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
t
...
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 breasts 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 extremities
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.=End-point nystagmus at an
extreme lateral gaze occurs normally. Assess any other nystagmus carefully. Severe nystagmus occurs with
disease of the vestibular system, cerebellum, or brainstem.
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 upper outer quadrant at 1 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:-“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–midthighs 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
Which of the following are changes associated with menopause?-Uterine and ovarian atrophy along with
thinning vaginal epithelium
When performing a musculoskeletal assessment, the nurse knows the correct approach for the examination
should be:-proximal to distal
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=With the same instrument, draw a light stroke up the lateral side of the
sole of the foot and across the ball of the foot, like an upside-down “J.” The normal response is plantar flexion
of the toes and sometimes of the whole foot.
1
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
bestresponse?-Tell her that, because of the changing hormones during the monthly menstrual
cycle, cyclic breast changes are common.
A pt states during the interview that she noticed a new 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
A 16-yr-old girl is being seen at clinic for gastrointestinal complaints + 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 and 1 weekend day.
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.=At 3 months
of age, the baby raises the head and arches the back as if in a swan dive. This is the Landau reflex, which
persists until 11/2 years of age.
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 high-pitched shrill cry or cat-sounding screech occurs with central nervous system damage.
Lethargy, hypo reactivity, hyperirritability, and parent’s report of significant change in behavior all warrant
referral.
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 known as :-lordosis
2
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 is the:-brachial artery
The nurse is testing the function of cranial nerve XI. Which of these, best describes the response the nurse
should expect if the nerve is intact? The patient:-moves head and shoulder against resistance w/equal
strength
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