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The mother of a 10-year-old boy asks the nurse to discussthe recognition of puberty. The nurse should reply by saying:
-“Puberty usuallybegins about age fifteen.”
-“The first sign of puberty is enlargement of the testes.”
-“Penis size does notincrease until about the age of sixteen.”
-"The development ofpubic hair precedes testicular or penis enlargement.”
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 valid
ates 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.”
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.
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
Tell her that, because of the changing hormones during the monthly menstrual
cycle, cyclic breast changes are common.
Fooddiaries require the individual to write down everything consumed for a certaintime period. Because of the erratic eating patterns of this individual,assessing dietary intake over a few days would produce more accurateinformation regarding eating patterns. Direct observation is best used withyoung children or older adults.
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.
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 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 high-pitched shrill cry or cat-sounding screech occurs with central nervous system damage. Lethargy, hyporeactivity, hyperirritability, and parent’s report of significant change in behavior all warrant referral.
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
It is a normal variation and not a significant finding
Hyperreflexia, diminished or absent superficial reflexes, increased muscle tone or spasticity can be expected with upper motor neuron lesions.
A few days after a summer hiking trip, a 25-year-old man comes to the clinic with a rash. On examination, the nurse notes that the rash is red, macular, with a bull's eye pattern across his midriff and behind his knees. The nurse suspects:
lateral to the extensor tendon of the great toe.
The dorsalis pedis artery is located on the dorsum of the foot. Palpate just lateral to and parallel with the extensor tendon of the big toe.
Loss of vibration sense occurs with peripheral neuropathy (e.g., diabetes and alcoholism). Peripheral neuropathy is worse at the feet and gradually improves as you move up leg, as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome
During an interview, a patient reveals that she is pregnant. She states that she is not sure whether she
will breastfeed her baby and asks for some information about this. Which of these statements by the nurse is accurate with regard to breastfeeding?
“Breastfeeding provides the perfect food and antibodies for your baby.”
Breast-feeding may reduce the risk of breast cancer.
The nurse is conducting a class about breast self-examination (BSE). Which of these statements
indicates proper BSE technique?
The best time to perform BSE is 4 to 7 days after the first day of the menstrual
During the finger-to-finger test, if the person has clumsy movement with overshooting the mark, either a cerebellar disorders or acute alcohol intoxication should be suspected.
Which of the following assessment findings is most consistent with clubbing of the fingernails?
An angle of the nail base of 180 degrees or greater with a nail base that feels spongy
When performing the bimanual examination, the nurse notices that the cervix feels smooth and firm, is round, and is fixed in place (does not move). When cervical palpation is performed, the patient complains of some pain. The nurse’s interpretation of these results should be which of these?
A 75-year-old woman who has a history of diabetes and peripheral vascular disease has been trying to remove a corn on the bottom of her foot with a pair of scissors. The nurse will encourage her to stop trying to remove the corn with scissors because:
The assessment of an 80 year old patient, the nurse notes that his hands show tremors when he reaches for something and that his head is always nodding. There is no associated rigidily with movement. Which of the following statements is most accurate?
During an internal examination of a woman’s genitalia, the nurse will use which technique for proper insertion of the speculum?
A male patient with possible fertility problems asks the nurse where sperm is produced. The nurse knows that sperm production occurs in the:
A patient has had a "terrible itch" for several months that he has been scratching continuously. On examination, the nurse might expect to find:
Let at least 2 seconds elapse between each stimulus to avoid summation. With summation, frequent consecutive stimuli are perceived as one strong stimulus.
assessing a 7-month-old infant you make a loud noise and note the following response: Abduction and flexion of arms and legs; fanning of fingers and curling of index finger and thumb in C-position; followed by infant bringing in arms and legs to body. What do you know about this?
The nurse is assessing a 75-year-old man. As the nurse beings the mental status portion of the assessment, the nurse expects that this patient:
may take a little longer to respond, but his general knowledge and abilities should not have declined.
A 40-year-old woman reports a change in mole size, accompanied by color changes, itching, burning, and bleeding over the past month. She has a dark complexion and has no family history of skin cancer, but she has had many blistering sunburns in the past. The nurse would:
Which of the following veins are responsible for most of the venous return in the arm?
Normal capillary refill time is less than 1 to 2 seconds. Note that these conditions can skew your findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia.
When performing a genital assessment on a middle-aged man, the nurse notices multiple soft, moist, painless papules in the shape of cauliflower-like patches scattered across the shaft of the penis. These lesions are characteristic of:
During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on
her breast for about 2 weeks. In trying to find the cause of the rash, which of these would be
important for the nurse to determine?
Where did it first appear—on the nipple, the areola, or the surrounding skin?
When doing the history on a patient with a seizure disorder, the nurse assesses whether the patient has an aura. Which of the following would be the best question for obtaining this information?
3. Do you have any warning sign before your seizure starts?
Feedback: Aura is a subjective sensation that precedes a seizure; it could be auditory, visual, or motor.
In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which
of the following describes the nurse’s best course of action?
Explain that this condition may be the result of hormonal changes and recommend
that he see his physician.
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