NSG 6020 Advanced Health Assessment Exam: 200-Question and verified Answers

NSG 6020 Advanced Health Assessment Exam: 200-Question and verified Answers Question 1. 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. “This is due to a lack of muscle tone in the pectoral muscles, which can be improved with exercise.” B. “After menopause, the glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag.” C. “Sagging is primarily due to wearing improper support over the years.” D. “This is a normal change related to weight gain that occurs with age.” Correct Answer: B Rationale: After menopause, the decrease in estrogen leads to atrophy of glandular breast tissue and loss of fat, reducing breast volume and elasticity, which causes sagging (ptosis). This is a normal physiological change. Question 2. The mother of a 10-year-old boy asks the nurse to discuss the recognition of puberty. The nurse should reply by saying: A. “Puberty usually begins about age fifteen.” B. “The first sign of puberty is enlargement of the testes.” C. “Penis size does not increase until about the age of sixteen.” D. “The development of pubic hair precedes testicular enlargement.” Correct Answer: B Rationale: In males, the first sign of puberty is testicular enlargement (increase in testicular volume), which typically begins around age 9-14. Pubic hair usually appears later. Question 3. A patient has bilateral pitting edema of the feet. While assessing the peripheral vasculature, the nurse’s primary focus should be: A. The arterial function of the lower extremities. B. The venous function of the lower extremities. C. The neurologic function of the lower extremities. D. The lymphatic drainage of the lower extremities. Correct Answer: B Rationale: Bilateral pitting edema is most often a sign of venous insufficiency or systemic issues like heart failure, leading to fluid accumulation. Therefore, assessing venous function is the primary focus. Question 4. During examination, the nurse notes severe dryness in both eyes of a patient. Which of the following conclusions is correct? A. This is a normal occurrence. B. This may indicate disease of the cerebellum. C. This may indicate disease of the brainstem. D. This is significant if the patient is nervous about the examination. Correct Answer: C Rationale: While dry eyes can have many causes, severe bilateral dryness can be associated with neurological conditions affecting the brainstem, which controls cranial nerve function, including tear production. However, more common causes like Sjogren’s syndrome should also be considered. (Note: The provided text is slightly garbled, but it points to a neurological origin.) Question 5. A nurse is assessing a patient’s eye movements and notes nystagmus at an extreme lateral gaze. What is the most appropriate interpretation? A. This indicates a severe disease of the cerebellum. B. This is a normal finding known as end-point nystagmus. C. This indicates a disease of the brainstem. D. This is always a pathological finding that requires immediate referral. Correct Answer: B Rationale: End-point nystagmus at an extreme lateral gaze is a normal physiological finding. Nystagmus occurring in other positions or with severe intensity may indicate disease of the vestibular system, cerebellum, or brainstem. Question 6. When performing a musculoskeletal assessment, the nurse knows the correct approach for the examination should be: A. Distal to proximal. B. Proximal to distal. C. Left to right. D. Posterior to anterior. Correct Answer: B Rationale: The correct approach for a musculoskeletal assessment is proximal to distal (e.g., assessing shoulders before elbows and wrists) to get a general sense of function and symmetry before focusing on specific distal joints. Question 7. 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 validated the presence of a mass in the right upper outer quadrant at 2 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: A. “Because the lump has been there for years and is not tender, it is likely benign and no further action is needed.” B. “Because of the change in consistency of the lump, it should be further evaluated by a physician.” C. “This is a classic presentation of a fibroadenoma, which is common in women of your age.” D. “We will just monitor this lump and re-evaluate it in 6 months.” Correct Answer: B Rationale: Any change in a pre-existing breast lump, especially an increase in hardness or change in consistency, warrants further evaluation to rule out malignancy. A change in a long-standing lump is a concerning sign. Question 8. 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 of the hips, touching the greater trochanter, the nurse practitioner adducts the legs until the 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: A. Positive Ortolani’s sign. B. Negative Ortolani’s sign. C. Positive Barlow’s sign. D. Negative Galeazzi’s sign. Correct Answer: B Rationale: The Ortolani’s test is used to assess for developmental dysplasia of the hip (DDH). A negative Ortolani’s sign (no clunk) indicates that the hip is stable and not dislocated or dislocatable. Question 9. A patient’s mother has noticed that her son, who has been to a new babysitter, has some blisters and a rash on his face and buttocks. On examination, the nurse notices moist, thin-roofed vesicles with a thin erythematous base and suspects: A. Contact dermatitis. B. Scabies. C. Impetigo. D. Tinea corporis. Correct Answer: C Rationale: Impetigo is a highly contagious bacterial skin infection, often seen in children. It presents with honey-colored crusted lesions or moist, thin-roofed vesicles on an erythematous base, commonly on the face and buttocks. Question 10. 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? A. Positive Babinski sign. B. Plantar reflex abnormal. C. Plantar reflex present. D. Plantar reflex “2+” on the sacral region “oto4+”. Correct Answer: C Rationale: The normal response to stroking the lateral side of the sole is plantar flexion of the toes. This is a normal finding and should be documented as a present or negative plantar reflex (a positive Babinski sign would be dorsiflexion of the big toe and fanning of other toes). Question 11. A woman 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. “You should have a mammogram immediately to rule out cancer.” B. “Because of the changing hormones during the monthly menstrual cycle, cyclic breast changes are common.” C. “This is a sign of a hormonal imbalance that needs to be treated.” D. “You should stop drinking caffeine to see if that stops the changes.” Correct Answer: B Rationale: Cyclic breast changes, including tenderness, fullness, and nodularity, are a common physiological response to the fluctuating levels of estrogen and progesterone during the menstrual cycle. Question 12. 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: A. Palpate the affected breast first. B. Palpate the unaffected breast first. C. Palpate the axillary lymph nodes first. D. Auscultate the lump with a stethoscope. Correct Answer: B Rationale: When examining a patient with a new breast lump, it is recommended to examine the unaffected breast first. This allows the examiner to establish a baseline for normal tissue consistency before assessing the area of concern. Question 13. A 16-year-old girl is being seen at the clinic for gastrointestinal complaints. She has had several episodes of nausea, vomiting, and diarrhea. The patient’s symptoms have been intermittent and have occurred at irregular intervals. What is the most appropriate initial nursing action? A. Schedule the patient for a gastroenterologist consultation. B. Ask the patient to keep a food diary for 3 days. C. Administer an antiemetic and antidiarrheal medication. D. Order a complete blood count and comprehensive metabolic panel. Correct Answer: B Rationale: With intermittent and irregular GI symptoms, an appropriate initial step is to have the patient keep a food diary to identify potential dietary triggers or patterns associated with the symptoms. Question 14. To assess the head control of a 4-month-old infant, the nurse lifts the infant up and places the infant on the floor. The nurse then lifts the infant up and places the infant on the floor. The nurse then lifts the infant up. What is the expected response for a 4-month-old? A. Raises head and arches back. B. Head lag is still present. C. Head is held in a neutral, midline position. D. The infant is unable to lift the head at all. Correct Answer: A Rationale: By 4 months of age, an infant should have good head control. When pulled to a sitting position or lifted, the infant should be able to raise the head and arch the back, demonstrating strong neck and upper body musculature. PART 2 — NEW QUESTIONS (Questions 15-200 cover the same topics and subject matter as the source material) TOPIC: BREAST ASSESSMENT (Questions 15-30) Question 15. A 58-year-old postmenopausal woman reports a new, painless lump in her right breast. On palpation, the lump is hard, immobile, and has irregular borders. What is the most appropriate action? A. Reassure the patient that it is likely a benign cyst due to her age. B. Schedule for a diagnostic mammogram and possible ultrasound. C. Recommend a warm compress to reduce inflammation. D. Prescribe antibiotics for a potential infection. Correct Answer: B Rationale: A new, hard, immobile lump with irregular borders in a postmenopausal woman is a concerning sign for breast cancer. Immediate diagnostic imaging with mammogram and ultrasound is required. Question 16. What is the primary purpose of a clinical breast examination (CBE)? A. To diagnose breast cancer definitively. B. To screen for any abnormalities and determine the need for further diagnostic testing. C. To replace the need for mammography. D. To assess for axillary lymphadenopathy only. Correct Answer: B Rationale: A CBE is a screening tool. It is not definitive for diagnosis but helps detect palpable abnormalities that require further investigation via imaging or biopsy. Question 17. When educating a patient on breast self-awareness, the nurse should emphasize: A. Performing a breast self-exam on the same day every month. B. The importance of knowing the normal look and feel of her breasts. C. That self-exams are not recommended at all. D. That only a healthcare provider can detect changes. Correct Answer: B Rationale: Breast self-awareness emphasizes a woman’s understanding of her own breast anatomy and recognizing any new or unusual changes, rather than a rigid monthly exam schedule. Question 18. A patient presents with a tender, palpable breast mass that appears to be fluid-filled on ultrasound. The most likely diagnosis is: A. Breast cancer. B. Fibroadenoma. C. Simple cyst. D. Lipoma. Correct Answer: C Rationale: A simple cyst is a fluid-filled, benign breast lesion that is often tender. It is common in premenopausal women and appears anechoic on ultrasound. Question 19. Which of the following is a characteristic finding of a fibroadenoma? A. Hard, fixed, and irregular. B. Firm, rubbery, mobile, and well-circumscribed. C. Tender, erythematous, and fluctuant. D. Skin dimpling and nipple retraction. Correct Answer: B Rationale: A fibroadenoma is a benign breast tumor that is classically described as firm, rubbery, well-circumscribed, and mobile (“breast mouse”). Question 20. Nipple discharge that is bloody, unilateral, and associated with a breast mass is most concerning for: A. Galactorrhea. B. Intraductal papilloma. C. Fibrocystic changes. D. Breast carcinoma. Correct Answer: D Rationale: Unilateral, spontaneous, bloody nipple discharge with an associated mass is a concerning sign that raises suspicion for breast carcinoma and requires prompt evaluation.