NUR 6505 FINAL EXAM
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:
“Puberty usually begins about age fifteen.”
“The first sign of puberty is enlargement of the testes.”
“Penis size does not increase until about the age of sixteen.”
"The development of pubic hair precedes testicular or penis enlargement.”
A patient has bilateral pitting edema of the feet. While assessing the
peripheral vascular system, the nurse's primary focus should be:
The correct answer is: 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?
1.This is a normal occurrence.
2.This may indicate disease of the cerebellum or brainstem.
3.This is a sign that the patient is nervous about the examination.
4.This indicates a visual problem and a referral to an ophthalmologist is indicated.
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.
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, 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–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:
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 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?
1.Positive Babinski sign
2.Plantar reflex abnormal
3.Plantar reflex present
4.Plantar reflex “2+” on a scale from “0 to 4+”
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 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-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?
•1. Schedule a time for direct observation of the adolescent during meals.
•2. Ask the patient for a 24-hour diet recall and assume this is reflective of a
typical day for her.
3. 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
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.
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?
1.Raises head and arches back.
2.Extends arms and drops head down.
3.Flexes knees and elbows with back straight.
4.Holds head at 45 degrees and keeps back straight.
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 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:
“Puberty usually begins about age fifteen.”
“The first sign of puberty is enlargement of the testes.”
“Penis size does not increase until about the age of sixteen.”
"The development of pubic hair precedes testicular or penis enlargement.”
A patient has bilateral pitting edema of the feet. While assessing the
peripheral vascular system, the nurse's primary focus should be:
The correct answer is: 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?
1.This is a normal occurrence.
2.This may indicate disease of the cerebellum or brainstem.
3.This is a sign that the patient is nervous about the examination.
4.This indicates a visual problem and a referral to an ophthalmologist is indicated.
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.
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, 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–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:
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 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?
1.Positive Babinski sign
2.Plantar reflex abnormal
3.Plantar reflex present
4.Plantar reflex “2+” on a scale from “0 to 4+”
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 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-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?
•1. Schedule a time for direct observation of the adolescent during meals.
•2. Ask the patient for a 24-hour diet recall and assume this is reflective of a
typical day for her.
3. 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
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.
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?
1.Raises head and arches back.
2.Extends arms and drops head down.
3.Flexes knees and elbows with back straight.
4.Holds head at 45 degrees and keeps back straight.
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.
