NR-304: Health Assessment II FINAL EXAM REVIEW
What you need to know for Health Assessment final exam
1. If a patient is suffering from urine retention, what condition is that a symptom for?
- common in men due to bladder outlet obstruction such as benign prostatic hyperplasia
(BPH)
2. Which of the following group would be at most risk of getting a Pap smear?
o African American women would have not had the HPV vaccine. Pap testing
should begin at 21 years.
3. Know the chart that has different type of breast characteristics (peau d’ orange)?
o Normally has no edema is present. Edema exaggerates the hair follicles,
giving a “pigskin” or “orange-peel” look (also called peau d'orange). It has a
lymphatic obstruction that produces edema.
4. Know the tail of Spence and why it is important when palpating it.
o superior lateral corner of breast tissue, called the axillary tail of
Spence, projects up and laterally into the axilla. In the upper outer quadrant
note the axillary tail of Spence, the cone-shaped breast tissue that projects up
into the axilla, close to the pectoral group of axillary lymph nodes.
5. A woman has a bloody discharge from her nipple. What choice would the nurse
conclude?
o Dimpling and Retraction.
6. A man complaining pain at the nipple. Which of the following would make the nurse to
think that the patient has cancer?
o Bloody discharge of the nipple
7. A woman has learned that she is pregnant. What are some of the things the nurse should
teach her about her breasts?
o Breast size change in the 2nd month, nipples grow larger, darker, and more
erectile. Areolae becomes larger and dark brown as pregnancy progresses. The
brown color fades after lactation, the areolae never return to original color,
After the 4th month colostrum may be expressed. This thick, yellow fluid is
the precursor for milk, containing the same amount of protein and lactose but
practically no fat. Milk production (lactation) begins 1 to 3 days after delivery
8. A 65-year-old patient remarks that she just cannot believe that her breasts “sag so much”.
She states it must be from a lack of exercise. What explanation should the nurse offer
her?
o After menopause, the glandular and fat tissue atrophies, causing breast size
and elasticity to diminish, resulting in breasts that sag.
9. In examining a 70-year-old male patient, the nurse notices that has bilateral
gynecomastia. Which of the following describes the nurse’s best course of action?
o Explain that this condition may be the result of hormonal changes and
recommend that he see his physician
, 10. The nurse is reviewing statistics regarding breast cancer. Which woman, aged 40 years,
the United States has the highest risk for developing breast cancer?
o African-American
11. During a breast health interview, a patient states that she has noticed pain in her left
breast. The nurse’s most appropriate response to this would be:
o "I would like some more information about the pain in your left breast."
12. During a health history interview, a female patient starts that she has noticed a few drops
of clear discharge from her right nipple. What should the nurse do next?
o Ask her some additional questions about the medications she is taking.
13. During an annual physical examination, a 43-year-old patient states that she does not
perform monthly breast self-examinations (BSEs). She tells the nurses that she believes
that mammograms “do a much better job that I could find a lump”?
o BSEs may detect lumps that appear between mammograms.
14. A patient is newly diagnosed with benign breast disease. The nurse recognizes which
statement about benign breast disease to be true? The presence of benign breast disease:
o makes it harder to examine the breasts.
15. During an examination of a woman, the nurse notices that her left breast is slightly larger
than her right breast. Which of these statements is true about this finding?
o This finding is not unusual, nurse should verify that this change is not new.
16. The nurse is assisting with a SBE clinic. Which of these women reflect abnormal findings
during the inspection phase of breast examination?
o Woman whose nipples are in different planes (deviated)
17. The nurse is performing a breast examination. Which of these statements best describes
the correct procedure to use when screening for nipple and skin retraction during a breast
examination? Have the woman:
o slowly lift her arms above her head and note any retraction or lag in
movement
18. Which of these clinical situations would the nurse consider to be outside normal limits?
o A patient has had two pregnancies and she breastfed both of her children. Her
youngest child is now 10 years old. Her breast examination reveals breast
tissue that is somewhat soft and she has a small amount of thick yellow
discharge from both nipples.
19. The nurse has palpated a lump in a female patient’s right breast. The nurse documents
this as a small, round, firm distinct, lump located a 2 o’clock, 2 cm from the nipple. It is
nontender and fixed. No associated retraction of skin or nipple, no erythema, and no
axillary lymphadethopathy are observed. What information is missing from the
documentation?
o the size of the lump.
What you need to know for Health Assessment final exam
1. If a patient is suffering from urine retention, what condition is that a symptom for?
- common in men due to bladder outlet obstruction such as benign prostatic hyperplasia
(BPH)
2. Which of the following group would be at most risk of getting a Pap smear?
o African American women would have not had the HPV vaccine. Pap testing
should begin at 21 years.
3. Know the chart that has different type of breast characteristics (peau d’ orange)?
o Normally has no edema is present. Edema exaggerates the hair follicles,
giving a “pigskin” or “orange-peel” look (also called peau d'orange). It has a
lymphatic obstruction that produces edema.
4. Know the tail of Spence and why it is important when palpating it.
o superior lateral corner of breast tissue, called the axillary tail of
Spence, projects up and laterally into the axilla. In the upper outer quadrant
note the axillary tail of Spence, the cone-shaped breast tissue that projects up
into the axilla, close to the pectoral group of axillary lymph nodes.
5. A woman has a bloody discharge from her nipple. What choice would the nurse
conclude?
o Dimpling and Retraction.
6. A man complaining pain at the nipple. Which of the following would make the nurse to
think that the patient has cancer?
o Bloody discharge of the nipple
7. A woman has learned that she is pregnant. What are some of the things the nurse should
teach her about her breasts?
o Breast size change in the 2nd month, nipples grow larger, darker, and more
erectile. Areolae becomes larger and dark brown as pregnancy progresses. The
brown color fades after lactation, the areolae never return to original color,
After the 4th month colostrum may be expressed. This thick, yellow fluid is
the precursor for milk, containing the same amount of protein and lactose but
practically no fat. Milk production (lactation) begins 1 to 3 days after delivery
8. A 65-year-old patient remarks that she just cannot believe that her breasts “sag so much”.
She states it must be from a lack of exercise. What explanation should the nurse offer
her?
o After menopause, the glandular and fat tissue atrophies, causing breast size
and elasticity to diminish, resulting in breasts that sag.
9. In examining a 70-year-old male patient, the nurse notices that has bilateral
gynecomastia. Which of the following describes the nurse’s best course of action?
o Explain that this condition may be the result of hormonal changes and
recommend that he see his physician
, 10. The nurse is reviewing statistics regarding breast cancer. Which woman, aged 40 years,
the United States has the highest risk for developing breast cancer?
o African-American
11. During a breast health interview, a patient states that she has noticed pain in her left
breast. The nurse’s most appropriate response to this would be:
o "I would like some more information about the pain in your left breast."
12. During a health history interview, a female patient starts that she has noticed a few drops
of clear discharge from her right nipple. What should the nurse do next?
o Ask her some additional questions about the medications she is taking.
13. During an annual physical examination, a 43-year-old patient states that she does not
perform monthly breast self-examinations (BSEs). She tells the nurses that she believes
that mammograms “do a much better job that I could find a lump”?
o BSEs may detect lumps that appear between mammograms.
14. A patient is newly diagnosed with benign breast disease. The nurse recognizes which
statement about benign breast disease to be true? The presence of benign breast disease:
o makes it harder to examine the breasts.
15. During an examination of a woman, the nurse notices that her left breast is slightly larger
than her right breast. Which of these statements is true about this finding?
o This finding is not unusual, nurse should verify that this change is not new.
16. The nurse is assisting with a SBE clinic. Which of these women reflect abnormal findings
during the inspection phase of breast examination?
o Woman whose nipples are in different planes (deviated)
17. The nurse is performing a breast examination. Which of these statements best describes
the correct procedure to use when screening for nipple and skin retraction during a breast
examination? Have the woman:
o slowly lift her arms above her head and note any retraction or lag in
movement
18. Which of these clinical situations would the nurse consider to be outside normal limits?
o A patient has had two pregnancies and she breastfed both of her children. Her
youngest child is now 10 years old. Her breast examination reveals breast
tissue that is somewhat soft and she has a small amount of thick yellow
discharge from both nipples.
19. The nurse has palpated a lump in a female patient’s right breast. The nurse documents
this as a small, round, firm distinct, lump located a 2 o’clock, 2 cm from the nipple. It is
nontender and fixed. No associated retraction of skin or nipple, no erythema, and no
axillary lymphadethopathy are observed. What information is missing from the
documentation?
o the size of the lump.
