Quiz #4 - Chapter 22, 23, 24, 25 and 26 Flashcards
(130 cards)
1
Q
A patient is being assessed for range of joint movement. The nurse asks him to move his arm in toward the center of his body. This movement is called?
A
Moving a limb toward the midline of the body is called adduction; abduction is moving a limb away from the midline of the body.
2
Q
A patient tells the nurse that she is having a hard time bringing her hand to her mouth when she eats or tries to brush her teeth. The nurse knows that for her to move her hand to her mouth, she must perform the following movement?
A
Flexion, or bending a limb at a joint, would be required to move your hand to your mouth.
3
Q
Hematopoiesis takes place where in the body?
A
The musculoskeletal system functions to encase and protect inner vital organs, support the body, produce red blood cells in the bone marrow, and store minerals.
4
Q
The nurse notices that a woman in an exercise class is unable to jump rope. The nurse knows that to jump rope, one’s shoulder has to be capable of?
A
Circumduction is defined as moving the arm in a circle around the shoulder.
5
Q
To palpate the temporomandibular joint, the nurse’s fingers should be placed in the depression where?
A
The temporomandibular joint can be felt in the depression anterior to the tragus of the ear.
6
Q
Of the 33 vertebrae in the spinal column, there are how many in each section?
A
7 Cervical 12 Thoracic 5 Lumbar 5 Sacral 3 - 4 Coccygeal
7
Q
The nurse is checking the range of motion in a patient’s knee and knows that the knee is capable of what movements?
A
The knee is a hinge joint, permitting flexion and extension of the lower leg on a single plane.
8
Q
A woman who is 8 months pregnant 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 known as what?
A
Lordosis compensates for the enlarging fetus, which would shift the center of balance forward. This shift in balance in turn creates strain on the low back muscles, felt as low back pain during late pregnancy by some women.
9
Q
The nurse knows that the incidence of osteoporosis is greatest in which group?
A
The incidence of osteoporosis is lowest in black men and highest in white women.
10
Q
A patient is complaining of pain in his joints that is worse in the morning, is better after he has moved around for awhile, and then gets worse again if he sits for long periods of time. The nurse suspects that he may have what?
A
Rheumatoid arthritis is worse in the morning when arising. Movement increases most joint pain, except in rheumatoid arthritis, in which movement decreases pain.
11
Q
A patient states, “I can hear a crunching or grating sound when I kneel.” She also states “it is very difficult to get out of bed in the morning because of stiffness and pain in my joints.” The nurse suspects that the sound she hears is what?
A
Crepitation is an audible and palpable crunching or grating that accompanies movement and occurs when articular surfaces in the joints are roughened, as with rheumatoid arthritis.
12
Q
An 80-year-old woman is visiting the clinic for a checkup. The nurse is observing for motor dysfunction in her hip and would have her do what?
A
Limitation of abduction of the hip while supine is the most common motion dysfunction found in hip disease.
13
Q
During an examination, the nurse asks a patient to bend forward from the waist and notes that the patient has lateral tilting. When his leg is raised straight up, he complains of a pain going down his buttock into his leg. The nurse suspects what condition?
A
Lateral tilting and sciatic pain with straight leg raising are findings that occur with a herniated nucleus pulposus.
14
Q
The nurse 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 adducts the legs until the nurse’s thumbs touch and then abducts the legs until the infant’s knees touch the table. The nurse does not note any “clunking” sounds and is confident to record what?
A
Normally this maneuver feels smooth and has no sound. With a positive Ortolani sign, you will feel and hear a “clunk” as the head of the femur pops back into place.
15
Q
A 40-year-old man has come into the clinic with complaints of “extreme tenderness in my toes.” The nurse notes that his toes are slightly swollen, reddened, and warm to the touch. His complaints would suggest what condition?
A
Acute gout occurs primarily in men over 40 years of age. Clinical findings consist of redness, swelling, heat, and extreme tenderness. Gout is a metabolic disorder of disturbed purine metabolism, associated with elevated serum uric acid.
16
Q
A 68-year-old woman has come in for an assessment of her rheumatoid arthritis, and the nurse notes raised, firm, nontender nodules at the olecranon bursa and along the ulna. These nodules are most commonly diagnosed as what?
A
Subcutaneous nodules that are raised, firm, and nontender occur with rheumatoid arthritis in the olecranon bursa and along the extensor surface of the ulna.
17
Q
A woman who has had rheumatoid arthritis for years is starting to notice that her fingers are drifting to the side. The nurse knows that this condition is commonly referred to as what?
A
Fingers drift to the ulnar side because of stretching of the articular capsule and muscle imbalance caused by chronic rheumatoid arthritis.
18
Q
A patient’s annual physical examination reveals a lateral curvature of the thoracic and lumbar segments of his spine; however, this curvature disappears with forward bending. The nurse knows that this abnormality of the spine would be called what?
A
Functional scoliosis is flexible; it is apparent with standing and disappears with forward bending.
19
Q
When assessing muscle strength, the nurse observes that a patient has complete range of motion against gravity with full resistance. What should the nurse record using a 0 to 5+ scale?
A
Complete range of motion against gravity is normal muscle strength and is recorded as 5+ muscle strength.
20
Q
When performing a musculoskeletal assessment, the nurse knows that the correct approach for the examination should be in what order?
A
The musculoskeletal assessment should be done in an orderly approach, head to toe, proximal to distal.
21
Q
The nurse is assessing the joints of a woman who has stated, “I have a long family history of arthritis, and my joints hurt.” The nurse suspects that she has osteoarthritis, what are the symptoms of this condition?
A
In osteoarthritis, asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. Affected joints have stiffness, swelling with hard bony protuberances, pain with motion, and limitation of motion.
22
Q
The two parts of the nervous system are what?
A
The nervous system can be divided into two parts—central and peripheral.
The central nervous system includes the brain and spinal cord.
The peripheral nervous system includes the 12 pairs of cranial nerves (CNs), the 31 pairs of spinal nerves, and all of their branches.
23
Q
The wife of a 65-year-old man tells the nurse that she is concerned because she has noticed a change in her husband’s personality and ability to understand. He also cries very easily and becomes angry. The nurse recalls that the cerebral lobe responsible for these behaviors is the __________ lobe.
A
Its the Frontal lobe here is why:
The frontal lobe has areas responsible for personality, behavior, emotions, and intellectual function.
The parietal lobe has areas responsible for sensation; the occipital lobe is responsible for visual reception.
The temporal lobe is responsible for hearing, taste,
and smell.
24
Q
The hypothalamus is responsible for what?
A
The hypothalamus is a vital area with many important functions: body temperature controller, sleep center, anterior and posterior pituitary gland regulator, and coordinator of autonomic nervous system activity and emotional status.
25
The cerebellum is responsible for what?
The cerebellum controls motor coordination, equilibrium, and balance.
26
The basal ganglia is responsible for what?
The basal ganglia control autonomic movements
| of the body.
27
Where do the various motor pathways synapse?
The motor pathways of the spinal cord synapse in various areas of the spinal cord, not in the thalamus.
28
The area of the nervous system that is responsible for mediating reflexes is where?
The spinal cord is the main highway for ascending and descending fiber tracts that connect the brain to the spinal nerves; it is responsible for mediating reflexes.
29
To interpret the sensation of being pricked or poked which areas of your nervous system must be intact?
The spinothalamic tract contains sensory fibers that transmit the sensations of pain, temperature, and crude or light touch.
Fibers carrying pain and temperature sensations
ascend the lateral spinothalamic tract, whereas the sensations of crude touch form the anterior spinothalamic tract.
At the thalamus, the fibers synapse with another sensory neuron, which carries the message to the sensory cortex for full interpretation.
30
A patient with a lack of oxygen to his heart will have pain in his chest and possibly in the shoulder, arms, or jaw. The nurse knows that the best explanation why this occurs is which one of these statements?
The sensory cortex is arranged in a specific pattern, forming a corresponding map of the body. Pain in the right hand is perceived at a specific spot on the map.
Some organs, such as the heart, liver, and spleen, are absent from the brain map. Pain originating in these organs is referred because no felt image exists in which to have pain. Pain is felt by proxy, that is, by another body part that does have a felt image.
31
The ability that humans have to perform very skilled movements such as writing is controlled by what tract?
A. Basal ganglia.
B. Corticospinal tract.
C. Spinothalamic tract.
D. Extrapyramidal tract.
Answer is B, Corticospinal Tract,
Corticospinal fibers mediate voluntary movement, particularly very skilled, discrete, and purposeful movements, such as writing.
The corticospinal tract, also known as the pyramidal tract, is a newer, “higher” motor system that humans have that permits very skilled and purposeful movements.
32
A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these
findings would concern the nurse?
A. Thalamus
B. Brainstem
C. Cerebellum
D. Extrapyramidal tract
Answer: C, Cerebellum
The cerebellar system coordinates movement, maintains equilibrium, and helps maintain posture.
The thalamus is the primary relay station where sensory pathways of the spinal cord, cerebellum, and brainstem form synapses on their way to the cerebral cortex.
The brainstem consists of the midbrain, pons, and medulla and has various functions, especially concerning autonomic centers.
The extrapyramidal tract maintains muscle tone
for gross automatic movements, such as walking.
33
Which of these statements about the peripheral nervous system is correct?
A. The CNs enter the brain through the spinal cord.
B. Efferent fibers carry sensory input to the central
nervous system through the spinal cord.
C. The peripheral nerves are inside the central nervous
system and carry impulses through their motor
fibers.
D. The peripheral nerves carry input to the central
nervous system by afferent fibers and away from the
central nervous system by efferent fibers.
Answer, D
A nerve is a bundle of fibers outside of the central nervous system.
The peripheral nerves carry input to the central nervous system by their sensory afferent fibers and deliver output from the central nervous system by their efferent fibers.
The other responses are not related to the peripheral nervous system.
34
A patient has a severed spinal nerve as a result of trauma. Which statement is TRUE in this situation?
A. Because there are 31 pairs of spinal nerves, no effect
results if only one nerve is severed.
B. The dermatome served by this nerve will no longer
experience any sensation.
C. The adjacent spinal nerves will continue to carry
sensations for the dermatome served by the
severed nerve.
D. A severed spinal nerve will only affect motor
function of the patient because spinal nerves have
no sensory component.
Answer, C
A dermatome is a circumscribed skin area that is primarily supplied from one spinal cord segment through a particular spinal nerve. The dermatomes overlap, which is a form of biologic insurance; that is, if one nerve is severed, then most of the sensations can be
transmitted by the spinal nerve above and the spinal nerve below the severed nerve.
35
A 21-year-old patient has a head injury resulting from trauma and is unconscious. There are NO OTHER injuries. During the assessment what would the nurse expect to find when testing the patient’s deep tendon reflexes?
A. Reflexes will be normal.
B. Reflexes cannot be elicited.
C. All reflexes will be diminished but present.
D. Some reflexes will be present, depending on the
area of injury.
Answer, A
A reflex is a defense mechanism of the nervous system. It operates below the level of conscious control and permits a quick reaction to potentially painful or damaging situations.
36
A mother of a 1-month-old infant asks the nurse why it takes so long for infants to learn to roll over. The nurse knows that the reason for this is:
A. A demyelinating process must be occurring with her
infant.
B. Myelin is needed to conduct the impulses, and the
neurons of a newborn are not yet myelinated.
C. The cerebral cortex is not fully developed; therefore,
control over motor function gradually occurs.
D. The spinal cord is controlling the movement
because the cerebellum is not yet fully developed.
Answer, B
The infant’s sensory and motor development proceeds along with the gradual acquisition of myelin, which is needed to conduct most impulses.
Very little cortical control exists, and the neurons are not yet myelinated. Making the other responses are not correct.
37
During an assessment of an 80-year-old patient, the nurse notices the following: an inability to identify vibrations at her ankle and to identify the position of her big toe, a slower and more deliberate gait, and a slightly impaired tactile sensation. All other neurologic findings are normal. The nurse should interpret that these findings indicate:
A. CN dysfunction.
B. Lesion in the cerebral cortex.
C. Normal changes attributable to aging.
D. Demyelination of nerves attributable to a lesion.
Answer, C
Some aging adults show a slower response to requests, especially for those calling for coordination of movements.
The findings listed are normal in the absence of other significant abnormal findings. The other responses are incorrect.
38
A 70-year-old woman tells the nurse that every time she gets up in the morning or after she’s been sitting, she gets “really dizzy” and feels like she is going to fall over.
The nurse’s best response would be to tell her what?
Aging is accompanied by a progressive decrease in cerebral blood flow. In some people, this decrease causes dizziness and a loss of balance with a position change. These individuals need to be taught to get up slowly.
39
During the taking of the health history, a patient tells the nurse that “it feels like the room is spinning around me.” The nurse would document this finding as what?
A. Vertigo.
B. Syncope.
C. Dizziness.
D. Seizure activity.
Answer, A
True vertigo is rotational spinning caused by a neurologic dysfunction or a problem in the
vestibular apparatus or the vestibular nuclei in the brainstem.
Syncope is a sudden loss of strength or a temporary loss of consciousness.
Dizziness is a lightheaded, swimming sensation.
Seizure activity is characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances.
40
When taking the health history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. This is what type of data?
Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor.
41
In obtaining a health history on a 74-year-old patient, the nurse notes that he drinks alcohol daily and that he has noticed a tremor in his hands that affects his ability to hold things. The alcohol does not relieve the tremors, the nurse should suspect what?
Senile tremor is relieved by alcohol, although not a recommended treatment. The nurse should assess whether the person is abusing alcohol in an effort to relieve the tremor.
42
A 50-year-old woman is in the clinic for weakness in her left arm and leg that she has noticed for the past week. The nurse should perform which type of neurologic
examination?
A Glasgow Coma Scale
B. Neurologic recheck examination
C. Screening neurologic examination
D. Complete neurologic examination
Answer, D
The nurse should perform a complete neurologic examination on an individual who has neurologic concerns (e.g., headache, weakness, loss of coordination) or who is showing signs of neurologic dysfunction.
The Glasgow Coma Scale is used to define a person’s
level of consciousness.
The neurologic recheck examination is appropriate for those who are demonstrating neurologic deficits.
The screening neurologic examination is performed on seemingly well individuals who have no significant subjective findings from the health history.
43
During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate
dysfunction of which of these CNs?
```
A. Motor component of CN IV
B. Motor component of CN VII
C. Motor and sensory components
D. Motor component of CN X and sensory component
of CN VII
```
Answer, B
The findings listed reflect a dysfunction of the motor component of the facial nerve (CN VII).
44
The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient:
A. Demonstrates the ability to hear normal conversation.
B. Sticks out the tongue midline without tremors or
deviation.
C. Follows an object with his or her eyes without
nystagmus or strabismus.
D. Moves the head and shoulders against resistance
with equal strength.
Answer, D
The following normal findings are expected when testing the spinal accessory nerve (CN XI): The patient’s sternomastoid and trapezius muscles are equal in size; the person can forcibly rotate the head both ways against resistance applied to the side of the chin with
equal strength; and the patient can shrug the shoulders against resistance with equal strength on both sides.
Checking the patient’s ability to hear normal conversation checks the function of CN VIII.
Having the patient stick out the tongue checks the function of CN XII.
Testing the eyes for nystagmus or strabismus is performed to check CNs III, IV, and VI.
45
When the nurse asks a 68-year-old patient to stand with his feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. The nurse would document this finding as:
A. Ataxia.
B. Lack of coordination.
C. Negative Homans sign.
D. Positive Romberg sign.
Answer, D
Abnormal findings for the Romberg test include swaying, falling, and a widening base of the feet to avoid falling.
A positive Romberg sign is a loss of balance that is increased by the closing of the eyes.
Ataxia is an uncoordinated or unsteady gait.
Homans sign is used to test the legs for deep-vein thrombosis.
46
The nurse is performing an assessment on a 29-year-old woman who visits the clinic complaining of “always dropping things and falling down.” While testing rapid
alternating movements, the nurse notices that the woman is unable to pat both of her knees. Her response is extremely slow and she frequently misses. What should the nurse suspect?
A. Vestibular disease
B. Lesion of CN IX
C. Dysfunction of the cerebellum
D. Inability to understand directions
Answer, C
When a person tries to perform rapid, alternating movements, responses that are slow, clumsy, and sloppy are indicative of cerebellar disease.
47
The assessment of a 60-year-old patient has taken longer than anticipated. In testing his pain perception, the nurse decides to complete the test as quickly as possible. When the nurse applies the sharp point of the pin on his arm several times, he is only able to
identify these as one “very sharp prick.” What would be the most accurate explanation for this?
This is most likely the summation affect, at least 2 seconds should be allowed to elapse between each stimulus to avoid summation. With summation, frequent consecutive stimuli are perceived as one strong
stimulus.
48
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 notices that the patient is unable to feel vibrations on the great toe or ankle bilaterally, but she is able to feel vibrations on both patellae. Given this information, what would the nurse suspect?
Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Peripheral neuropathy is worse at the feet and gradually improves as the examiner moves up the leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome.
49
The nurse places a key in the hand of a patient and he incorrectly identifies it as a penny. What term would the nurse use to describe this finding?
It would be documented as Asterognosis.
Stereognosis is the person’s ability to recognize objects by feeling their forms, sizes, and weights. Whereas astereognosis is an inability to identify objects correctly, and it occurs in sensory cortex lesions.
50
In assessing a 70-year-old patient who has had a recent cerebrovascular accident, the nurse notices right-sided weakness. What might the nurse expect to find when testing his reflexes on the right side?
A. Lack of reflexes
B. Normal reflexes
C. Diminished reflexes
D. Hyperactive reflexes
Answer, D
Hyperreflexia is the exaggerated reflex observed when the monosynaptic reflex arc is released from the influence of higher cortical levels. This response occurs with upper motor neuron lesions (e.g., a cerebrovascular accident).
51
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 should the nurse document this finding?
A. Positive Babinski sign
B. Plantar reflex abnormal
C. Plantar reflex present
D. Plantar reflex 2+ on a scale from “0 to 4+”
Answer, C
With the same instrument, the nurse should draw a light stroke up the lateral side of the sole of the foot and across the ball of the foot, similar to an upside-down J.
The normal response is plantar flexion of the toes and sometimes of the entire foot.
A positive Babinski sign is abnormal and occurs with the response of dorsiflexion of the big toe and
fanning of all toes.
The plantar reflex is not graded on a 0 to 4+ scale.
52
Which of these tests would the nurse use to check the motor coordination of an 11-month-old infant?
A. Denver II
B. Stereognosis
C. Deep tendon reflexes
D. Rapid alternating movements
Answer, A
To screen gross and fine motor coordination, the nurse should use the Denver II with its age-specific developmental milestones.
Stereognosis tests a person’s ability to recognize
objects by feeling them and is not appropriate for an 11-month-old infant.
Testing the deep tendon reflexes is not appropriate for checking motor coordination.
Testing rapid alternating movements is appropriate for testing coordination in adults.
53
To assess the head control of a 4-month-old infant, the nurse lifts up the infant in a prone position while supporting his chest. The nurse looks for what normal response? The infant:
A. Raises the head, and arches the back.
B. Extends the arms, and drops down the head.
C. Flexes the knees and elbows with the back straight.
D. Holds the head at 45 degrees, and keeps the back
straight.
Answer, A
At 3 months of age, the infant raises the head and arches the back as if in a swan dive. This response is the Landau reflex, which persists until 1 years of age.
54
While assessing a 7-month-old infant, the nurse makes a loud noise and notices the following response: abduction and flexion of the arms and legs; fanning of the fingers, and curling of the index finger and thumb in a C position, followed by the infant bringing in the arms and legs to the body. What does the nurse know about this response?
A. This response could indicate brachial nerve palsy.
B. This reaction is an expected startle response at this
age.
C. This reflex should have disappeared between 1 and
4 months of age.
D. This response is normal as long as the movements
are bilaterally symmetric.
Answer, C
The Moro reflex is present at birth and usually disappears at 1 to 4 months. Absence of the Moro reflex in the newborn or its persistence after 5 months of age indicates severe central nervous system injury.
55
To test for gross motor skill and coordination of a 6-year-old child, which of these techniques would be appropriate? Ask the child to:
A. Hop on one foot.
B. Stand on his head.
C. Touch his finger to his nose.
D. Make “funny” faces at the nurse.
Answer, A
Normally, a child can hop on one foot and can balance on one foot for approximately 5 seconds by 4 years of age and can balance on one foot for 8 to 10 seconds at 5 years of age. Children enjoy performing these tests. Failure to hop after 5 years of age indicates incoordination of gross motor skills.
Asking the child to touch his or her finger to the
nose checks fine motor coordination; and asking the child to make “funny” faces tests CN VII.
Asking a child to stand on his or her head is not appropriate.
56
During the assessment of an 80-year-old patient, the nurse notices that his hands show tremors when he reaches for something and his head is always nodding. No associated rigidity is observed with movement. Which of these statements is most accurate?
A. These findings are normal, resulting from aging.
B. These findings could be related to hyperthyroidism.
C. These findings are the result of Parkinson disease.
D. This patient should be evaluated for a cerebellar
lesion.
Answer, A
Senile tremors occasionally occur. These benign tremors include an intention tremor of the hands, head nodding (as if saying yes or no), and tongue protrusion.
Tremors associated with Parkinson disease include rigidity, slowness, and a weakness of voluntary
movement. The other responses are incorrect.
57
The nurse is caring for a patient who has just had neurosurgery. To assess for increased intracranial pressure, what would the nurse include in the assessment?
A. CNs, motor function, and sensory function.
B. Deep tendon reflexes, vital signs, and coordinated
movements.
C. Level of consciousness, motor function, pupillary
response, and vital signs.
D. Mental status, deep tendon reflexes, sensory
function, and pupillary response.
Answer, C
Some hospitalized persons have head trauma or a neurologic deficit from a systemic disease process. These people must be closely monitored for any improvement or deterioration in neurologic status and for any indication of increasing intracranial pressure.
The nurse should use an abbreviation of the neurologic examination in the following sequence: level of consciousness, motor function, pupillary response, and vital signs.
58
During an assessment of a 22-year-old woman who sustained a head injury from an automobile accident 4 hours earlier, the nurse notices the following changes: pupils were equal, but now the right pupil is fully dilated and nonreactive, and the left pupil is 4 mm
and reacts to light. What do these findings suggest?
A. Injury to the right eye
B. Increased intracranial pressure
C. Test inaccurately performed
D. Normal response after a head injury
Answer, B
In a person with a brain injury, a sudden, unilateral, dilated, and nonreactive pupil is ominous.
CN III runs parallel to the brainstem. When increasing intracranial pressure pushes down the brainstem (uncal herniation), it puts pressure on CN III, causing pupil
dilation. The other responses are incorrect.
59
A 32-year-old woman tells the nurse that she has noticed “very sudden, jerky movements” mainly in her hands and arms. She says, “They seem to come and go, primarily when I am trying to do something. I haven’t noticed them when I’m sleeping.” This description suggests:
A. Tics.
B. Athetosis.
C. Myoclonus.
D. Chorea.
Answer, D
Chorea is characterized by sudden, rapid, jerky, purposeless movements that involve the limbs, trunk, or face. Chorea occurs at irregular intervals, and the movements are all accentuated by voluntary actions.
60
During an assessment of a 62-year-old man, the nurse notices the patient has a stooped posture, shuffling walk with short steps, flat facial expression, and pill-rolling finger movements. These findings would be consistent with:
A. Parkinsonism.
B. Cerebral palsy.
C. Cerebellar ataxia.
D. Muscular dystrophy.
Answer, A
The stooped posture, shuffling walk, short steps, flat facial expression, and pill-rolling finger movements are all found in parkinsonism.
61
During an assessment of a 32-year-old patient with a recent head injury, the nurse notices that the patient responds to pain by extending, adducting, and internally rotating his arms. His palms pronate, and his lower extremities extend with plantar flexion.
Which statement concerning these findings is most accurate? This patient’s response:
A. Indicates a lesion of the cerebral cortex.
B. Indicates a completely nonfunctional brainstem.
C. Is normal and will go away in 24 to 48 hours.
D. Is a very ominous sign and may indicate brainstem
injury.
Answer, D
These findings are all indicative of decerebrate rigidity, which is a very ominous condition and may indicate a brainstem injury.
62
A 78-year-old man has a history of a cerebrovascular accident. The nurse notes that when he walks, his left arm is immobile against the body with flexion of the shoulder, elbow, wrist, and fingers and adduction of the shoulder. His left leg is stiff and extended and circumducts with each step. What type of gait disturbance is this individual experiencing?
A. Scissors gait
B. Cerebellar ataxia
C. Parkinsonian gait
D. Spastic hemiparesis
Answer, D
With spastic hemiparesis, the arm is immobile against the body. Flexion of the shoulder, elbow, wrist, and fingers occurs, and adduction of the shoulder, which does not swing freely, is observed. The leg is stiff and extended and circumducts with each step. Causes of this type of gait include cerebrovascular accident.
63
In a person with an upper motor neuron lesion such as a cerebrovascular accident, which of these physical assessment findings should the nurse expect?
A. Hyperreflexia
B. Fasciculations
C. Loss of muscle tone and flaccidity
D. Atrophy and wasting of the muscles
Answer, A
Hyperreflexia, diminished or absent superficial reflexes, and increased muscle tone or spasticity can be expected with upper motor neuron lesions.
The other options reflect a lesion of lower motor neurons
64
A 59-year-old patient has a herniated intervertebral disk. Which of the following findings should the nurse expect to see on physical assessment of this individual?
A. Hyporeflexia
B. Increased muscle tone
C. Positive Babinski sign
D. Presence of pathologic reflexes
Answer, A
With a herniated intervertebral disk or lower motor neuron lesion, loss of tone, flaccidity, atrophy, fasciculations, and hyporeflexia or areflexia are demonstrated.
No Babinski sign or pathologic reflexes would be observed. The other options reflect a lesion of upper motor neurons.
65
A patient is unable to perform rapid alternating movements such as rapidly patting her knees. The nurse should document this inability as:
A. Ataxia.
B. Astereognosis.
C. Presence of dysdiadochokinesia.
D. Loss of kinesthesia.
Answer, C
Slow clumsy movements and the inability to perform rapid alternating movements occur with cerebellar disease. The condition is termed dysdiadochokinesia.
Ataxia is an uncoordinated or unsteady gait.
Astereognosis is the inability to identify an object by
feeling it.
Kinesthesia is the person’s ability to perceive passive movement of the extremities or the loss of position sense.
66
The nurse knows that determining whether a person is oriented to his or her surroundings will test the functioning of which structure(s)?
A. Cerebrum
B. Cerebellum
C. CNs
D. Medulla oblongata
Answer, A
The cerebral cortex is responsible for thought, memory, reasoning, sensation, and voluntary movement. The other structures are not responsible for a person’s level of
consciousness.
67
The nurse knows that testing kinesthesia is a test of a person’s:
A. Fine touch.
B. Position sense.
C. Motor coordination.
D. Perception of vibration
Answer, B
Kinesthesia, or position sense, is the person’s ability to perceive passive movements of the extremities. The other options are incorrect.
68
The nurse is reviewing a patient’s medical record and notes that he is in a coma. Using the Glasgow Coma Scale, which number indicates that the patient is in a coma?
A. 6
B. 12
C. 15
D. 24
Answer, A
A fully alert, normal person has a score of 15, whereas a score of 7 or less reflects coma on the Glasgow Coma Scale
69
A 69-year-old patient has been admitted to an adult psychiatric unit because his wife thinks he is getting more and more confused. He laughs when he is found to be forgetful, saying “I’m just getting old!” After the nurse completes a thorough neurologic assessment, which findings would be indicative of Alzheimer disease? Select all that apply.
A. Occasionally forgetting names or appointments
B. Difficulty performing familiar tasks, such as placing a
telephone call
C. Misplacing items, such as putting dish soap in the
refrigerator
D. Sometimes having trouble finding the right word
E. Rapid mood swings, from calm to tears, for no
apparent reason
F. Getting lost in one’s own neighborhood
Answers, B, C, E, F
Difficulty performing familiar tasks, misplacing items, rapid mood swings, and getting lost in one’s own neighborhood can be warning signs of Alzheimer disease.
Occasionally forgetting names or appointments, and sometimes having trouble finding the right word
are part of normal aging.
70
During the assessment of deep tendon reflexes, the nurse finds that a patient’s responses are bilaterally normal. What number is used to indicate normal deep
tendon reflexes when the documenting this finding? ____+
Responses to assessment of deep tendon reflexes are graded on a 4-point scale.
A rating of 2+ indicates normal or average response. A rating of 0 indicates no response, and a rating of 4+ indicates very brisk, hyperactive response with clonus, which is indicative of disease.
71
Which of the following statements about the testes is true?
A. The lymphatics of the testes drain into the
abdominal lymph nodes.
B. The vas deferens is located along the inferior portion
of each testis.
C. The right testis is lower than the left because the
right spermatic cord is longer.
D. The cremaster muscle contracts in response to cold
and draws the testicles closer to the body.
Answer, D
When it is cold, the cremaster muscle contracts, raising the sac and bringing the testes closer to the body to absorb heat necessary for sperm viability.
72
A 62-year-old man states that his doctor told him that he has an “inguinal hernia.” He asks the nurse to explain what a hernia is. The nurse should:
A. Tell him not to worry and that most men his age
develop hernias.
B. Explain that a hernia is often the result of prenatal
growth abnormalities.
C. Refer him to his physician for additional consultation
because the physician made the initial diagnosis.
D. Explain that a hernia is a loop of bowel protruding
through a weak spot in the abdominal muscles.
Answer, D
A hernia is a loop of bowel protruding through a weak spot in the musculature.
73
During an examination of an aging male, the nurse recognizes that normal changes to expect would be:
A. Premature ejaculation.
B. Declining testosterone production.
C. Difficulty in maintaining an erection.
D. A decreased refractory state after ejaculation.
Answer, B
After age 55-60 years, testosterone production declines.
The older male may find that an erection takes longer to develop and that it is less full or firm.
Once obtained, the erection may be maintained for longer periods without ejaculation. The refractory state (when the male is physiologically unable to ejaculate) lasts longer, from 12 to 24 hours compared with
2 minutes in the younger male.
74
A 59-year-old patient has been diagnosed with prostatitis and is being seen at the clinic for
complaints of burning and pain during urination. He is experiencing:
A. Dysuria.
B. Nocturia.
C. Polyuria.
D. Hematuria.
Answer, A
Dysuria or burning is common with acute cystitis, prostatitis, and urethritis.
75
A 45-year-old carpenter is seen at the clinic for complaints of “losing my urine when I lift heavy objects.” He is experiencing:
A. frequency.
B. urinary hesitancy.
C. stress incontinence.
D. urgency incontinence.
Answer, C
Stress incontinence is loss of urine with physical strain as a result of weakness of sphincters. The individual accidentally urinates when sneezing, laughing, coughing, or bearing down.
76
Which of the following statements is most appropriate when the nurse is obtaining a genitourinary history from an elderly man?
A. “Do you need to get up at night to urinate?”
B. “Do you experience nocturnal emissions, or ‘wet
dreams?’”
C. “Do you know how to perform testicular self
examination?”
D. “Has anyone ever touched your genitals and you did
not want them to?”
Answer, A
The elderly male patient should be asked about the presence of nocturia. This may be due to diuretic medication, fluid retention from mild heart failure or varicose veins, or fluid ingestion.
77
The nurse is examining the glans and knows that which of the following is a normal finding for this area?
A. The dorsal vein may be visible.
B. Hair is without pest inhabitants.
C. The skin is wrinkled and without lesions.
D. Smegma may be present under the foreskin of an
uncircumcised male.
Answer, D
The glans looks smooth and without lesions and does not have hair. Some cheesy smegma may have collected under the foreskin of an uncircumcised male.
78
When performing a genitourinary assessment, the nurse notes that the urethral meatus is positioned ventrally. This finding is:
A. Is called hypospadius.
B. Is the result of phimosis.
C. Is probably due to a stricture.
D. Is often associated with aging.
Answer, A
Hypospadius is the ventral location of the urethral meatus. Normally the urethral meatus is positioned just about centrally.
79
The nurse is performing a genital examination on a male patient and notes urethral drainage. When collecting urethral discharge for microscopic examination and culture, the nurse should:
A. Ask the patient to urinate into a sterile cup.
B. Ask the patient to obtain a specimen of semen.
C. Insert a cotton-tipped applicator into the urethra.
D. Compress the glans between the examiner’s thumb
and forefinger and collect any discharge.
Answer, D
If urethral discharge is noted, collect a smear for microscopic examination and culture by compressing the glans anteroposteriorly between the thumb and forefinger.
This also called milking, and can also be done by the patient if discharge was previously present but is not upon examination.
80
When assessing the scrotum of a male patient, the nurse notes the presence of multiple firm, nontender, yellow 1-cm nodules. The nurse knows that these nodules are most likely:
A. from urethritis.
B. sebaceous cysts.
C. subcutaneous plaques.
D. from inflammation of the epididymis.
Answer, B
Sebaceous cysts are commonly found on the scrotum. These are yellowish, 1-cm nodules and are firm, nontender, and often multiple.
81
When performing a scrotal assessment, the nurse notes that the scrotal contents transilluminate and show a red glow. On the basis of this finding the nurse would:
A. Assess the patient for the presence of a hernia.
B. Suspect the presence of serous fluid in the scrotum.
C. Consider this normal and proceed with the
examination.
D. Refer the patient for evaluation of a mass in the
scrotum.
Answer, B
Normal scrotal contents do not transilluminate. Serous fluid does transilluminate and shows as a red glow.
82
The nurse is aware that which of the following statements is true regarding the incidence of
testicular cancer?
A. Testicular cancer is the most common cancer in men aged 30-50 years.
B. The early symptoms of testicular cancer are pain and induration.
C. Men with a history of cryptorchidism are at greatest risk for development of testicular cancer.
D. Nonwhite men are four times more likely to develop testicular cancer than white men are.
Answer, C
Men with undescended testicles (cryptorchidism) are at greatest risk for development of testicular cancer.
83
The nurse is describing how to perform a testicular self-examination to a patient. Which of the following statements is most appropriate?
A. “A good time to examine your testicles is just before you take a shower.”
B. “If you notice an enlarged testicle or a painless lump, call your health care provider.”
C. “The testicle is egg shaped and movable. It feels firm and has a lumpy consistency.”
D. “Perform a testicular exam at least once a week to detect the early stages of testicular cancer.”
Answer, B
If the patient notices a firm painless lump, a hard area, or an overall enlarged testicle, he should call his health care provider for further evaluation. The testicle normally feels
rubbery with a smooth surface.
84
A 2-year-old boy has been diagnosed with “physiologic cryptorchidism.” Given this diagnosis, during assessment, the nurse will most likely observe:
A. Testes that are hard and painful to palpation.
B. An atrophic scrotum and absence of the testis bilaterally.
C. An absence of the testis in the scrotum, but the testis can be milked down.
D. Testes that migrate into the abdomen when the child squats or sits cross-legged.
Answer, C
Migratory testes (physiologic cryptorchidism) are common because of the strength of the cremasteric reflex and the small mass of the prepubertal testes.
The affected side has a normally developed scrotum and the testis can be milked down.
85
During an examination of an aging male, the nurse recognizes that normal changes to expect would be:
A. A change in scrotal color.
B. A decrease in the size of the penis.
C. Enlargement of the testes and scrotum.
D. An increase in the number of rugae over the scrotal sac.
Answer, B
When assessing the genitals of an older man, the nurse may note thinner, graying pubic hair, a lower hanging more pendulous scrotum and a decrease in the size of the penis.
86
When performing a genital assessment on a 34-year-old man, the nurse notes the following: Multiple soft, moist, painless papules in the shape of cauliflower-like patches scattered across the shaft of the penis. These lesions are characteristic of what disease or infection?
The lesions of genital warts are soft, pointed, moist, fleshy, painless papules that may be single or multiple in a cauliflower-like patch. They occur on the shaft of the penis, behind the corona, or around the anus, where they may grow into large grape-like clusters.
87
When performing a genitourinary assessment on a 16-year-old boy, the nurse notices a swelling in the scrotum that increases with increased intra-abdominal pressure and decreases when he is lying down. The patient complains of pain when straining. The nurse knows that this description is most consistent with a/an:
A. Femoral hernia.
B. Incisional hernia.
C. Direct inguinal hernia.
D. Indirect inguinal hernia.
Answer, D
With indirect inguinal hernias there is pain with straining; a soft swelling that increases with increased intra-abdominal pressure, which may decrease when the patient lies down.
This is the most common type of hernia. It is more common in infants less than 1 year and in men 16 to 20 years of age.
88
The nurse is inspecting the scrotum and testes of a 43-year-old man. Which finding would require additional follow-up and evaluation?
A. The skin on the scrotum is shiny and smooth.
B. The left testicle hangs lower than the right testicle.
C. The scrotum is a darker color than the general skin color.
D. The testes move closer to the body in response to cold temperatures.
Answer, A
Scrotal swelling may cause the skin to become shiny and smooth. Normal scrotal skin is rugate.
89
A 55-year-old man is experiencing severe pain of sudden onset in the scrotal area. It is somewhat relieved by elevation. On examination the nurse notes an enlarged, red scrotum that is very tender to palpation. It is difficult to distinguish the epididymis from the testis and the scrotal skin is thick and edematous. This description is consistent with which of the following?
A. Varicocele
B. Epididymitis
C. Spermatocele
D. Testicular torsion
Answer, B
Epididymitis presents as severe pain of sudden onset in the scrotum that is somewhat relieved by elevation. On examination, the scrotum is enlarged, reddened, and exquisitely tender. The epididymis is enlarged and indurated and may be hard to distinguish from the
testis. The overlying scrotal skin may be thick and edematous.
90
During a health history, a patient tells the nurse that he has trouble in starting his urine stream. This problem is known as what?
Hesitancy is trouble in starting the urine stream.
91
During a physical examination, the nurse finds that a male patient’s foreskin is fixed and tight and will not retract over the glans. The nurse recognizes that this condition as what?
Phimosis, or foreskin is advanced and fixed so tightly that it is impossible to retract over the glans. This
may be congenital or acquired from adhesions related to infection.
92
A 55-year-old man is in the clinic for a yearly check-up. He is worried because his father died of prostate cancer. The nurse knows that which tests should be done at this time? SELECT ALL THAT APPLY.
```
A. Blood test for prostate-specific antigen
B. Urinalysis
C. Transrectal ultrasound
D. Digital rectal examination
E. Prostate biopsy
```
Answers, A & D
Prostate cancer is typically detected by testing the blood for prostate-specific antigen (PSA) or on digital rectal exam (DRE). It is recommended that both PSA and DRE should be offered to men yearly, beginning at age 50 years. If the PSA is elevated, further lab work or
a transrectal ultrasound (TRUS) and biopsy may be recommended.
93
1. Which statement concerning the anal canal is true? The anal canal:
A. Is approximately 2 cm long in the adult.
B. Slants backward toward the sacrum.
C. Contains hair and sebaceous glands.
D. Is the outlet for the gastrointestinal tract.
Answer, D
The anal canal is the outlet for the gastrointestinal tract and is approximately 3.8 cm long in the adult. It is lined with a modified skin that does not contain hair or sebaceous glands, and it slants forward toward the umbilicus.
94
Which statement concerning the sphincters is correct?
A. The internal sphincter is under voluntary control.
B. The external sphincter is under voluntary control.
C. Both sphincters remain slightly relaxed at all times.
D. The internal sphincter surrounds the external sphincter.
Answer, B
The external sphincter surrounds the internal sphincter but also has a small section overriding the tip of the internal sphincter at the opening. The external sphincter is under voluntary control. Except for the passing of feces and gas, the sphincters keep the anal canal tightly closed.
95
The nurse is caring for a newborn infant. Thirty hours after birth, the infant passes a dark green meconium stool. The nurse recognizes this is important because it tells the nurse what about the infants GI tract?
The first stool passed by the newborn is dark green meconium and occurs within 24 to 48 hours of birth, indicating anal patency.
96
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.”
Answer, D
The infant passes stools by reflex. Voluntary control of the external anal sphincter cannot occur until the nerves supplying the area have become fully myelinated, usually around 1 to 2 years of age. Toilet training usually starts after the age of 2 years.
97
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.”
Answer, D
The prostate gland commonly starts to enlarge during the middle adult years. BPH is present in 1 in 10 men at the age of 40 years and increases with age. It is believed that the hypertrophy is caused by hormonal imbalance that leads to the proliferation of benign adenomas. The other responses are not appropriate.
98
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 what?
Black stools may be tarry as a result of occult blood (melena) from gastrointestinal bleeding or nontarry from ingestion of iron medications (not diet).
Other conditions to be aware of:
Excessive fat causes the stool to become frothy.
The absence of bile pigment causes clay-colored stools.
99
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?
The shiny blue skin sac indicates a thrombosed hemorrhoid.
The anus normally looks moist and hairless, with coarse folded skin that is more pigmented than the perianal skin, and the anal opening is tightly closed.
100
During an assessment of the newborn, the nurse expects to see which finding when the anal area is slightly stroked?
To assess sphincter tone, the nurse should check the anal reflex by gently stroking the anal area and normally should notice a quick contraction of the sphincter.
101
During an assessment of a 20-year-old man, the nurse finds a small palpable lesion with a tuft of hair located directly over the coccyx. The nurse knows that this lesion would most likely be a:
A. Rectal polyp.
B. Pruritus ani.
C. Carcinoma.
D. Pilonidal cyst.
Answer, D
A pilonidal cyst or sinus is a hair-containing cyst or sinus located in the midline over the coccyx or lower sacrum. It often opens as a dimple with a visible tuft of hair and, possibly, an erythematous halo.
102
During an examination, the nurse asks the patient to perform the Valsalva maneuver and notices that the patient has a moist, red, doughnut-shaped protrusion from the anus. The nurse knows that this finding is consistent with what condition?
In rectal prolapse, the rectal mucous membrane protrudes through the anus, appearing as a moist red doughnut with radiating lines. It occurs after a Valsalva maneuver, such as straining at passing stool or with exercising.
103
A 70-year-old man is visiting the clinic for difficulty in passing urine. In the health history, he indicates that he has to urinate frequently, especially at night. He has burning when he urinates and has noticed pain in his back. Considering this history, what might the
nurse expect to find during the physical assessment?
A. Asymmetric, hard, and fixed prostate gland
B. Occult blood and perianal pain to palpation
C. Symmetrically enlarged, soft prostate gland
D. Soft nodule protruding from the rectal mucosa
Answer, A
Subjective symptoms of carcinoma of the prostate include frequency, nocturia, hematuria, weak stream, hesitancy, pain or burning on urination, and continuous pain in lower back, pelvis, and thighs.
Objective symptoms of carcinoma of the prostate include a malignant neoplasm that often starts as a single hard nodule on the posterior surface, producing
asymmetry and a change in consistency. As it invades normal tissue, multiple hard nodules appear, or the entire gland feels stone hard and fixed.
104
A 40-year-old black man is in the office for his annual physical examination. Which statement regarding the PSA blood test is true, according to the American Cancer Society? The PSA:
A. Should be performed with this visit.
B. Should be performed at age 45 years.
C. Should be performed at age 50 years.
D. Is only necessary if a family history of prostate cancer exists.
Answer, B
According to the American Cancer Society (2006), the PSA blood test should be performed annually for black men beginning at age 45 years and annually for all other men over age 50 years.
105
A 62-year-old man is experiencing fever, chills, malaise, urinary frequency, and urgency. He also reports urethral discharge and a dull aching pain in the perineal and rectal area. These symptoms are most consistent with which condition?
The common presenting symptoms of PROSTATITIS are fever, chills, malaise, and urinary frequency and urgency. The individual may also have dysuria, urethral discharge, and a dull aching pain in the perineal and rectal area.
106
During a discussion for a men’s health group, the nurse relates that the group with the highest incidence of prostate cancer is:
a. Asian Americans.
b. Blacks.
c. American Indians.
d. Hispanics.
Answer, B
According to the American Cancer Society (2010), black men have a higher rate of prostate cancer than other racial groups.
107
The nurse notices that a patient has had a pale, yellow, greasy stool, or steatorrhea, and recalls that this is caused by:
a. Occult bleeding.
b. Absent bile pigment.
c. Increased fat content.
d. Ingestion of bismuth preparations.
Answer, C
Steatorrhea (pale, yellow, greasy stool) is caused by increased fat content in the stools, as in malabsorption syndrome.
Occult bleeding and ingestion of bismuth products cause a black stool.
The absence of bile pigment causes a gray-tan stool.
108
While assessing a patient who is hospitalized and bedridden, the nurse notices that the patient has been incontinent of stool. The stool is loose and gray-tan in color. The nurse recognizes that this finding indicates which of the following?
a. Occult blood
b. Inflammation
c. Absent bile pigment
d. Ingestion of iron preparations
Answer, C
The presence of gray-tan stool indicates absent bile pigment, which can occur with obstructive jaundice. The ingestion of iron preparations and the presence of occult blood turns the stools to a black color. Jellylike mucus shreds mixed in the stool would indicate inflammation.
109
The nurse is performing a digital examination of a patient’s prostate gland and notices that a normal prostate gland includes which of the following characteristics? Select all that apply.
a. 1 cm protrusion into the rectum
b. Heart-shaped with a palpable central groove
c. Flat shape with no palpable groove
d. Boggy with a soft consistency
e. Smooth surface, elastic, and rubbery consistency
f. Fixed mobility
Answers, A, B & E
The size of a normal prostate gland should be 2.5 cm long by 4 cm wide and should not protrude more than 1 cm into the rectum. The prostate should be heart-shaped, with a palpable central groove, a smooth surface, and elastic with a rubbery consistency.
Abnormal findings include a flat shape with no palpable groove, boggy with a soft consistency, and fixed
mobility.
110
During a health history, a 22-year old woman asks, “Can I get that vaccine for human papilloma virus (HPV)? I have genital warts and I’d like them to go away!” What is the nurse’s best response?
a. “The HPV vaccine is for girls and women ages 9 to 26 years, so we can start that today.”
b. “This vaccine is only for girls who have not yet started to become sexually active.”
c. “Let’s check with the physician to see if you are a candidate for this vaccine.”
d. “The vaccine cannot protect you if you already have an HPV infection.”
Answer, D
The HPV vaccine is appropriate for girls and women age 9 to 26 years and is administered to prevent cervical cancer by preventing HPV infections before girls become sexually active.
However, it cannot protect the woman if an HPV infection is already present.
111
During an examination, the nurse observes a female patient’s vestibule and expects to see the:
a. Urethral meatus and vaginal orifice.
b. Vaginal orifice and vestibular (Bartholin) glands.
c. Urethral meatus and paraurethral (Skene) glands.
d. Paraurethral (Skene) and vestibular (Bartholin) glands.
Answer, A
The labial structures encircle a boat-shaped space, or cleft, termed the vestibule. Within the vestibule are numerous openings. The urethral meatus and vaginal orifice are visible. The ducts of the paraurethral (Skene) glands and the vestibular (Bartholin) glands are present but not visible.
112
The uterus is usually positioned tilting forward and superior to the bladder. This position is known as:
a. Anteverted and anteflexed.
b. Retroverted and anteflexed.
c. Retroverted and retroflexed.
d. Superiorverted and anteflexed.
Answer, A
The uterus is freely movable, not fixed, and usually tilts forward and superior to the bladder (a position labeled as anteverted and anteflexed).
113
Generally, the changes normally associated with menopause occur because the cells in the reproductive tract are:
a. Aging.
b. Becoming fibrous.
c. Estrogen dependent.
d. Able to respond to estrogen.
Answer, C
Because cells in the reproductive tract are estrogen dependent, decreased estrogen levels during menopause bring dramatic physical changes. The other options are not correct.
114
The nurse is reviewing the changes that occur with menopause. Which changes are associated with menopause?
a. Uterine and ovarian atrophy, along with a thinning of the vaginal epithelium
b. Ovarian atrophy, increased vaginal secretions, and increasing clitoral size
c. Cervical hypertrophy, ovarian atrophy, and increased acidity of vaginal secretions
d. Vaginal mucosa fragility, increased acidity of vaginal secretions, and uterine
hypertrophy
Answer, A
The uterus shrinks because of its decreased myometrium.
The ovaries atrophy to 1 to 2 cm and are not palpable after menopause.
The sacral ligaments relax, and the pelvic musculature
weakens; consequently, the uterus droops.
The cervix shrinks and looks paler with a thick
glistening epithelium.
The vaginal epithelium atrophies, becoming thinner, drier, and itchy.
The vaginal pH becomes more alkaline, and secretions are decreased, which results in a fragile mucosal surface that is at risk for vaginitis.
115
A 54-year-old woman who has just completed menopause is in the clinic today for a yearly physical examination. Which of these statements should the nurse include in patient education? “A postmenopausal woman:
a. Is not at any greater risk for heart disease than a
younger woman.”
b. Should be aware that she is at increased risk for
dyspareunia because of decreased vaginal
secretions.”
c. Has only stopped menstruating; there really are no
other significant changes with which she should be
concerned.”
d. Is likely to have difficulty with sexual pleasure as a
result of drastic changes in the female sexual
response cycle.”
Answer, B
Decreased vaginal secretions leave the vagina dry and at risk for irritation and pain with intercourse (dyspareunia). The other statements are incorrect.
116
A woman is in the clinic for an annual gynecologic examination. The nurse should plan to begin the interview with the:
a. Menstrual history, because it is generally nonthreatening.
b. Obstetric history, because it includes the most important information.
c. Urinary system history, because problems may develop in this area as well.
d. Sexual history, because discussing it first will build rapport.
Answer, A
Menstrual history is usually nonthreatening and therefore a good topic with which to begin the interview. Obstetric, urinary, and sexual histories are also part of the interview but not necessarily the best topics with which to start.
117
A patient has had three pregnancies and two live births. The nurse would record this
information as grav _____, para _____, AB _____.
a. 2; 2; 1
b. 3; 2; 0
c. 3; 2; 1
d. 3; 3; 1
Answer, C
Gravida (grav) is the number of pregnancies. Para is the number of births. Abortions are interrupted pregnancies, including elective abortions and spontaneous miscarriages.
118
A 50-year-old woman calls the clinic because she has noticed some changes in her body and breasts and wonders if these changes could be attributable to the hormone replacement therapy (HRT) she started 3 months earlier. The nurse should tell her:
a. “HRT is at such a low dose that side effects are very unusual.”
b. “HRT has several side effects, including fluid retention, breast tenderness, and
vaginal bleeding.”
c. “Vaginal bleeding with HRT is very unusual; I suggest you come into the clinic
immediately to have this evaluated.”
d. “It sounds as if your dose of estrogen is too high; I think you may need to decrease
the amount you are taking and then call back in a week.”
Answer, B
Side effects of HRT include fluid retention, breast pain, and vaginal bleeding. The other responses are not correct.
119
A 52-year-old patient states that when she sneezes or coughs she “wets herself a little.” She is very concerned that something may be wrong with her. The nurse suspects that the problem is:
a. Dysuria.
b. Stress incontinence.
c. Hematuria.
d. Urge incontinence.
Answer, B
Stress incontinence is involuntary urine loss with physical strain, sneezing, or coughing.
Dysuria is pain or burning with urination.
Hematuria is bleeding with urination.
Urge incontinence is involuntary urine loss that occurs as a result of an overactive detrusor muscle
in the bladder that contracts and causes an urgent need to void.
120
A 22-year-old woman has been considering using oral contraceptives. As a part of her health history, the nurse should ask:
a. “Do you have a history of heart murmurs?”
b. “Will you be in a monogamous relationship?”
c. “Have you carefully thought this choice through?”
d. “If you smoke, how many cigarettes do you smoke per day?”
Answer, D
Oral contraceptives, together with cigarette smoking, increase the risk for cardiovascular side effects. If cigarettes are used, then the nurse should assess the patient’s smoking history. The other questions are not appropriate.
121
A nurse is assessing a patient’s risk of contracting a sexually transmitted infection (STI). An appropriate question to ask would be:
a. “You know that it’s important to use condoms for protection, right?”
b. “Do you use a condom with each episode of sexual intercourse?”
c. “Do you have a sexually transmitted infection?”
d. “You are aware of the dangers of unprotected sex, aren’t you?”
Answer, B
In reviewing a patient’s risk for STIs, the nurse should ask in a nonconfrontational manner whether condoms are being used during each episode of sexual intercourse.
Asking a person whether he or she has an infection does not address the risk.
122
The nurse is preparing to interview a postmenopausal woman. Which of these statements is true as it applies to obtaining the health history of a postmenopausal woman?
a. The nurse should ask a postmenopausal woman if she has ever had vaginal bleeding.
b. Once a woman reaches menopause, the nurse does not need to ask any history questions.
c. The nurse should screen for monthly breast tenderness.
d. Postmenopausal women are not at risk for contracting STIs; therefore, these questions can be omitted.
Answer, A
Postmenopausal bleeding warrants further workup and referral. The other statements are not true.
123
The nurse has just completed an inspection of a nulliparous woman’s external genitalia. Which of these would be a description of a finding within normal limits?
a. Redness of the labia majora
b. Multiple nontender sebaceous cysts
c. Discharge that is foul smelling and irritating
d. Gaping and slightly shriveled labia majora
Answer, B
No lesions should be noted, except for the occasional sebaceous cysts, which are yellowish 1- cm nodules that are firm, nontender, and often multiple.
The labia majora are dark pink, moist,
and symmetric; redness indicates inflammation or lesions.
Discharge that is foul smelling and
irritating may indicate infection.
In the nulliparous woman, the labia majora meet in the
midline, are symmetric and plump.
124
When assessing a newborn infant’s genitalia, the nurse notices that the genitalia are somewhat engorged. The labia majora are swollen, the clitoris looks large, and the hymen is thick. The vaginal opening is difficult to visualize. The infant’s mother states that she is
worried about the labia being swollen. The nurse should reply:
a. “This is a normal finding in newborns and should resolve within a few weeks.”
b. “This finding could indicate an abnormality and may need to be evaluated by a physician.”
c. “We will need to have estrogen levels evaluated to ensure that they are within normal limits.”
d. “We will need to keep close watch over the next few days to see if the genitalia decrease in size.”
Answer, A
It is normal for a newborn’s genitalia to be somewhat engorged. A sanguineous vaginal discharge or leukorrhea is normal during the first few weeks because of the maternal estrogen effect. During the early weeks, the genital engorgement resolves, and the labia minora atrophy and remain small until puberty.
125
During a vaginal examination of a 38-year-old woman, the nurse notices that the vulva and vagina are erythematous and edematous with thick, white, curdlike discharge adhering to the vaginal walls. The woman reports intense pruritus and thick white discharge from her vagina. The nurse knows that these history and physical examination findings are most consistent with which condition?
a. Candidiasis
b. Trichomoniasis
c. Atrophic vaginitis
d. Bacterial vaginosis
Answer, A
The woman with candidiasis often reports intense pruritus and thick white discharge. The vulva and vagina are erythematous and edematous. The discharge is usually thick, white, and curdlike.
Infection with trichomoniasis causes a profuse, watery, gray-green, and frothy discharge.
Bacterial vaginosis causes a profuse discharge that has a “foul, fishy, rotten” odor.
Atrophic vaginitis may have a mucoid discharge.
126
A 46-year-old woman is in the clinic for her annual gynecologic examination. She voices a concern about ovarian cancer because her mother and sister died of it. Which statement does the nurse know to be correct regarding ovarian cancer?
a. Ovarian cancer rarely has any symptoms.
b. The Pap smear detects the presence of ovarian cancer.
c. Women at high risk for ovarian cancer should have annual transvaginal ultrasonography
for screening.
d. Women over age 40 years should have a thorough pelvic examination every 3 years.
Answer, C
With ovarian cancer, the patient may have abdominal pain, pelvic pain, increased abdominal size, bloating, and nonspecific gastrointestinal symptoms; or she may be asymptomatic. The Pap smear does not detect the presence of ovarian cancer. Annual transvaginal ultrasonography may detect ovarian cancer at an earlier stage in women who are at high risk for developing it.
127
A 25-year-old woman comes to the emergency department with a sudden fever of 38.3° C and abdominal pain. Upon examination, the nurse notices that she has rigid, boardlike lower abdominal musculature. When the nurse tries to perform a vaginal examina-tion, the patient has severe pain when the uterus and cervix are moved. The nurse knows that these signs and symptoms are suggestive of:
a. Endometriosis.
b. Uterine fibroids.
c. Ectopic pregnancy.
d. Pelvic inflammatory disease.
Answer, D
These signs and symptoms are suggestive of acute pelvic inflammatory disease, also known as acute salpingitis
128
During an internal examination, the nurse notices that the cervix bulges outside the introitus when the patient is asked to strain. The nurse will document this as:
a. Uterine prolapse, graded first degree.
b. Uterine prolapse, graded second degree.
c. Uterine prolapse, graded third degree.
d. A normal finding.
Answer, B
The cervix should not be found to bulge into the vagina. Uterine prolapse is graded as follows:
first degree—the cervix appears at the introitus with straining; second degree—the cervix bulges outside the introitus with straining; and third degree—the whole uterus protrudes, even without straining (essentially, the uterus is inside out).
129
A 35-year-old woman is at the clinic for a gynecologic examination. During the examination, she asks the nurse, “How often do I need to have this Pap test done?” Which reply by the nurse is correct?
a. “It depends. Do you smoke?”
b. “A Pap test needs to be performed annually until you are 65 years of age.”
c. “If you have two consecutive normal Pap tests, then you can wait 5 years between tests.”
d. “After age 30 years, if you have three consecutive normal Pap tests, then you may be screened every 2 to 3 years.”
Answer, D
Cervical cancer screening with the Pap test continues annually until age 30 years.
After age 21, regardless of sexual history or activity, women should be screened every 3 years until age 30, then every 5 years until age 65.
130
The nurse is palpating an ovarian mass during an internal examination of a 63-year-old woman. Which findings of the mass’s characteristics would suggest the presence of an ovarian cyst? Select all that apply.
a. Heavy and solid
b. Mobile and fluctuant
c. Mobile and solid
d. Fixed
e. Smooth and round
f. Poorly defined
Answer, B & E
An ovarian cyst (fluctuant ovarian mass) is usually asymptomatic and would feel like a smooth, round, fluctuant, mobile, nontender mass on the ovary. A mass that is heavy, solid, fixed, and poorly defined suggests malignancy. A benign mass may feel mobile and solid.
