Exam (elaborations) NUR 6505 FINAL EXAM

Exam (elaborations) NUR 6505 FINAL EXAM 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? After menopause, the glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag. The mother of a 10-year-old boy asks the nurse to discuss the recognition of puberty. The nurse should reply by saying: “Puberty usually begins 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 of pubic 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 NUR 6505 FINAL EXAM A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a breast lump in her right breast for years. Recently, it has begun to change in consistency and is becoming harder. She reports that 5 years ago her physician evaluated the lump and determined that it “was nothing 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, with borders 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 evaluated by 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: Impetigo 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 her breasts “change all month long” and that she is worried that this is unusual. What is the nurse’s best response? Tell her that, because of the changing hormones during the monthly menstrual cycle, 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 Food diaries 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 for postmenopausal women to perform breast selfexamination 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: varicocele 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: lordosis 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 get breasts?” 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 finding is correct? It is a normal variation and not a significant finding The major artery that supplies blood to arm brachial artery 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? 1.Hyperreflexia 2.Fasciculations 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: Lyme Disease 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? 1.Hyperalgesia 2.Hyperesthesia 3.Peripheral neuropathy 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 of pulse? A.Bounding B.Normal C.Weak D.Absent 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: syphilitic chancre 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? “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. Direct inguinal The nurse is conducting a class about breast self-examination (BSE). Which of these statements indicates proper BSE technique? C) The best time to perform BSE is 4 to 7 days after the first day of the menstrual period. 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... 1.Cerebral injury 2.Cerebrovascular accident 3.Acute alcohol intoxication 4.Peripheral neuropathy 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: stress incontinence 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? Lymphedema 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 bl