South University – NSG 6020Final exam study guide
A 65-year-old patient remarks that she just can’t believe that her breasts sag so much. She states itmust
be from lack of exercise. What explanation should the nurse offer her?
The mother of a 10-year-old boy asks the nurse to discussthe recognition of puberty. The nurse should reply by saying:
“Puberty usuallybegins about age fifteen.”
“The first sign of puberty is enlargement of the testes.”
“Penis size does not increase until about the age of sixteen.”
“The development ofpubic hair precedes testicular or penis enlargement.”
A patient has bilateral pitting edema of the feet. While assessing the peripheral vascular system, the nurse’s primary focus should be:
The correct answer is: Venous function of the lower extremities
During an examination, the nurse notes severe nystagmus in both eyes of a patient. Which of the following conclusions is correct?
1.This is a normal occurrence.
2.This may indicate disease of the cerebellum or brainstem.
3.This is a sign that the patient is nervous about the examination.
4.This indicates a visual problem and a referral to an ophthalmologist is indicated.
End-point nystagmus at an extreme lateral gaze occurs normally. Assess any other nystagmus carefully. Severe nystagmus occurs with disease of the vestibular system, cerebellum, or brainstem.
When performing a musculoskeletal assessment, the nurse knows the correct approach for the examination should be:
proximal to distal
A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a breastlump in her right breast for years. Recently, it has begun to change in consistency and is becomingharder. She reports that 5 years ago her physician evaluated the lump and determined that it “wasnothing to worry about.” The examination validates the presence of a mass in the right upper outer quadrant at 1 o’clock, approximately 5 cm from the nipple. It is firm, mobile, nontender, withborders that are not well defined. The nurse’s recommendation to her is:
“Because of the change in consistency of the lump, it should be further evaluatedby a physician.”
The nurse practitioner 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 practitioner adducts the legs until the nurse practitioner’s thumbs touch and then abducts the legs until the infant’s knees touch the table. The nurse practitioner does not note any “clunking” sounds and is confident to record a:
Negative Ortolani’s sign.
A patient’s mother has noticed that her son, who has been to a new babysitter, has some blisters and scabs on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects:
The nurse is testing superficial reflexes on an adult patient. When stroking up the lateral side of the sole and across the ball of the foot, the nurse notices the plantar flexion of the toes. How would the nurse document this finding?
1.Positive Babinski sign
2.Plantar reflex abnormal
3.Plantar reflex present
4.Plantar reflex “2+” on a scale from “0 to 4+”
With the same instrument, draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot, like an upside-down “J.” The normal response is plantar flexion of the toes and sometimes of the whole foot.
A woman is in the family planning clinic seeking birth control information. She states that herbreasts “change all month long” and that she is worried that this is unusual. What is the nurse’s bestresponse?
Tell her that, because of the changing hormones during the monthly menstrualcycle, cyclic breast changes are common.
A patient states during the interview that she noticed a new breast lump in the shower a few days ago. It was on her left breast near her axilla. The RN should plan to:
palpate the unaffected breast first
A 16-yr-old girl is being seen at clinic for gastrointestinal complaints+weight loss. Nurse determines that many of her complaints may be related to erratic eating patterns, eating predominantly fast foods, + high caffeine intake. In this situation, which is most appropriate when collecting current dietary intake information?
•1. Schedule a time for direct observation of the adolescent during meals.
•2. Ask the patient for a 24-hour diet recall and assume this is reflective of a typical day for her.
3. Have the patient complete a food diary for 3 days=2 weekdays + 1 weekend day
Fooddiaries require the individual to write down everything consumed for a certaintime period. Because of the erratic eating patterns of this individual,assessing dietary intake over a few days would produce more accurateinformation regarding eating patterns. Direct observation is best used withyoung children or older adults.
To assess the head control of a 4-month-old infant, the nurse lifts the infant up in a prone position while supporting his chest. The nurse looks for what normal response?
1.Raises head and arches back.
2.Extends arms and drops head down.
3.Flexes knees and elbows with back straight.
4.Holds head at 45 degrees and keeps back straight.
At 3 months of age, the baby raises the head and arches the back as if in a swan dive. This is the Landau reflex, which persists until 11/2 years of age.
A patient has a positive Homans’ sign. The nurse knows that a positive Homans’ sign may indicate:
deep vein thrombosis.
The nurse is discussing breast self-examination with a postmenopausal woman. The best time forpostmenopausal women to perform breast self-examination is:
A=the same day every month.
A 15-year-old boy is seen in the clinic for complaints of “dull pain and pulling” in the scrotal area. On examination the nurse palpates a soft, irregular mass posterior to and above the testis on the left. This mass collapses when the patient is supine and refills when he is upright. This description is consistent with:
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?
An increased loss of elastin and a decrease in subcutaneous fat in the elderly
A woman who is 22 weeks pregnant has a vaginal infection. She tells the nurse that she is afraid that this infection will hurt the fetus. The nurse knows that which of these statements is true?
A thick mucus plug forms that protects the fetus from infection.
In assessment of 1-month-old, nurse notes a lack of response to noise or stimulation. mother reports that in the last week he has been sleeping all the time + when awake all he does is cry. nurse hears that infant’s cries are very high pitched and shrill. What would be nurse’s appropriate response?
1.Refer the infant for further testing.
2.Talk with the mother about eating habits.
3.Nothing; these are expected findings for an infant this age.
4.Tell the mother to bring the baby back in a week for a recheck.
A high-pitched shrill cry or cat-sounding screech occurs with central nervous system damage. Lethargy, hyporeactivity, hyperirritability, and parent’s report of significant change in behavior all warrant referral.
A female patient is 8 months pregnant. She 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:
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:
she began to develop breasts
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 getbreasts?” The nurse’s best response would be:
“I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age.”
During an examination, the nurse notes a supernumerary nipple just under the patient’s left breast.The patient tells the nurse that she always thought it was a mole. Which statement about this findingis correct?
It is a normal variation and not a significant finding
The major artery that supplies blood to arm
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
moves head and shoulder against resistance w/equal strength
In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of the following physical assessment findings would the nurse expect to see?
3.Loss of muscle tone and flaccidity
4.Atrophy and wasting of the muscles
Hyperreflexia, diminished or absent superficial reflexes, increased muscle tone or spasticity can be expected with upper motor neuron lesions.
A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull’s eye pattern across his midriff and behind his knees. The nurse suspects:
To assess the dorsalis pedis artery, the nurse would palpate
lateral to the extensor tendon of the great toe.The dorsalis pedis artery is located on the dorsum of the foot. Palpate just lateral to and parallel with the extensor tendon of the big toe.
The nurse is performing a neurologic assessment on a 41-year-old woman with a history of diabetes. When testing her ability to feel the vibrations of a tuning fork, the nurse notes the following: unable to feel vibrations on the great toe or ankle bilaterally; is able to feel vibrations on both patellae. Given this information, what would the nurse suspect?
4.Lesion of sensory cortex
Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Peripheral neuropathy is worse at the feet and gradually improves as you move up leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome
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 ofpulse?
During an examination, you note that a male patient has a red, round, superficial ulcer with a yellowish-serous discharge on his penis. Upon palpation, you note a nontender base that feels like a small button between your thumb and fingers. At this point you suspect that this patient has:
During an interview, a patient reveals that she is pregnant. She states that she is not sure whether shewill breastfeed her baby and asks for some information about this. Which of these statements by the nurse is accurate with regard to breastfeeding?
“Breastfeeding provides the perfect food and antibodies for your baby.”
or Breast-feeding may reduce the risk of breast cancer.
To palpate the temporomandibular joint, the nurse’s finger should be placed in the depression of the ear.
anterior to the tragus
The nurse practitioner is examining only the rectal area of a woman and should place the woman in what position?
The nurse should place the female patient in lithotomy position if examining genitalia as well; use the left lateral decubitus position for the rectal area alone.
The nurse is performing a genitourinary assessment on a 50-year-old obese male laborer. On examination the nurse notices a painless round swelling close to the pubis in the area of the internal inguinal ring that is easily reduced when the individual is supine. These findings are most consistent with a(n) _____ hernia.
The nurse is conducting a class about breast self-examination (BSE). Which of these statementsindicates proper BSE technique?
C)The best time to perform BSE is 4 to 7 days after the first day of the menstrual
A man found wandering in park at 2AM has been brought to emergency department for examination because he said he fell+hit head. During examination, nurse asks him to use his index finger to touch nurse’s finger, then own nose, then nurse’s finger again (moved to a different location). patient is clumsy, unable to follow the instructions, +overshoots mark, missing finger. nurse suspects…
3.Acute alcohol intoxication
During the finger-to-finger test, if the person has clumsy movement with overshooting the mark, either a cerebellar disorders or acute alcohol intoxication should be suspected.
Which of the following assessment findings is most consistent with clubbing of the fingernails?
An angle of the nail base of 180 degrees or greater with a nail base that feels spongy
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 patient calls the clinic for instructions before having a Papanicolaou (Pap) smear. The most appropriate instructions from the nurse are:
“Avoid intercourse, inserting anything into the vagina, or douching within 24 hours of your appointment.”
Which of the following statements is true regarding the penis?
The corpus spongiosum expends into a cone of erectile tissue called the glans
During an assessment, the nurse notes that a patient’s left arm is swollen from the shoulder down to the fingers, with nonpitting edema. The right arm is normal. The patient had a mastectomy 1 year ago. The nurse suspects which problem?
When performing the bimanual examination, the nurse notices that the cervix feels smooth and firm, is round, and is fixed in place (does not move). When cervical palpation is performed, the patient complains of some pain. The nurse’s interpretation of these results should be which of these?
The cervix should move when palpated; an immobile cervix may indicate malignancy.
You are examining a 6 month old baby. You place the baby’s feet flat on the table and flex his knees up. you note that the right knee is significantly lower than the left. Which of the following is true of this finding?
This is a positive Allis sign and suggests hip dislocation
A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because:
the woman could be at increased risk for infection and lesions because of her chronic disease
You are examining Mr. O, and when you ask him to bend forward from the waist, you notice lateral tilting; when you raise his leg straight up, he complains of a pain going down his buttock into his leg. You suspect:
herniated nucleus pulposus
The assessment of an 80-year-old patient, the nurse notes that his hands show tremors when he reaches for something and that his head is always nodding. There is no associated rigidity with movement. Which of the following statements is most accurate?
these findings are normal
Which of the following statements is true regarding the arterial system?
The arterial system is a high-pressure system.
A patient who is visiting the clinic complains of having “stomach pains for 2 weeks” and describes his stools as being “soft and black” for about the last 10 days. He denies taking any medications. The NP is aware that these symptoms are most indicative of:
occult blood resulting from gastrointestinal bleeding.
During an internal examination of a woman’s genitalia, the nurse will use which technique for proper insertion of the speculum?
Instruct the woman to bear down, turn the width of the blades horizontally, and insert the speculum at a 45-degree angle downward toward the small of the woman’s back.
During an internal examination of a woman’s genitalia, the nurse practitioner will use which technique for proper insertion of the speculum?
Insert the blades of the speculum on a horizontal plane, turning them to a 45-degree angle while continuing to insert them. Ask the woman to bear down to ease insertion.
When assessing a patient the nurse practitioner documents the left femoral pulse as 0/0-4+. Which of the following findings would the nurse practitioner expect at the dorsalis pedis pulse?
0/0-4+Pulsations are graded on a four-point scale: 0, absent; 1+, weak; 2+, normal; 3+, increased; 4+, bounding. If a pulse is absent at the femoral site, one would expect the dorsalis pedis pulse to be absent also.
A 2-year-old boy has been diagnosed with “physiologic cryptorchidism.” Given this diagnosis, during assessment the nurse will most likely observe:
An absence of the testis in the scrotum, but the testis can be milked down
The nurse practitioner is doing an assessment on a 29-year-old woman who visits the clinic complaining of “always dropping things and falling down.” While testing rapid alternating movements, the nurse practitioner notices that the woman is unable to pat both her knees. Her response is very slow and she misses frequently. What might the nurse practitioner suspect?
Dysfunction of the cerebellum
In rapid, alternating movements, slow, clumsy, and sloppy response occurs with cerebellar disease.
The wife of a 65 year old man tells the nurse that she is concerned because she has noted a change in her husband’s personality and ability to understand. He also cries and becomes angry very easily. The nurse recalls that the cerebral lobe responsible for these behaviors is which of the following?
A male patient with possible fertility problems asks the nurse where sperm is produced. The nurse knows that sperm production occurs in the:
Which of the following statements reflects the best approach to teaching a woman about breast self-examination (BSE)?
“BSE on a monthly basis will help you feel familiar with your own breasts and their normal variations.”
When assessing a patient’s pulse, the nurse practitioner notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse practitioner measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing:
A patient has had a “terrible itch” for several months that he has been scratching continuously. On examination, the nurse might expect to find:
During an annual physical exam, a 43-year-old patient states that she doesn’t perform monthly breast self-examination (BSE). She tells the nurse that she believes that mammograms “do a much better job than I ever could to find a lump.” The nurse should explain to her that:
BSEs may detect lumps that appear between mammograms./ mammography may not detect all palpable lumps.
A patient’s annual physical examination reveals a lateral curvature of the thoracic and lumbar segments of his spine; however, this curvature disappears with forward bending. This abnormality of the spine would be called:
Assessment of a 60-yr-old patient has taken longer than anticipated. in testing pain perception nurse decides to complete the test as quickly as possible. When nurse applies sharp point of pin on his arm several times, he is only able to identify these as one ‘very sharp prick.’ most accurate explanation?
1.has hyperesthesia as a result of aging process
2.most likely the result of the summation effect.
3.The nurse was probably not poking hard enough with the pin in the other areas.
4.The patient most likely has analgesia in some areas of arm and hyperalgesia in others.
ANS: 2Let at least 2 seconds elapse between each stimulus to avoid summation. With summation, frequent consecutive stimuli are perceived as one strong stimulus.
Assessing a 7-month-old infant you make a loud noise and note the following response: Abduction and flexion of arms and legs; fanning of fingers and curling of index finger and thumb in C-position; followed by infant bringing in arms and legs to body. What do you know about this?
1.This could indicate brachial nerve palsy
2.This is an expected startle response at this age
3.This reflex should disappear between 1 and 4 months of age
4.It is normal as long as movements are symmetrical bilaterally
The nurse is assessing a 75-year-old man. As the nurse beings the mental status portion of the assessment, the nurse expects that this patient:
may take a little longer to respond, but his general knowledge and abilities should not have declined.
During an external genitalia examination of a woman, the nurse notices several lesions around the vulva. The lesions are pink, moist, soft, and pointed papules. The patient states that she is not aware ofany problems in that area. The nurse recognizes that these lesions may be:
HPV or genital WARTs
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:
Refer the patient because of the suspicion of melanoma on the basis of her symptoms.
Which of the following veins are responsible for most of the venous return in the arm?
A man who has had gout for several years comes to the clinic with a “problem with my toe.” On examination, the nurse practitioner notes the presence of hard, painless nodules over the great toe; one had burst open with a chalky discharge. This finding is known as:
Tophi are collections of sodium urate crystals resulting from chronic gout in and around the joint that cause extreme swelling and joint deformity. They appear as hard, painless nodules (tophi) over the metatarsophalangeal joint of the first toe and they sometimes burst with a chalky discharge
The nurse is performing a well-child assessment on a 3-year-old child. The child’s vital signs are normal. Capillary refill time is 5 seconds. The nurse would:
1.ask the parent if the child has had frostbite in the past.
2.suspect that the child has a venous insufficiency problem.
3.consider this a delayed capillary refill time and investigate further.
4.consider this a normal capillary refill time that requires no further assessment.
Normal capillary refill time is less than 1 to 2 seconds. Note that these conditions can skew your findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia.
A 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, “What happens to my circulation when the veins are removed?” The nurse should reply:
“Because the deeper veins in your leg are in good condition, this vein can be removed without harming your circulation.”
When observing the vestibule, the nurse practitioner should be able to see the:
Urethral meatus and vaginal orifice
When the nurse is conducting sexual history from a male adolescent, which statement would be most appropriate to use at the beginning of the interview?
Often boys your age have questions about sexual activity
The nurse practitioner is palpating the abdomen of a woman who is 35 weeks’ pregnant and notes that the fetal head is facing downward toward the pelvis. The nurse practitioner would document this as:
B) Fetal presentation
Fetal presentation describes the part of the fetus that is entering the pelvis first. Fetal lie is orientation of the fetal spine to the maternal spine. Attitude is the position of the fetal parts in relation to each other, and fetal variety is the location of the fetal back to the maternal pelvis.
Which of the following factors is most likely to affect the nutritional status of an 82-year-old person?
Socioeconomic conditions frequently have the greatest effect on the nutritional status of the aging adult; these factors should be closely evaluated. Physical limitations, income, and social isolation are frequent problems and can obviously interfere with the acquisition of a balanced diet.
When performing a genital examination on a 25-year-old man, the nurse notices deeply pigmented, wrinkled scrotal skin with large sebaceous follicles. On the basis of this information the nurse would:
consider this a normal finding and proceed with the examination.
Mrs. A has had arthritis for years and is starting to notice that her fingers are drifting to this side. This is commonly referred to as:
A nurse is assessing a patient’s risk of contracting a sexually transmitted infection (STI). An appropriate question to ask would be:
“Do you use a condom with each episode of sexual intercourse?”
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 practitioner is appropriate?
“Your disease is due to repeated stress on the patellar tendon. It is usually self-limited, and your symptoms should resolve with rest.”
Which of the following is considered a normal and expected finding when the nurse practitioner is performing a physical examination on a pregnant woman?
A 54-year-old woman who has just completed menopause is in the clinic today for a yearly physical examination. Which of these statements should the nurse include in patient education? “A postmenopausal woman:
should be aware that she is at increased risk for dyspareunia because of decreased vaginal secretions.”
The nurse practitioner has completed the musculoskeletal examination of a patient’s knee and has found a positive bulge sign. The nurse suspects:
Swelling from fluid in the suprapatellar pouch
Which of the following statements is true with regard to the history of a postmenopausal woman?
When performing a genital assessment on a middle-aged man, the nurse notices multiple soft, moist, painless papules in the shape of cauliflower-like patches scattered across the shaft of the penis. These lesions are characteristic of:
During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for about 2 weeks. In trying to find the cause of the rash, which of these would beimportant for the nurse to determine?
Where did it first appear—on the nipple, the areola, or the surrounding skin?
Which of the following statements is true regarding assessment of the ankle-brachial index (ABI)?
ABI = highest ankle pressure divided by the highest brachial pressure
The patient is in her first trimester of pregnancy. She complains of feeling nauseated and has vomited on occasion. She tells the nurse that she did not have this with her first pregnancy. She asks the nurse, “What is causing this and when will it end?” How should the nurse respond?
The nausea is caused by elevated levels of progesterone and estrogen, and the nausea should end once her body adjusts to the increased hormone levels.
A professional tennis player comes in complaining of a sore elbow. You suspect that he has tenderness at:
the medial and lateral epicondyle
During a bimanual examination, the nurse detects a solid tumor on the ovary that is heavy and fixed,with a poorly defined mass. This finding is suggestive of:
When doing the history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of the following would be the best question for obtaining this information?
Do you have any warning sign before your seizure starts?
Feedback: Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor.
The nurse practitioner is assessing a 1-week-old infant and testing his muscle strength. The nurse practitioner lifts the infant with hands under the axillae and notes that the infant starts to “slip” between the hands. The nurse practitioner should:
Suspect that the infant may have weakness of the shoulder muscles
In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Whichof the following describes the nurse’s best course of action?
Explain that this condition may be the result of hormonal changes and recommendthat he see his physician.
While the nurse practitioner is taking the history of a 68-year-old patient who sustained a head injury 3 days earlier, he tells the nurse practitioner that he is on a cruise ship and is 30 years old. The nurse practitioner knows that this finding is indicative of:
Decreased level of consciousness.
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.
During an annual check-up of a 55 y/o patient, the nurse discusses the early detection measures for colon cancer. The nurse should mention the need for a
colonoscopy every 10 years
What are the two main parts of the nervous system?
Central Nervous System (CNS) and Peripheral Nervous System (PNS)
While obtaining a history of a 3-month old infant from the mother, the nurse practitioner asks about the baby’s ability to suck and grasp the mother’s finger. What is the nurse practitioner assessing?
The nurse practitioner auscultates a functional systolic murmur, grade II/IV, on a woman in week 30 of her pregnancy. The remainder of her physical assessment is within normal limits. The nurse practitioner would:
The nurse practitioner knows that classic symptoms associated with preeclampsia include:
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