A 65-year-old patient remarks that she just can't believe that her breast 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
When performing a musculoskeletal assessment, the nurse knows the correct
approach for the examination should be:
proximal to distal
A 43-year-old woman is at the clinic for a routine examination. She reports that
she has had a breast lump in her right breast for years. Recently, it has begun to
change in consistency and is becoming harder. She reports that 5 years ago her
physician evaluated the lump and determined that it "was nothing to worry
about." the examination validates the presence of a mass in the right upper outer
quadrant at 1 o'clock approximately 5 cm from the nipple. It is firm, mobile, non-
tender, with borders that are not well defined. The nurse's recommendation to her
is:
Because of the change in consistency of the lump, it should be further evaluated by a
physician.
The nurse practitioner is examining a 3-month-old infant. While holding the
thumbs on the infant's inner -mid thighs and the fingers outside on the hips,
touching the greater trochanter, the nurse practitioner adducts the legs until the
nurse practitioner's thumb touch and then abducts the legs until the infant's
knees touch the table. The nurse practitioner does not note any "clunking"
sounds and is confident to record a"
Negative Ortolani's sign
A patient's mother has noticed that her son, who has been to a new babysitter
has some blisters and scabs on his face and buttocks. On examination, the nurse
notices moist, thin-roofed vesicles with a thin erythematous base and suspects:
Impetigo
The nurse is testing superficial reflexes on a adult patient. When stroking up the
lateral side of the sole and across the ball of the foot, the nurse notices the
plantar flexion of the toes. How would the nurse document this finding?
, Plantar reflex present
A woman is in the family planning clinic seeking birth control information. She
states that her breast "change all month long" and that she is worried that this is
unusual. What is the nurse's best response?
Tell her that, because of the changing hormones during the monthly menstrual cycle,
cyclic breast changes are common
A patient states during the interview that she noticed a new breast lump in the
shower a few days ago. It was on her left breast near her axilla. The RN should
plan to:
palpate the unaffected breast first
A 16-year-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, and 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 day= 2 weekdays + 2 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
A patient has a positive Homans' sign. the nurse know that a positive Homans'
sign may indicate:
Deep vein thrombosis
The nurse is discussing breast self- examination with a postmenopausal woman
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 descriptions 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 with hurt the fetus. The nurse knows that
which of these statements are 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
and when awake all he does is cry. The nurse hears that infant's cries are very
high pitched and shrill. what would be nurse's appropriate response?
Refer the infant for further testing
A female patient is 8-months-pregnant. She comments that she has noticed a
change in posture and is having lower back pain. The nurse tells her that during
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