response for the diagnostic positions test is parallel tracking of the object with both eyes. Eye movement that is not parallel indicates weakness of an extraocular muscle or dysfunction of the cranial nerve innervating it.

Question 109

The nurse suspects that a patient has otitis media. Early signs of otitis media include which of these findings of the tympanic membrane?

Answer 109

Hypomobility An early sign of otitis media is hypomobility of the tympanic membrane. As pressure increases, the tympanic membrane begins to bulge.

Question 110

The nurse is performing an otoscopic examination on an adult. Which of these actions is correct?

Answer 110

Pull the pinna up and back before inserting the speculum. Pull the pinna up and back on an adult or older child. This helps straighten the S-shape of the canal. Traction should not be released on the ear until the examination is completed and the otoscope is removed.

Question 111

The nurse is preparing to do an otoscopic examination on a 2-year-old child. Which of these reflects correct procedure?

Answer 111

Pull the pinna down. For an otoscopic examination, pull the pinna down on an infant and a child under 3 years of age. The other responses are not part of the correct procedure

Question 112

The nurse is performing an ear examination of an 80-year-old patient. Which of these would be considered a normal finding?

Answer 112

A high-tone frequency loss A high-tone frequency hearing loss is apparent for those affected with presbycusis, the hearing loss that occurs with aging. The pinna loses elasticity, causing earlobes to be pendulous. The eardrum may be whiter in color and more opaque and duller than in the young adult.

Question 113

The nurse is taking the history of a patient who may have a perforated eardrum. What would be an important question in this situation?

Answer 113

"Was there any relationship between the ear pain and the discharge you mentioned?” Typically with perforation, ear pain occurs first, stopping with a popping sensation, and then drainage occurs.

Question 114

A 70-year-old patient tells the nurse that he has noticed that he is having trouble hearing, especially in large groups. He says he “can’t always tell where the sound is coming from” and the words often sound “mixed up.” What might the nurse suspect as the cause for this change?

Answer 114

Nerve degeneration in the inner ear Presbycusis is a type of hearing loss that occurs in 60% of those older than 65 years of age, even in people living in a quiet environment. It is a gradual sensorineural loss caused by nerve degeneration in the inner ear. Words sound garbled, and the ability to localize sound is impaired also. This communication dysfunction is accentuated when background noise is present.

Question 115

The nurse is assessing a patient’s eyes for the accommodation response and would expect to see which normal finding?

Answer 115

Convergence of the axes of the eye The accommodation reaction includes pupillary constriction and convergence of the axes of the eyes. The other responses are not correct.

Question 116

The nurse is reviewing the structures of the ear. Which of these statements concerning the eustachian tube is true?

Answer 116

It helps equalize air pressure on both sides of the tympanic membrane. The eustachian tube allows equalization of air pressure on each side of the tympanic membrane so that the membrane does not rupture (e.g., during altitude changes in an airplane). The tube is normally closed, but it opens with swallowing or yawning.

Question 117

The nurse is performing a review of symptoms. Which of these questions are appropriate as health promotion questions to ask during this time?

Answer 117

“Do you use sunscreen while outside?” The review of symptoms is not a record of physical findings or subjective or objective data. The use of sunscreen is a health promotion item.

Question 118

A physician has diagnosed a patient with purpura. After leaving the room, a nursing student asks the nurse what the physician saw that led to that diagnosis. The nurse should say, "The physician is referring to: A) that blue dilation of blood vessels in a star-shaped linear pattern on the legs." B) that fiery red, star-shaped marking on the cheek that has a solid circular center." C) that confluent and extensive patch of petechiae and ecchymoses on the feet." D) those tiny little areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color."

Answer 118

C) that confluent and extensive patch of petechiae and ecchymoses on the feet." Purpura is a confluent and extensive patch of petechiae and ecchymoses and a flat macular hemorrhage seen in generalized disorders such as thrombocytopenia and scurvy. The blue dilation of blood vessels in a star-shaped linear pattern on the legs describes a venous lake. The fiery red, star-shaped marking on the cheek that has a solid circular center describes a spider or star angioma. The tiny little areas of hemorrhage that are less than 2 mm, round, discrete, and dark red in color describes petechiae.

Question 119

The nurse is bathing an 80-year-old man and notices that his skin is wrinkled, thin, lax, and dry. This finding would be related to which factor? A) Increased vascularity of the skin in the elderly B) Increased numbers of sweat and sebaceous glands in the elderly C) An increase in elastin and a decrease in subcutaneous fat in the elderly D) An increased loss of elastin and a decrease in subcutaneous fat in the elderly

Answer 119

D) An increased loss of elastin and a decrease in subcutaneous fat in the elderly An accumulation of factors place the aging person at risk for skin disease and breakdown: the thinning of the skin, the decrease in vascularity and nutrients, the loss of protective cushioning of the subcutaneous layer, a lifetime of environmental trauma to skin, the social changes of aging, the increasingly sedentary lifestyle, and the chance of immobility.

Question 120

During an examination, the nurse finds that a patient has excessive dryness of the skin. The best term to describe this condition is: A) xerosis. B) pruritus. C) alopecia. D) seborrhea.

Answer 120

A) xerosis.

Question 121

The nurse has discovered decreased skin turgor in a patient and knows that this is an expected finding in which of these conditions? A) Severe obesity B) Childhood growth spurts C) Severe dehydration D) Connective tissue disorders such as scleroderma

Answer 121

C) Severe dehydration Decreased skin turgor is associated with severe dehydration or extreme weight loss. Page 215

Question 122

A patient is especially worried about an area of skin on her feet that has turned white. The health care provider has told her that her condition is vitiligo. The nurse explains to her that vitiligo is:

Answer 122

caused by the complete absence of melanin pigment in that particular area. Vitiligo is the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, body folds, and around orifices—otherwise the depigmented skin is normal.

Question 123

T or F Nutrition screening is required for all patients in all health care settings within 24 hours.

Answer 123

True Nutrition screening, the first step in assessing nutritional status, is required for all patients in all health care settings within 24 hours of admission.

Question 124

A patient has been admitted for severe psoriasis. The nurse can expect to see what finding in the patient’s fingernails?

Answer 124

Pitting Pitting nails are characterized by sharply defined pitting and crumbling of the nails with distal detachment, and they are associated with psoriasis. See Table 12-13 for descriptions of the other terms.

Question 125

The nurse is assessing for clubbing of the fingernails and would expect to find: A) a nail base that is firm and slightly tender. B) curved nails with a convex profile and ridges across the nail. C) a nail base that feels spongy with an angle of the nail base of 150 degrees. D) an angle of the nail base of 180 degrees or greater with a nail base that feels spongy.

Answer 125

D) an angle of the nail base of 180 degrees or greater with a nail base that feels spongy. The normal nail is firm at its base and has an angle of 160 degrees. In clubbing, the angle straightens to 180 degrees or greater and the nail base feels spongy. Pages: 217-218

Question 126

A 65-year-old man with emphysema and bronchitis has come to the clinic for a follow-up appointment. On assessment, the nurse might expect to see which assessment finding? A) Anasarca B) Scleroderma C) Pedal erythema D) Clubbing of the nails

Answer 126

D) Clubbing of the nails Clubbing of the nails occurs with congenital cyanotic heart disease, neoplastic, and pulmonary diseases. The other responses are assessment findings not associated with pulmonary diseases. Pages 217-218

Question 127

The nurse keeps in mind that a thorough skin assessment is very important because the skin holds information about a person's: A) support systems. B) circulatory status. C) socioeconomic status. D) psychological wellness.

Answer 127

B) circulatory status. The skin holds information about the body's circulation, nutritional status, and signs of systemic diseases as well as topical data on the integument itself.

Question 128

A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would: A) tell the patient to watch the lesion and report back in 2 months. B) refer the patient because of the suspicion of melanoma on the basis of her symptoms. C) ask additional questions regarding environmental irritants that may have caused this condition. D) suspect that this is a compound nevus, which is very common in young to middle-aged adults.

Answer 128

B) refer the patient because of the suspicion of melanoma on the basis of her symptoms. The ABCD danger signs of melanoma are asymmetry, border irregularity, color variation, and diameter. In addition, individuals may report a change in size, development of itching, burning, bleeding, or a new-pigmented lesion. Any of these signs raise suspicion of malignant melanoma and warrant immediate referral. Pages: 212-213

Question 129

List the 4 assessment techniques and know what is involved with each

Answer 129

Inspection – begins the moment you meet a person and develops a “general survey.” Always comes first. Palpation – follows inspection and confirms points noted during inspection. Applies sense of touch to assess these factors: texture, temperature, moisture, organ location and size, as well as any swelling, vibration or pulsation, rigidity or spasticity, creptitation, presence of lumps or masses, and presence of tenderness or pain Percussion – tapping the person’s skin with short, sharp strokes to assess underlying structures. Depicts the location, size, and density of an underlying organ. Auscultation – listening to sounds produced by the body, such as heart and blood vessels and lungs and abdomen.

Question 130

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 locations in the breast.

Answer 130

B. The location of most breast tumors

Question 131

During an interview, a patient reveals that she is pregnant. She states that she is not sure whether she will breastfeed her baby and asks for some information about this. Which of these statements by the nurse is accurate with regard to breastfeeding? A) "Breastfed babies tend to be more colicky." B) "Breastfeeding provides the perfect food and antibodies for your baby." C) "Breastfed babies eat more often than infants on formula." D) "Breastfeeding is second nature and every woman can do it."

Answer 131

B. Breastfeeding provides the perfect food and antibodies for your baby.

Question 132

When a breastfeeding mother is diagnosed with a breast abscess, which of these instructions from the nurse is correct? The mother needs to: A) continue to nurse on both sides to encourage milk flow. B) discontinue nursing immediately to allow for healing. C) temporarily discontinue nursing on affected breast and manually express milk and discard it. D) temporarily discontinue nursing on affected breast but can manually express milk and give it to the baby.

Answer 132

C) temporarily discontinue nursing on affected breast and manually express milk and discard it.

Question 133

A 55-year-old postmenopausal woman is being seen in the clinic for a yearly examination. She is concerned about changes in her breasts that she has noticed over the past 5 years. She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem "flat and flabby." The nurse's best reply would be: A) "This change occurs most often because of long-term use of bras that do not provide enough support to the breast tissues." B) "This is a normal change that occurs as women get older. It is due to the increased levels of progesterone during the aging process." C) "Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast. This is a normal process of aging." D) "Postural changes in the spine make it appear that your breasts have changed in shape. Exercises to strengthen the muscles of the upper back and chest wall will help to prevent the changes in elasticity and size."

Answer 133

C) "Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast. This is a normal process of aging."

Question 134

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.

Answer 134

C) This finding is not unusual, but the nurse should verify that this change is not new.

Question 135

A woman has just learned that she is pregnant. What are some things the nurse should teach her about her breasts? A) She can expect her areolae to become larger and darker in color. B) Breasts may begin secreting milk after the fourth month of pregnancy. C) She should inspect her breasts for visible veins and report this immediately. D) During pregnancy, breast changes are fairly uncommon; most of the changes occur after the birth.

Answer 135

A) She can expect her areolae to become larger and darker in color.

Question 136

A 9-year-old girl is in the clinic for a sports physical. After some initial shyness she finally asks, "Am I normal? I don't seem to need a bra yet, but I have some friends who do. What if I never get breasts?" The nurse's best response would be: A) "Don't worry, you still have plenty of time to develop." B) "I know just how you feel, I was a late bloomer myself. Just be patient and they will grow." C) "You will probably get your periods before you notice any significant growth in your breasts." D) "I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age."

Answer 136

D) "I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age."

Question 137

The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place them at a higher risk for breast cancer? A) 37 year old who is slightly overweight B) 42 year old who has had ovarian cancer C) 45 year old who has never been pregnant D) 65 year old whose mother had breast cancer

Answer 137

D) 65 year old whose mother had breast cancer

Question 138

The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct? A) "Your breast milk is present immediately after delivery of the baby." B) "Breast milk is rich in protein and sugars (lactose) but has very little fat." C) "The colostrum, which is present right after birth, does not contain the same nutrition as breast milk does." D) "You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy."

Answer 138

D) "You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy."

Question 139

In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse's best course of action? A) Recommend that he make an appointment with his physician for a mammogram. B) Ignore it; it is not unusual for men to have benign breast enlargement. C) Explain that this condition may be the result of hormonal changes and recommend that he see his physician. D) Tell him that gynecomastia in men is usually associated with prostate enlargement and recommend that he be screened thoroughly.

Answer 139

C. Explain that this condition may be the result of hormonal changes and recommend that he see his physician

Question 140

A woman is in the family planning clinic seeking birth control information. She states that her breasts "change all month long" and that she is worried that this is unusual. What is the nurse's best response? A) Tell her that it is unusual. The breasts of nonpregnant females usually stay pretty much the same all month long. B) Tell her that it is very common for breasts to change in response to stress and that she should assess her life for stressful events. C) Tell her that, because of the changing hormones during the monthly menstrual cycle, cyclic breast changes are common. D) Tell her that breast changes normally occur only during pregnancy and that a pregnancy test is needed at this time.

Answer 140

C. Tell her that, because of changing hormones during the monthly menstrual cycle, cyclic breast changes are common

Question 141

During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's most appropriate response to this would be: A) "Don't worry about the pain; breast cancer is not painful." B) "I would like some more information about the pain in your left breast." C) "Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct." D) "Breast pain is almost always the result of benign breast disease."

Answer 141

B. I would like some more information about the pain in your left breast.

Question 142

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

Answer 142

A. Supine with arms raised over her head

Question 143

``` A 14-year-old girl is anxious about not having reached menarche. When taking the history, the nurse should ascertain which of the following? The age: A) she began to develop breasts B) her mother developed breasts C) she began to develop pubic hair D) she began to develop axillary hair. ```

Answer 143

A) she began to develop breasts

Question 144

The nurse has palpated a lump in a female patient's right breast. The nurse documents this as a small, round, firm, distinct, lump located at 2 o'clock, 2 cm from the nipple. It is nontender and fixed. There is no associated retraction of skin or nipple, no erythema, and no axillary lymphadenopathy. Which of these statements reveals the information that is missing from the documentation? It is missing information about: A) the shape of the lump. B) the lump's consistency. C) the size of the lump. D) whether the lump is solitary or multiple.

Answer 144

C. The size of the lump

Question 145

The nurse is assisting with a self-breast examination clinic. Which of these women reflect abnormal findings during the inspection phase of breast examination? A) Woman whose nipples are in different planes (deviated) B) Woman whose left breast is slightly larger than her right C) Nonpregnant woman whose skin is marked with linear striae D) Pregnant woman whose breasts have a fine blue network of veins visible under the skin

Answer 145

A) Woman whose nipples are in different planes (deviated)

Question 146

A 65-year-old patient remarks that she just can't believe that her breasts sag so much. She states it must be from lack of exercise. What explanation should the nurse offer her? A) After menopause, only women with large breasts experience sagging. B) After menopause, sagging is usually due to decreased muscle mass within the breast. C) After menopause, a diet that is high in protein will help maintain muscle mass, which keeps the breasts from sagging. D) After menopause, the glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag.

Answer 146

D) After menopause, the glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag.

Question 147

The most important reason to share information and offer brief teaching while performing the physical examination is to help: 1. the examiner feel more comfortable and gain control of the situation. 2. build rapport and increase the patient's confidence in the examiner. 3. the patient understand his or her disease process and treatment modalities. 4. the patient identify questions about his or her disease and potential areas of patient education.

Answer 147

2. build rapport and increase the patient's confidence in the examiner.

Question 148

The most important step that the nurse can take to prevent transmission of nosocomial infections in the hospital setting is to: 1. wear protective eye wear at all times. 2. wear gloves during any and all contact with patients. 3. wash hands before and after contact with each patient. 4. clean the stethoscope with an alcohol swab between patients.

Answer 148

3. wash hands before and after contact with each patient.

Question 149

Before auscultating the abdomen for the presence of bowel sounds on a patient, the nurse will: 1. warm the end piece of the stethoscope by placing it in warm water. 2. leave the gown on so that the patient does not get chilled during the examination. 3. make sure that the bell side of the stethoscope is turned to the "on" position. 4. check the temperature of the room and offer blankets to the patient if he or she feels cold.

Answer 149

4. check the temperature of the room and offer blankets to the patient if he or she feels cold.

Question 150

When performing the physical assessment, the examiner should: 1. perform the examination from the left side of the bed. 2. examine tender or painful areas first to help relieve the patient's anxiety. 3. follow the same examination sequence regardless of the patient's age or condition. 4. organize the assessment so that the patient does not change positions too often.

Answer 150

4. organize the assessment so that the patient does not change positions too often.

Question 151

When performing a physical assessment, the technique the nurse will always use first is: 1. palpation. 2. inspection. 3. percussion. 4. auscultation.

Answer 151

2. inspection.

Question 152

The inspection phase of the physical assessment: 1. yields little information. 2. takes time and reveals a surprising amount of information. 3. may be somewhat uncomfortable for the expert practitioner. 4. requires a quick glance at the patient's body systems before proceeding on with palpation.

Answer 152

2. takes time and reveals a surprising amount of information.

Question 153

A patient states that the pain medication is “not working” and rates his postoperative pain at a 10 on a 1 to 10 scale. Which of these assessment findings indicates an acute pain response to poorly controlled pain?

Answer 153

Increased blood pressure and pulse Responses to poorly controlled acute pain include tachycardia, elevated blood pressure, and hypoventilation. Confusion and depression are associated with poorly controlled chronic pain. See Table 10-1.

Question 154

Which statement is true regarding the diaphragm of the stethoscope? 1. Use the diaphragm to listen for high-pitched sounds. 2. Use the diaphragm to listen for low-pitched sounds. 3. Hold the diaphragm lightly against the person's skin to block out low-pitched sounds. 4. Hold the diaphragm lightly against the person's skin to listen for extra heart sounds and murmurs.

Answer 154

1. Use the diaphragm to listen for high-pitched sounds.

Question 155

Which technique of assessment is used to determine the presence of crepitus, swelling, and pulsations? 1. Palpation 2. Inspection 3. Percussion 4. Auscultation

Answer 155

1. Palpation

Question 156

When evaluating the temperature of older adults, the nurse remembers which aspect about an older adult’s body temperature?

Answer 156

It is lower than that of younger adults. In older adults, temperature is usually lower than in other age groups, with a mean temperature of 36.2° C (97.2° F).

Question 157

The nurse is performing a general survey. Which action is a component of the general survey?

Answer 157

Observing the patient’s body stature and nutritional status The general survey is a study of the whole person that includes observation of physical appearance, body structure, mobility, and behavior.

Question 158

Which of the following statements is true regarding the stethoscope and its use? 1. The slope of the earpieces should point posteriorly (toward the occiput). 2. The stethoscope does not magnify sound but does block out extraneous room noise. 3. The fit and quality of the stethoscope are not as important as its ability to magnify sound. 4. The ideal tubing length should be 22 inches long to dampen distortion of sound.

Answer 158

2. The stethoscope does not magnify sound but does block out extraneous room noise. The stethoscope does not magnify sound but does block out extraneous room sounds. The slope of the earpieces should point forward toward the examiner’s nose. Longer tubing will distort sound. The fit and quality of the stethoscope are important.

Question 159

The nurse is assessing a patient's skin during an office visit. What is the best technique to use to best assess the patient's skin temperature? 1. Use the fingertips because they're more sensitive to small changes in temperature. 2. Use the dorsal surface of the hand because the skin is thinner than on the palms. 3. Use the ulnar portion of the hand because there is increased blood supply that enhances temperature sensitivity. 4. Use the palmar surface of the hand because it is most sensitive to temperature variations because of increased nerve supply in this area.

Answer 159

2. Use the dorsal surface of the hand because the skin is thinner than on the palms.

Question 160

The nurse is preparing to percuss to assess the underlying: 1. tissue turgor. 2. tissue texture. 3. tissue density. 4. tissue consistency.

Answer 160

3. tissue density.

Question 161

When assessing the force, or strength, of a pulse, the nurse recalls that it:

Answer 161

is a reflection of the heart’s stroke volume. The heart pumps an amount of blood (the stroke volume) into the aorta. The force flares the arterial walls and generates a pressure wave, which is felt in the periphery as the pulse.

Question 162

The nurse is examining a 2-year-old child and asks, "May I listen to your heart now?" Which critique of her technique is most accurate? 1. Asking questions enhances the child's autonomy. 2. Asking the child for permission helps to develop a sense of trust. 3. This is an appropriate statement because children at this age like to have choices. 4. Children at this age like to say "No." The examiner should not offer a choice when there is none.

Answer 162

4. Children at this age like to say "No." The examiner should not offer a choice when there is none.

Question 163

When assessing the quality of a patient’s pain, the nurse should ask which question?

Answer 163

“What does your pain feel like?” To assess the quality of a person’s pain, have the patient describe the pain in his or her own words.

Question 164

The nurse is preparing to assess a patient's abdomen by palpation. How should the nurse proceed? 1. Avoid palpation of reported "tender" areas because this may cause the patient pain. 2. Quickly palpate the area to avoid any discomfort that the patient may experience. 3. Begin the assessment with deep palpation, encouraging the patient to relax and take deep breaths. 4. Start with light palpation to detect surface characteristics and to accustom the patient to being touched.

Answer 164

4. Start with light palpation to detect surface characteristics and to accustom the patient to being touched.

Question 165

The nurse is assessing a patient’s pain. The nurse knows that the most reliable indicator of pain would be the:

Answer 165

subjective report. The subjective report is the most reliable indicator of pain. Physical examination findings can lend support, but the clinician cannot base the diagnosis of pain exclusively on physical assessment findings.

Question 166

When listening to heart sounds, the nurse knows that S1: A) is louder than S2 at the apex of the heart. B) indicates the beginning of diastole. C) coincides with the carotid artery pulse. D) is caused by closure of the semilunar valves.

Answer 166

A. is heard louder than S2 at the apex of the heart. Although S1 and S2 are heard throughout the heart, S1 is louder than S2 at the apex of the heart.

Question 167

A 45-year-old man is in the clinic for a routine physical. During the history the patient states he's been having difficulty sleeping. "I'll be sleeping great and then I wake up and feel like I can't get my breath." The nurse's best response to this would be: A) "When was your last electrocardiogram?" B) "It's probably because it's been so hot at night." C) "Do you have any history of problems with your heart?" D) "Have you had a recent sinus infection or upper respiratory infection?"

Answer 167

C) "Do you have any history of problems with your heart?" Paroxysmal nocturnal dyspnea occurs with heart failure. Lying down increases volume of intrathoracic blood, and the weakened heart cannot accommodate the increased load. Classically, the person awakens after 2 hours of sleep, arises, and flings open a window with the perception of needing fresh air.

Question 168

The nurse is preparing to auscultate for heart sounds. Which technique is correct? A) Listen to the sounds at the aortic, tricuspid, pulmonic, and mitral areas. B) Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex. C) Listen to the sounds only at the site where the apical pulse is felt to be the strongest. D) Listen for all possible sounds at a time at each specified area.

Answer 168

B) Listen by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex. Do not limit auscultation of breath sounds to only four locations. Sounds produced by the valves may be heard all over the precordium. Inch the stethoscope in a rough Z pattern from the base of the heart across and down, then over to the apex. Or, start at the apex and work your way up. See Figure 19-22. Listen selectively to one sound at a time.

Question 169

The precordium is:

Answer 169

the area of the anterior chest overlying the heart and great vessels.

Question 170

In assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would: A) palpate the artery in the upper one third of the neck. B) listen with the bell of the stethoscope to assess for bruits. C) palpate both arteries simultaneously to compare amplitude. D) instruct patient to take slow deep breaths during auscultation.

Answer 170

B) listen with the bell of the stethoscope to assess for bruits. If cardiovascular disease is suspected, then the nurse should auscultate each carotid artery for the presence of a bruit. The nurse should avoid compressing the artery because this could create an artificial bruit, and it could compromise circulation if the carotid artery is already narrowed by atherosclerosis. Avoid excessive pressure on the carotid sinus area higher in the neck; excessive vagal stimulation here could slow down the heart rate, especially in older adults. Palpate only one carotid artery at a time to avoid compromising arterial blood to the brain.

Question 171

``` During an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate: A) a valvular disorder. B) blood flow turbulence (bruit). C) fluid volume overload. D) ventricular hypertrophy ```

Answer 171

B) blood flow turbulence (bruit). A bruit is a blowing, swishing sound indicating blood flow turbulence; normally none is present.

Question 172

A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous exam, the nurse notes that her blood pressure in her second month was 124/80 mm Hg. In evaluating this change, what does the nurse know to be true?

Answer 172

This is the result of peripheral vasodilatation and is an expected change. Despite the increased cardiac output, arterial blood pressure decreases in pregnancy because of peripheral vasodilatation. The blood pressure drops to its lowest point during the second trimester and then rises after that.

Question 173

During a cardiovascular assessment, the nurse knows that a “thrill” is A. a vibration that is palpable. B. palpated in the right epigastric area. C. a murmur auscultated at the third intercostal space. D. associated with ventricular hypertrophy.

Answer 173

A. a vibration that is palpable. A thrill is a palpable vibration. It signifies turbulent blood flow and accompanies loud murmurs. The absence of a thrill does not rule out the presence of a murmur.

Question 174

During an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse? A) Third left intercostal space at the midclavicular line B) Fourth left intercostal space at the sternal border C) Fourth left intercostal space at the anterior axillary line D) Fifth left intercostal space at the midclavicular line

Answer 174

D) Fifth left intercostal space at the midclavicular line The apical impulse should occupy only one intercostal space, the fourth or fifth, and it should be at or medial to the midclavicular line.

Question 175

When listening to heart sounds, the nurse knows that the valve closures that can be heard best at the base of the heart are:

Answer 175

aortic and pulmonic. The second heart sound (S2) occurs with closure of the semilunar (aortic and pulmonic) valves and signals the end of systole. Although it is heard over all the precordium, S2 is loudest at the base of the heart.

Question 176

A 30-year-old woman with a history of mitral valve problems states that she has been “very tired.” She has started waking up at night and feels like her “heart is pounding.” During the assessment, the nurse palpates a thrill and lift at the fifth left intercostal space midclavicular line. In the same area the nurse also auscultates a blowing, swishing sound right after S1. These findings would be most consistent with:

Answer 176

mitral regurgitation. Mitral regurgitation subjective findings include fatigue, palpitation, and orthopnea. Objective findings are (1) a thrill in systole at apex, (2) lift at apex, (3) apical impulse displaced down and to the left, (4) S1 diminished, S2 accentuated, S3 at apex often present, and (5) murmur: pansystolic, often loud, blowing, best heard at apex, radiating well to the left axilla.

Question 177

While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse’s response?

Answer 177

No further response is needed because this is normal. The rhythm should be regular, although sinus arrhythmia occurs normally in young adults and children. With sinus arrhythmia, the rhythm varies with the person’s breathing, increasing at the peak of inspiration, and slowing with expiration.

Question 178

In assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 and slightly irregular; split S2. Which of these findings can be explained by expected hemodynamic changes related to age?

Answer 178

Increase in systolic blood pressure With aging, there is an increase in systolic blood pressure. No significant change in diastolic pressure occurs with age. No change in resting heart rate occurs with aging. Cardiac output at rest is not changed with aging.

Question 179

Which of these statements describes the closure of the valves in a normal cardiac cycle?

Answer 179

The tricuspid valve closes slightly later than the mitral valve. Events occur just slightly later in the right side of the heart because of the route of myocardial depolarization. As a result, two distinct components to each of the heart sounds exist, and sometimes they can be heard separately. In the first heart sound, the mitral component (M1) closes just before the tricuspid component (T1).

Question 180

The findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:

Answer 180

elevated pressure related to heart failure. Because no cardiac valve exists to separate the superior vena cava from the right atrium, the jugular veins give information about activity on the right side of the heart. They reflect filling pressures and volume changes. Normal jugular venous pulsation is 2 cm or less above the sternal angle. Elevated pressure is more than 3 cm above the sternal angle at 45 degrees and occurs with heart failure.

Question 181

The nurse is assessing a patient’s apical impulse. Which of these statements is true regarding the apical impulse?

Answer 181

Its location may be indicative of heart size. The apical impulse is palpable in about 50% of adults. It is located in the fifth left intercostal space in the midclavicular line. Horizontal or downward displacement of the apical impulse may indicate an enlargement of the left ventricle.

Question 182

The nurse is preparing for a class on risk factors for hypertension, and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world?

Answer 182

African-Americans According to the American Heart Association, the prevalence of hypertension is higher among African-Americans than in other racial groups.

Question 183

When auscultating the heart, your first step is to: a. identify S1 and S2 b. listen for S3 and S4 c. listen for murmurs d. identify all four sounds on the first round

Answer 183

a. identify S1 and S2

Question 184

A patient comes to the clinic complaining of a cough that is worse at night but not as bad during the day. The nurse recognizes that this may indicate:

Answer 184

postnasal drip or sinusitis. A cough that occurs mainly at night may indicate postnasal drip or sinusitis. Exposure to irritants at work causes an afternoon or evening cough. Smokers experience early morning coughing. Coughing associated with acute illnesses such as pneumonia is continuous throughout the day.

Question 185

A woman in her 26th week of pregnancy states that she is “not really short of breath” but feels that she is aware of her breathing and the need to breathe. What is the nurse’s best reply?

Answer 185

“What you are experiencing is normal. Some women may interpret this as shortness of breath, but it is a normal finding and nothing is wrong.” During pregnancy, the woman may develop an increased awareness of the need to breathe. Some women may interpret this as dyspnea, even though structurally nothing is wrong. Estrogen increases relax the chest cage ligaments, causing an increase in transverse diameter. The growing fetus does increase the oxygen demand on the mother's body, but this is met easily by the increasing tidal volume (deeper breathing). Little change occurs in the respiratory rate.

Question 186

The pulse oximeter measures:

Answer 186

arterial oxygen saturation.

Question 187

During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation?

Answer 187

When the bronchial tree is obstructed Decreased or absent breath sounds occur when the bronchial tree is obstructed, as in emphysema, and when sound transmission is obstructed, as in pleurisy, pneumothorax, or pleural effusion.

Question 188

The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? “Tactile fremitus:

Answer 188

is caused by sounds generated from the larynx.” Fremitus is a palpable vibration. Sounds generated from the larynx are transmitted through patent bronchi and the lung parenchyma to the chest wall where they are felt as vibrations. Crepitus is the term for air in the subcutaneous tissues.

Question 189

The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? They are:

Answer 189

expected near the major airways. Bronchovesicular sounds are heard over major bronchi where fewer alveoli are located: posteriorly, between the scapulae, especially on the right; anteriorly, around the upper sternum in the first and second intercostal spaces. The other responses are not correct.

Question 190

During auscultation of breath sounds, the nurse should use the stethoscope correctly, in which of the following ways?

Answer 190

Listen to at least one full respiration in each location. During auscultation of breath sounds with a stethoscope, it is important to listen to one full respiration in each location. During the examination, the nurse should monitor the breathing and offer times for the person to breathe normally to prevent possible dizziness.

Question 191

One type of adventitious lung sounds, __________________, is not pathologic. They are short , popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths. May occur immediately upon waking and typically disappear after the first few breaths or after a cough.

Answer 191

atelectic crackles Atelectic crackles are often heard immediately after waking and are cleared after the first few breaths or after coughing.

Question 192

During palpation of the anterior chest wall, the nurse notices a coarse, crackling sensation over the skin surface. On the basis of these findings, the nurse suspects:

Answer 192

crepitus. Crepitus is a coarse, crackling sensation palpable over the skin surface. It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as after open thoracic injury or surgery.

Question 193

A patient has been admitted to the emergency department with a possible medical diagnosis of pulmonary embolism. The nurse expects to see which assessment findings related to this condition?

Answer 193

Chest pain that is worse on deep inspiration, dyspnea Findings for pulmonary embolism include chest pain that is worse on deep inspiration, dyspnea, apprehension, anxiety, restlessness, PaO2 less than 80, diaphoresis, hypotension, crackles, and wheezes.

Question 194

When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. This characteristic is:

Answer 194

a normal finding in a healthy adult. The right and left costal margins form an angle where they meet at the xiphoid process. Usually, this angle is 90 degrees or less. The angle increases when the rib cage is chronically overinflated, as in emphysema.

Question 195

The Angle of Louis is:.

Answer 195

the articulation of the manubrium and body of the sternum; continuous with the 2nd rib. A fissure is the narrow crack dividing the lobes of the lungs; the Xiphoid process is the sword-shaped lower tip of the sternum; and the space between the ribs is the intercostal space

Question 196

The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds?

Answer 196

Wheezes Wheezes are caused by air squeezed or compressed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors, such as with acute asthma or chronic emphysema.

Question 197

The nurse is assessing the lungs of an older adult. Which of these describes normal changes in the respiratory system of the older adult?

Answer 197

The lungs are less elastic and distensible, which decreases their ability to collapse and recoil. In the aging adult the lungs are less elastic and distensible, which decreases their ability to collapse and recoil. There is a decreased vital capacity and a loss of intraalveolar septa, causing less surface area for gas exchange. The lung bases become less ventilated, and the older person is at risk for dyspnea with exertion beyond his or her usual workload.

Question 198

The nurse is auscultating the chest in an adult. Which technique is correct?

Answer 198

Use the diaphragm of the stethoscope held firmly against the chest. The diaphragm of the stethoscope held firmly on the chest is the correct way to auscultate breath sounds. The patient should be instructed to breathe through his or her mouth, a little deeper than usual, but not to hyperventilate.

Question 199

A 65-year-old patient with a history of heart failure comes to the clinic with complaints of “being awakened from sleep with shortness of breath.” Which action by the nurse is most appropriate?

Answer 199

Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. The patient is experiencing paroxysmal nocturnal dyspnea: being awakened from sleep with shortness of breath and the need to be upright to achieve comfort.

Question 200

The nurse is observing the auscultation technique of another nurse. The correct method to use when progressing from one auscultatory site on the thorax to another is ____ comparison. A. posterior-to-anterior B. side-to-side C. interspace-by-interspace D. top-to-bottom

Answer 200

B. side-to-side Side-to-side comparison is most important when auscultating the chest. The nurse should listen to at least one full respiration in each location. The other techniques are incorrect.

Question 201

A patient has a long history of chronic obstructive pulmonary disease. During the assessment, the nurse is most likely to observe which of these?

Answer 201

An anteroposterior-to-transverse diameter ratio of 1:1 An anteroposterior-to-transverse diameter of 1:1 or “barrel chest” is seen in individuals with chronic obstructive pulmonary disease because of hyperinflation of the lungs. The ribs are more horizontal, and the chest appears as if held in continuous inspiration. Neck muscles are hypertrophied from aiding in forced respiration. Chest expansion may be decreased but symmetric. Decreased tactile fremitus occurs from decreased transmission of vibrations.

Question 202

When inspecting the anterior chest of an adult, the nurse should include which assessment?

Answer 202

The shape and configuration of the chest wall Inspection of the anterior chest includes shape and configuration of the chest wall; assessment of the patient’s level of consciousness, skin color and condition; quality of respirations; presence or absence of retraction and bulging of the intercostal spaces; and use of accessory muscles. Symmetric chest expansion is assessed by palpation. Diaphragmatic excursion is assessed by percussion of the posterior chest. Breath sounds are assessed by auscultation.

Question 203

A newborn baby boy is about to have a circumcision. The nurse knows that indications for circumcision include: A. improving the sperm count later in life. B. preventing dysuria. C. cultural and religious beliefs. D. prevention of testicular cancer.

Answer 203

C. cultural and religious beliefs

Question 204

A 22-year-old woman has been considering using oral contraceptives. As a part of her history, the nurse should ask: A. “If you smoke, how many cigarettes do you smoke per day?” B. “Have you thought this choice through carefully?” C. “Do you have a history of heart murmurs?” D. “Will you be in a monogamous relationship?”

Answer 204

A. “If you smoke, how many cigarettes do you smoke per day?”

Question 205

During an assessment of a 20-year-old man, the nurse finds a small palpable lesion with a tuft of hair located directly over the coccyx. The nurse knows that this lesion would most likely be a: A. polyp. B. pruritus ani. C. pilonidal cyst. D. carcinoma.

Answer 205

C. pilonidal cyst.

Question 206

The nurse notices that a patient has had a pale, yellow, greasy stool, or steatorrhea, and recalls that this is caused by: A. absent bile pigment. B. ingestion of bismuth preparations. C. increased fat content. D. occult bleeding.

Answer 206

C. increased fat content

Question 207

During a health history, a patient tells the nurse that he has trouble in starting his urine stream. This problem is known as: A. urgency. B. frequency. C. hesitancy. D. dribbling.

Answer 207

C. hesitancy

Question 208

The nurse is aware that which of these statements is true regarding the incidence of testicular cancer? A. The cure rate for testicular cancer is low. 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. Testicular cancer is the most common cancer in men aged 30 to 50 years.

Answer 208

C. Men with a history of cryptorchidism are at greatest risk for development of testicular cancer.

Question 209

A woman has just been diagnosed with HPV, or genital warts. The nurse should counsel her to receive regular examinations because this virus makes her at a higher risk for _____ cancer. A. uterine B. ovarian C. cervical D. endometrial

Answer 209

C. Cervical

Question 210

The changes normally associated with menopause occur generally because the cells in the reproductive tract are: A. able to respond to testosterone. B. aging. C. becoming fibrous. D. estrogen dependent.

Answer 210

D. Estrogen dependent

Question 211

A 60-year-old man has just been told he has benign prostatic hypertrophy. He has a friend who just died from cancer of the prostate, and he is concerned this will happen to him. How should the nurse respond? A. “It would be very unusual for a man your age to have cancer of the prostate.” B. “The enlargement of your prostate is caused by hormone changes and not cancer.” C. “We will treat you with chemotherapy so we can control the cancer.” D. “The swelling in your prostate is only temporary and will go away.”

Answer 211

B. “The enlargement of your prostate is caused by hormone changes and not cancer.”

Question 212

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. priapism. B. orchitis. C. phimosis. D. stricture.

Answer 212

A. priapism

Question 213

A nurse is assessing a patient’s risk of contracting a sexually transmitted infection (STI). An appropriate question to ask would be: A. “You are aware of the dangers of unprotected sex, aren’t you?” B. “Do you use a condom with each episode of sexual intercourse?” C. “Do you have a sexually transmitted infection?” D. “You know that it’s important to use condoms for protection, right?”

Answer 213

B. “Do you use a condom with each episode of sexual intercourse?”

Question 214

After completing an assessment of a 60-year-old man with a family history of colon cancer, the nurse discusses with him early detection measures for colon cancer. The nurse should mention the need for a(n): A. fecal test for blood every 6 months. B. annual proctoscopy. C. digital rectal examinations every 2 years. D. colonoscopy every 10 years.

Answer 214

D. colonoscopy every 10 years.

Question 215

During a discussion for a men’s health group, the nurse relates that the group with the highest incidence of prostate cancer is: A. Hispanics. B. Asian Americans. C. African-Americans. D. American Indians.

Answer 215

C. African-Americans.

Question 216

When performing a genitourinary assessment, the nurse notices that the urethral meatus is positioned ventrally. This finding is: A. called hypospadias. B. often associated with aging. C. the result of phimosis. D. probably due to a stricture.

Answer 216

A. called hypospadias.

Question 217

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: A. phimosis. B. urethral stricture. C. episadias. D. peyronie's disease.

Answer 217

A. phimosis.

Question 218

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: A. nocturia. B. dysuria. C. hematuria. D. polyuria.

Answer 218

B. dysuria.

Question 219

A 55-year-old man is experiencing severe pain of sudden onset in the scrotal area. It is somewhat relieved by elevation. On examination the nurse notices an enlarged, red scrotum that is very tender to palpation. It is difficult to distinguish the epididymis from the testis, and the scrotal skin is thick and edematous. This description is consistent with which of these? A. Spermatocele B. Variocele C. Epididymitis D. Testicular torsion

Answer 219

C. Epididymitis

Question 220

During the interview a patient reveals that she has some vaginal discharge. She is worried that it may be a sexually transmitted infection. The nurse’s most appropriate response to this would be: A. “Oh, don’t worry. Some cyclic vaginal discharge is normal.” B. “Have you been engaging in unprotected sexual intercourse?” C. “Have you had any urinary incontinence associated with the discharge?” D. “I’d like some information about the discharge. What color is it?”

Answer 220

D. “I’d like some information about the discharge. What color is it?”

Question 221

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: A. urinary frequency. B. stress incontinence. C. urge incontinence. D. enuresis.

Answer 221

B. stress incontinence.

Question 222

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. “The testicle is egg shaped and movable. It feels firm and has a lumpy consistency.” C. “If you notice an enlarged testicle or a painless lump, call your health care provider.” D. “Perform a testicular exam at least once a week to detect the early stages of testicular cancer.”

Answer 222

C. “If you notice an enlarged testicle or a painless lump, call your health care provider.”

Question 223

A 40-year-old black man is in the office for his annual physical. Which statement regarding the prostate-specific antigen (PSA) blood test is true, according to the American Cancer Society? The PSA: A. should be done at age 50 years. B. is only necessary if there is a family history of prostate cancer. C. should be done with the visit. D. should be done at age 45 years.

Answer 223

D. should be done at age 45 years.

Question 224

The mother of a 5-year-old girl tells the nurse that she has noticed her daughter “scratching at her bottom a lot the last few days.” During the assessment, the nurse finds redness and raised skin in the anal area. This most likely indicates: A. pinworms. B. chickenpox. C. bacterial infection. D. constipation.

Answer 224

A. pinworms.

Question 225

Syncope

Answer 225

Sudden loss of strength, a temporary loss of consciousness (a faint) due to lack of cerebral blood flow (e.g., low BP).

Question 226

The nurse places a key in the hand of a patient and he identifies it as a penny. What term would the nurse use to describe this finding? A. Extinction B. Astereognosis C. Graphesthesia D. Tactile discrimination

Answer 226

B. Astereognosis

Question 227

What are: stereognosis/astereognosis graphasthesia

Answer 227

- Stereognosis – ability to recognize objects by feeling their forms, sizes, and weights. - Astereognosis – inability to identify object correctly. Occurs in sensory cortex lesions (e.g. stroke) - Graphasthesia – ability to “read” a number by having it traced on the skin (good measure of sensory loss if person cannot make the hand movements needed for stereognosis, as occurs in arthritis)

Question 228

``` The nurse is explaining the mechanism of the growth of long bones to a mother of a toddler. Where does lengthening of the bones occur? A) Bursa B) Calcaneus C) Epiphyses D) Tuberosities ```

Answer 228

C) Epiphyses

Question 229

In a patient with acromegaly, the nurse will expect to discover which assessment findings?

Answer 229

Overgrowth of bone in the face, head, hands, and feet