NSG6020 Final #3

NSG6020 Final #3 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 breast 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? - the first sign of puberty is enlargement of the testes A patient has bilateral pitting edema of the feet. While assessing the peripheral vascular system, the nurse's primary focus should be: - venous function of the lower extremitites During an examination, the nurse notes severe nystagmus in both eyes of a patient. Which of the following conclusions is correct? - this may indicate disease of the 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 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 appear upper outer quadrant at 1 o'clock, approximately 5 cm form the nipple. It is frim, 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? - Plantar reflex present 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 1. A 16-yr-old girl is being seen at clinic for gastrointestinal complaints and 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? - 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 certain time period. Because of the erratic eating patterns of this individual, assessing dietary intake over a few days would produce more accurate information regarding eating patterns. Direct observation is best used with young 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? - Raises head and arches back. 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 self-examination is: - 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? - Refer the infant for further testing 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