PRACTICE QUESTIONS AND VERIFIED
CORRECT ANSWERS ADVANCED HEALTH
ASSESSMENT, SYSTEM FOCUSED
PHYSICAL EXAMINATION, CLINICAL
REASONING, DOCUMENTATION AND
NURSING STUDY GUIDE GRADE A+ STUDY
RESOURCE
During the assessment of an 18-month-old infant, the mother expresses
concern to the nurse about the infant's inability to toilet train. What would
be the nurse's best response?
a. "Some children are just more difficult to train, so I wouldn't worry about
it yet."
b. "Have you considered reading any of the books on toilet training? They
can be very helpful."
c. "This could mean that there is a problem in your baby's development.
We'll watch her closely for the next few months."
d. "The nerves that will allow your baby to have control over the passing of
stools are not developed until at least 18 to 24 months of age." - CORRECT
ANSWER -d. "The nerves that will allow your baby to have control over the
passing of stools are not developed until at least 18 to 24 months of age."
A 60-year-old man has just been told that he has benign prostatic
hypertrophy (BPH). He has a friend who just died from cancer of the
,prostate. He is concerned this will happen to him. How should the nurse
respond?
a. "The swelling in your prostate is only temporary and will go away."
b. "We will treat you with chemotherapy so we can control the cancer."
c. "It would be very unusual for a man your age to have cancer of the
prostate."
d. "The enlargement of your prostate is caused by hormonal changes, and
not cancer." - CORRECT ANSWER -d. "The enlargement of your prostate is
caused by hormonal changes, and not cancer."
A 30-year-old woman is visiting the clinic because of "pain in my bottom
when I have a bowel movement." The nurse should assess for which
problem?
a. Pinworms
b. Hemorrhoids
c. Colon cancer
d. Fecal incontinence - CORRECT ANSWER -b. Hemorrhoids
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 approximately
the last 10 days. He denies taking any medications. The nurse is aware that
these symptoms are mostly indicative of:
a. Excessive fat caused by malabsorption.
b. Increased iron intake, resulting from a change in diet.
c. Occult blood, resulting from gastrointestinal bleeding.
d. Absent bile pigment from liver problems. - CORRECT ANSWER -c. Occult
blood, resulting from gastrointestinal bleeding.
,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. Annual proctoscopy.
b. Colonoscopy every 10 years.
c. Fecal test for blood every 6 months.
d. DREs every 2 years. - CORRECT ANSWER -b. Colonoscopy every 10 years.
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
finding most likely indicates:
a. Pinworms.
b. Chickenpox.
c. Constipation.
d. Bacterial infection. - CORRECT ANSWER -a. Pinworms.
The nurse is examining only the rectal area of a woman and should place
the woman in what position?
a. Lithotomy
b. Prone
c. Left lateral decubitus
d. Bending over the table while standing - CORRECT ANSWER -c. Left lateral
decubitus
, While performing an assessment of the perianal area of a patient, the nurse
notices that the pigmentation of anus is darker than the surrounding skin,
the anal opening is closed, and a skin sac that is shiny and blue is noted.
The patient mentioned that he has had pain with bowel movements and has
occasionally noted some spots of blood. What would this assessment and
history most likely indicate?
a. Anal fistula
b. Pilonidal cyst
c. Rectal prolapse
d. Thrombosed hemorrhoid - CORRECT ANSWER -d. Thrombosed
hemorrhoid
The nurse is preparing to palpate the rectum and should use which of these
techniques? The nurse should:
a. Flex the finger, and slowly insert it toward the umbilicus.
b. First instruct the patient that this procedure will be painful.
c. Insert an extended index finger at a right angle to the anus.
d. Place the finger directly into the anus to overcome the tight sphincter. -
CORRECT ANSWER -a. Flex the finger, and slowly insert it toward the
umbilicus.
While performing a rectal examination, the nurse notices a firm, irregularly
shaped mass. What should the nurse do next?
a. Continue with the examination, and document the finding in the chart.
b. Instruct the patient to return for a repeat assessment in 1 month.
c. Tell the patient that a mass was felt, but it is nothing to worry about.