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? Correct Ans - 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? Correct Ans - 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:
Correct Ans - 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? Correct Ans -
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: Correct Ans -
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: Correct Ans -
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: Correct Ans -
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: Correct Ans - 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? Correct Ans - 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? Correct Ans -
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: Correct Ans - 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? Correct Ans - 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? Correct Ans - Raises head and arches back.
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