NSG6020- FINAL EXAM REVIEW
QUESTIONS AND CORRECT VERIFIED
ANSWERS
AA265-year-
oldA2patientA2remarksA2thatA2sheA2justA2can'tA2believeA2thatA2herA2breastA2sagA2soA2much.A
2SheA2statesA2itA2mustA2beA2fromA2lackA2ofA2exercise.A2WhatA2explanationA2shouldA2theA2n
urseA2offerA2her?A2-A2Ans--
AfterA2menopause,A2theA2glandularA2andA2fatA2tissueA2atrophies,A2causingA2breastA2sizeA2
andA2elasticityA2toA2diminish,A2resultingA2inA2breastsA2thatA2sag.
TheA2motherA2ofA2aA210-year-
oldA2boyA2asksA2theA2nurseA2toA2discussA2theA2recognitionA2ofA2puberty.A2TheA2nurseA2sho
uldA2replyA2byA2saying:A2-A2Ans--
TheA2firstA2signA2ofA2pubertyA2isA2enlargementA2ofA2theA2testes
AA2patientA2hasA2bilateralA2pittingA2edemaA2ofA2theA2feet.A2WhileA2assessingA2theA2periphe
ralA2vascularA2system,A2theA2nurse'sA2primaryA2focusA2shouldA2be:A2-A2Ans--
VenousA2functionA2ofA2theA2lowerA2extremities
DuringA2anA2examination,A2theA2nurseA2notesA2severeA2nystagmusA2inA2bothA2eyesA2ofA2a
A2patient.A2WhichA2ofA2theA2followingA2conclusionsA2isA2correct?A2-A2Ans--
ThisA2mayA2indicateA2diseaseA2ofA2theA2cerebellumA2orA2brainstem
WhenA2performingA2aA2musculoskeletalA2assessment,A2theA2nurseA2knowsA2theA2correctA2
approachA2forA2theA2examinationA2shouldA2be:A2-A2Ans--proximalA2toA2distal
AA243-year-
oldA2womanA2isA2atA2theA2clinicA2forA2aA2routineA2examination.A2SheA2reportsA2thatA2sheA2h
asA2hadA2aA2breastA2lumpA2inA2herA2rightA2breastA2forA2years.A2Recently,A2itA2hasA2begunA2
toA2changeA2inA2consistencyA2andA2isA2becomingA2harder.A2SheA2reportsA2thatA25A2yearsA2
agoA2herA2physicianA2evaluatedA2theA2lumpA2andA2determinedA2thatA2itA2"wasA2nothingA2to
A2worryA2about."A2theA2examinationA2validatesA2theA2presenceA2ofA2aA2massA2inA2theA2right
A2upperA2outerA2quadrantA2atA21A2o'clockA2approximatelyA25A2cmA2fromA2theA2nipple.A2ItA2is
A2firm,A2mobile,A2non-
tender,A2withA2bordersA2thatA2areA2notA2wellA2defined.A2TheA2nurse'sA2recommendationA2t
oA2herA2is:A2-A2Ans--
BecauseA2ofA2theA2changeA2inA2consistencyA2ofA2theA2lump,A2itA2shouldA2beA2furtherA2eval
uatedA2byA2aA2physician.
TheA2nurseA2practitionerA2isA2examiningA2aA23-month-
oldA2infant.A2WhileA2holdingA2theA2thumbsA2onA2theA2infant'sA2innerA2-
midA2thighsA2andA2theA2fingersA2outsideA2onA2theA2hips,A2touchingA2theA2greaterA2trochant
er,A2theA2nurseA2practitionerA2adductsA2theA2legsA2untilA2theA2nurseA2practitioner'sA2thumb
, touchA2andA2thenA2abductsA2theA2legsA2untilA2theA2infant'sA2kneesA2touchA2theA2table.A2T
A2
heA2nurseA2practitionerA2doesA2notA2noteA2anyA2"clunking"A2soundsA2andA2isA2confidentA2t
oA2recordA2a"A2-A2Ans--NegativeA2Ortolani'sA2sign
AA2patient'sA2motherA2hasA2noticedA2thatA2herA2son,A2whoA2hasA2beenA2toA2aA2newA2babys
itterA2hasA2someA2blistersA2andA2scabsA2onA2hisA2faceA2andA2buttocks.A2OnA2examination,
A2theA2nurseA2noticesA2moist,A2thin-
roofedA2vesiclesA2withA2aA2thinA2erythematousA2baseA2andA2suspects:A2-A2Ans--Impetigo
TheA2nurseA2isA2testingA2superficialA2reflexesA2onA2aA2adultA2patient.A2WhenA2strokingA2up
A2theA2lateralA2sideA2ofA2theA2soleA2andA2acrossA2theA2ballA2ofA2theA2foot,A2theA2nurseA2noti
cesA2theA2plantarA2flexionA2ofA2theA2toes.A2HowA2wouldA2theA2nurseA2documentA2thisA2findi
ng?A2-A2Ans--PlantarA2reflexA2present
AA2womanA2isA2inA2theA2familyA2planningA2clinicA2seekingA2birthA2controlA2information.A2Sh
eA2statesA2thatA2herA2breastA2"changeA2allA2monthA2long"A2andA2thatA2sheA2isA2worriedA2th
atA2thisA2isA2unusual.A2WhatA2isA2theA2nurse'sA2bestA2response?A2-A2Ans--
TellA2herA2that,A2becauseA2ofA2theA2changingA2hormonesA2duringA2theA2monthlyA2menstru
alA2cycle,A2cyclicA2breastA2changesA2areA2common
AA2patientA2statesA2duringA2theA2interviewA2thatA2sheA2noticedA2aA2newA2breastA2lumpA2inA
2theA2showerA2aA2fewA2daysA2ago.A2ItA2wasA2onA2herA2leftA2breastA2nearA2herA2axilla.A2TheA
2RNA2shouldA2planA2to:A2-A2Ans--palpateA2theA2unaffectedA2breastA2first
AA216-year-
oldA2girlA2isA2beingA2seenA2atA2clinicA2forA2gastrointestinalA2complaintsA2andA2weightA2loss.
A2NurseA2determinesA2thatA2manyA2ofA2herA2complaintsA2mayA2beA2relatedA2toA2erraticA2ea
tingA2patterns,A2eatingA2predominantlyA2fastA2foods,A2andA2highA2caffeineA2intake.A2InA2thi
sA2situation,A2whichA2isA2mostA2appropriateA2whenA2collectingA2currentA2dietaryA2intakeA2in
formation?A2-A2Ans--
HaveA2theA2patientA2completeA2aA2foodA2diaryA2forA23A2day=A22A2weekdaysA2+A22A2weeken
dA2day.
ToA2assessA2theA2headA2controlA2ofA2aA24-month-
oldA2infant,A2theA2nurseA2liftsA2theA2infantA2upA2inA2aA2proneA2positionA2whileA2supportingA2
hisA2chest.A2TheA2nurseA2looksA2forA2whatA2normalA2response?A2-A2Ans--
RaisesA2headA2andA2archesA2back
AA2patientA2hasA2aA2positiveA2Homans'A2sign.A2theA2nurseA2knowA2thatA2aA2positiveA2Hom
ans'A2signA2mayA2indicate:A2-A2Ans--DeepA2veinA2thrombosis
TheA2nurseA2isA2discussingA2breastA2self-
A2examinationA2withA2aA2postmenopausalA2womanA2toA2performA2breastA2selfA2examinatio
nA2is:A2-A2Ans--TheA2sameA2dayA2everyA2month
QUESTIONS AND CORRECT VERIFIED
ANSWERS
AA265-year-
oldA2patientA2remarksA2thatA2sheA2justA2can'tA2believeA2thatA2herA2breastA2sagA2soA2much.A
2SheA2statesA2itA2mustA2beA2fromA2lackA2ofA2exercise.A2WhatA2explanationA2shouldA2theA2n
urseA2offerA2her?A2-A2Ans--
AfterA2menopause,A2theA2glandularA2andA2fatA2tissueA2atrophies,A2causingA2breastA2sizeA2
andA2elasticityA2toA2diminish,A2resultingA2inA2breastsA2thatA2sag.
TheA2motherA2ofA2aA210-year-
oldA2boyA2asksA2theA2nurseA2toA2discussA2theA2recognitionA2ofA2puberty.A2TheA2nurseA2sho
uldA2replyA2byA2saying:A2-A2Ans--
TheA2firstA2signA2ofA2pubertyA2isA2enlargementA2ofA2theA2testes
AA2patientA2hasA2bilateralA2pittingA2edemaA2ofA2theA2feet.A2WhileA2assessingA2theA2periphe
ralA2vascularA2system,A2theA2nurse'sA2primaryA2focusA2shouldA2be:A2-A2Ans--
VenousA2functionA2ofA2theA2lowerA2extremities
DuringA2anA2examination,A2theA2nurseA2notesA2severeA2nystagmusA2inA2bothA2eyesA2ofA2a
A2patient.A2WhichA2ofA2theA2followingA2conclusionsA2isA2correct?A2-A2Ans--
ThisA2mayA2indicateA2diseaseA2ofA2theA2cerebellumA2orA2brainstem
WhenA2performingA2aA2musculoskeletalA2assessment,A2theA2nurseA2knowsA2theA2correctA2
approachA2forA2theA2examinationA2shouldA2be:A2-A2Ans--proximalA2toA2distal
AA243-year-
oldA2womanA2isA2atA2theA2clinicA2forA2aA2routineA2examination.A2SheA2reportsA2thatA2sheA2h
asA2hadA2aA2breastA2lumpA2inA2herA2rightA2breastA2forA2years.A2Recently,A2itA2hasA2begunA2
toA2changeA2inA2consistencyA2andA2isA2becomingA2harder.A2SheA2reportsA2thatA25A2yearsA2
agoA2herA2physicianA2evaluatedA2theA2lumpA2andA2determinedA2thatA2itA2"wasA2nothingA2to
A2worryA2about."A2theA2examinationA2validatesA2theA2presenceA2ofA2aA2massA2inA2theA2right
A2upperA2outerA2quadrantA2atA21A2o'clockA2approximatelyA25A2cmA2fromA2theA2nipple.A2ItA2is
A2firm,A2mobile,A2non-
tender,A2withA2bordersA2thatA2areA2notA2wellA2defined.A2TheA2nurse'sA2recommendationA2t
oA2herA2is:A2-A2Ans--
BecauseA2ofA2theA2changeA2inA2consistencyA2ofA2theA2lump,A2itA2shouldA2beA2furtherA2eval
uatedA2byA2aA2physician.
TheA2nurseA2practitionerA2isA2examiningA2aA23-month-
oldA2infant.A2WhileA2holdingA2theA2thumbsA2onA2theA2infant'sA2innerA2-
midA2thighsA2andA2theA2fingersA2outsideA2onA2theA2hips,A2touchingA2theA2greaterA2trochant
er,A2theA2nurseA2practitionerA2adductsA2theA2legsA2untilA2theA2nurseA2practitioner'sA2thumb
, touchA2andA2thenA2abductsA2theA2legsA2untilA2theA2infant'sA2kneesA2touchA2theA2table.A2T
A2
heA2nurseA2practitionerA2doesA2notA2noteA2anyA2"clunking"A2soundsA2andA2isA2confidentA2t
oA2recordA2a"A2-A2Ans--NegativeA2Ortolani'sA2sign
AA2patient'sA2motherA2hasA2noticedA2thatA2herA2son,A2whoA2hasA2beenA2toA2aA2newA2babys
itterA2hasA2someA2blistersA2andA2scabsA2onA2hisA2faceA2andA2buttocks.A2OnA2examination,
A2theA2nurseA2noticesA2moist,A2thin-
roofedA2vesiclesA2withA2aA2thinA2erythematousA2baseA2andA2suspects:A2-A2Ans--Impetigo
TheA2nurseA2isA2testingA2superficialA2reflexesA2onA2aA2adultA2patient.A2WhenA2strokingA2up
A2theA2lateralA2sideA2ofA2theA2soleA2andA2acrossA2theA2ballA2ofA2theA2foot,A2theA2nurseA2noti
cesA2theA2plantarA2flexionA2ofA2theA2toes.A2HowA2wouldA2theA2nurseA2documentA2thisA2findi
ng?A2-A2Ans--PlantarA2reflexA2present
AA2womanA2isA2inA2theA2familyA2planningA2clinicA2seekingA2birthA2controlA2information.A2Sh
eA2statesA2thatA2herA2breastA2"changeA2allA2monthA2long"A2andA2thatA2sheA2isA2worriedA2th
atA2thisA2isA2unusual.A2WhatA2isA2theA2nurse'sA2bestA2response?A2-A2Ans--
TellA2herA2that,A2becauseA2ofA2theA2changingA2hormonesA2duringA2theA2monthlyA2menstru
alA2cycle,A2cyclicA2breastA2changesA2areA2common
AA2patientA2statesA2duringA2theA2interviewA2thatA2sheA2noticedA2aA2newA2breastA2lumpA2inA
2theA2showerA2aA2fewA2daysA2ago.A2ItA2wasA2onA2herA2leftA2breastA2nearA2herA2axilla.A2TheA
2RNA2shouldA2planA2to:A2-A2Ans--palpateA2theA2unaffectedA2breastA2first
AA216-year-
oldA2girlA2isA2beingA2seenA2atA2clinicA2forA2gastrointestinalA2complaintsA2andA2weightA2loss.
A2NurseA2determinesA2thatA2manyA2ofA2herA2complaintsA2mayA2beA2relatedA2toA2erraticA2ea
tingA2patterns,A2eatingA2predominantlyA2fastA2foods,A2andA2highA2caffeineA2intake.A2InA2thi
sA2situation,A2whichA2isA2mostA2appropriateA2whenA2collectingA2currentA2dietaryA2intakeA2in
formation?A2-A2Ans--
HaveA2theA2patientA2completeA2aA2foodA2diaryA2forA23A2day=A22A2weekdaysA2+A22A2weeken
dA2day.
ToA2assessA2theA2headA2controlA2ofA2aA24-month-
oldA2infant,A2theA2nurseA2liftsA2theA2infantA2upA2inA2aA2proneA2positionA2whileA2supportingA2
hisA2chest.A2TheA2nurseA2looksA2forA2whatA2normalA2response?A2-A2Ans--
RaisesA2headA2andA2archesA2back
AA2patientA2hasA2aA2positiveA2Homans'A2sign.A2theA2nurseA2knowA2thatA2aA2positiveA2Hom
ans'A2signA2mayA2indicate:A2-A2Ans--DeepA2veinA2thrombosis
TheA2nurseA2isA2discussingA2breastA2self-
A2examinationA2withA2aA2postmenopausalA2womanA2toA2performA2breastA2selfA2examinatio
nA2is:A2-A2Ans--TheA2sameA2dayA2everyA2month