NR 509/ NR509 Final Exam V1 (New 2026/ 2027 Update) Advanced Physical Assessment Guide| Questions & Answers| Grade A| 100% Correct (Accurate Solutions)- Chamberlain.

…..DLDD NR 509/ NR509 Final Exam V1 (New 2026/ 2027 Update) Advanced Physical Assessment Guide| Questions & Answers| Grade A| 100% Correct (Accurate Solutions)- Chamberlain. Q. A 35-year-old female with a history of migraines presents to the clinic with worsening symptoms for the past few weeks. She reports waking up at night with headaches and nausea. Her only medication history is oral contraceptive pills (OCPs). Otherwise, she states she is healthy. Which of the following actions if taken by the NP is the best next step? ANSWER Take a further history and perform a very careful neurological exam Q. A grandmother is accompanying her 9-year-old granddaughter during a routine physical examination. She asks you privately if her granddaughter has started puberty yet. During the examination, the NP notes asymmetric projection of the areola and nipple of the right chest to form a secondary mound above the level of the breast. The left breast is underdeveloped. These assessment findings are consistent with which Tanner Stage of development? ANSWER IV Q. Primary prevention is defined as which of the following? ANSWER Interventions designed to prevent disease Q. Based on the U.S. Preventive Services Task Force (USPSTF) recommendations, which of the following statements is true about screening for breast cancer in average-risk women? ANSWER Mammography is recommended every 2 years for women aged 50-74 with insufficient evidence for screening women over the age of 75. Q. Which of the following statements is true regarding recommendations by the eighth Joint National Committee (JNC8) for adults aged 60 and older? Select all that apply. ANSWER Target blood pressure should be /= 150/90 mmHg but notes that if treatment results in SBP 140 and is "well tolerated and without adverse effects to health or quality of live, treatment does not need to be adjusted." Q. In those aged 80 or older, blood pressure targets of 140 to 150/70 to 80 appear optimal for notable ANSWER reductions in stroke, cardiovascular events, and all-cause mortality. Q. Which of the following is a useful strategy when examining young children between the ages of 1 and 4? ANSWER Have the parent facilitate the exam (e.g., removing clothes, holding the child on lap). Q. The NP is completing the review of systems on a 4-month-old female during a routine encounter. Which statement from the parent may indicate a cardiac problem in the infant and require a more thorough subjective history? ANSWER "It often takes the baby more than 30 minutes to finish a bottle." Q. Patient with eyelid drooping ANSWER CNIII Q. Which cranial nerve (CN) innervates the muscles of the pharynx and provides sensory fibers to portions of the tympanic membrane, auditory canal, pharynx, and the posterior third of the tongue? ANSWER CN IX Q. The NP should suspect injury to which cranial nerve (CN) if a patient presents with complaints of photosensitivity and uneven pupils after being struck in the eye with a baseball? ANSWER CNIII Q. Which of the following statements is true regarding risks and rapid recognition of suspected stroke? Select all that apply ANSWER Obesity doubles the risk of stroke even without associated glucose intolerance Hypertension is the leading risk factor for both ischemic and hemorrhagic stroke Q. The combination of both receptive and expressive aphasia is a characteristic of which type of speech disorder? ANSWER global aphasia Q. The NP is assessing a 42-year-old female who presents to the clinic with recurring headaches. What is an effective question to ask the patient? ANSWER Do you have any aura prior to the headaches? Q. A 55-year-old female presents to the clinic with a headache. During the interview, which of the following symptoms should prompt the NP to be concerned and investigate further? ANSWER The patient reports fever, night sweats, and thinks she lost weight. Q. When grading muscle strength on a scale of 1 to 5, a grade of 3 indicates which of the following? ANSWER Active movement against gravity Q. Which musculoskeletal disorder is paired correctly with the associated systemic manifestations? ANSWER Lyme disease and expanding erythematous targetoid patch in early illness Q. A 62-year-old female has a diagnosis of rheumatoid arthritis (RA). Which of the following are expected assessment findings consistent with the diagnosis? ANSWER Swelling of the synovial tissue in joints and tendon sheaths. Q. A 58-year-old male complains of pain in his knees, hips, hands, wrists, neck, and lower back. Based on the joints involved, the NP suspects that the patient most likely has which condition? ANSWER Osteoarthritis Q. A 55-year-old male has a diagnosis of lumbar spinal stenosis. Which sign should the NP expect to find on examination that is most consistent with the diagnosis? ANSWER Flexed forward posture with lower extremity weakness Q. What is the action(s) of the erector spinae muscle group? ANSWER Extension of the spine Q. A 17-year-old male presents to the clinic for a follow-up appointment. He fractured his left arm 8 weeks ago and remains in a cast. Upon inspection, the NP finds that his shoulder heights are unequal and there is winging of the scapula. The NP suspects contralateral weakness and muscle wasting as the etiology for the winged scapula. Which of the following physical assessment maneuvers should the NP perform to confirm the suspension? ANSWER Compare the strength of the trapezius muscles Q. A 31-year-old female presents to the clinic with a worsening stiff, painful neck. On inspection, the patient's head is laterally deviated toward the shoulder and rotated. Given this specific physical assessment finding, what condition should the NP suspect as a differential diagnosis? ANSWER Torticollis Q. During an evaluation of an athletic 30-year-old female, the NP conducts an active range of motion evaluation at the neck. All of the following muscles are being assessed when the patient is asked to extend, flex, and rotate the neck, EXCEPT? ANSWER Sacrospinalis A 58-year-old male complains of lower back pain for many years. He denies a recent injury. On examination, the NP finds that the patient has tenderness to palpation over the sacroiliac joint. Which of the following conditions is most consistent with this physical sign? ankylosing spondylitis Which of the following statements is true regarding prostate cancer screening? Setting normal cut-offs for prostate-specific antigen (PSA) testing relies on balancing A 53-year-old African American male presents for discussion of his prostate cancer risk and possible screening for this disease. His father was diagnosed at age 82 years with prostate cancer but died recently at age 87 years from a myocardial infarction before the disease progressed. Family history also reveals that his mother died of ovarian cancer when he was age 10 years, and two of his maternal aunts had breast cancer. Which of the following is true about prostate cancer risk for this patient and subsequent screening? This patient is at an elevated risk of prostate cancer due to his family history; thus, screening modalities should be discussed between the patient and provider. A 34-year-old female presents to primary care for follow-up regarding anal pain with defecation. A recent referral to GI for anoscopic examination revealed anal fissures that appear to be her source of pain. In addition, today she reports that she has developed episodic abdominal discomfort and sores in her mouth. Which of the following underlying conditions is the NP most likely to find? Inflammatory bowel disease A 45-year-old female presents to the primary care clinic. She complains of recently experiencing a change in the patterns of her bowel movements. Her PMH is significant for bleeding ulcers as well as Crohn's disease. Her family medical history includes a maternal aunt who died of colon cancer at age 49 years. Which of the following historical elements would be most concerning for colon cancer in this patient? recent onset of small-caliber stools A 67-year-old female presents to the office for an annual check-up. She retired as a police captain at age 66. Now she enjoys gardening and water aerobics several days a week. She states, "staying active keeps me limber". After a careful history and physical examination, the NP documents the following musculoskeletal system findings: Full range of motion in all joints. Hands with Heberden nodes at the DIP joints, Bouchard nodes at PIP joints. Mild pain with flexion, extension, and rotation of both hips. Full range of motion in the knees, with moderate crepitus. No effusion but bony enlargement along the tibiofemoral joint line bilaterally. Both feet with hallux valgus at the first MTP joints. Which of the following is the most accurate interpretation of these findings? These findings suggest osteoarthritis A 50-year-old male presents to the office for a routine physical examination. He has no complaints. His PMH is significant for non-alcoholic fatty liver disease and high cholesterol for which he is taking fenofibrate. On the social history intake form, he reported consuming 8 ounces of malt liquor daily for 20 years. After a careful history and physical examination, the NP documents the following nervous system findings: Mental Status: Alert, relaxed, and cooperative. Thought process coherent. Oriented to person, place, and time. Speech is fluent, follows commands. Detailed cognitive testing deferred. Cranial Nerves: I—not tested; II through XII intact. Motor: Normal muscle bulk and tone. Strength 5/5 throughout. No pronator drift. Cerebellar—Rapid alternating movements (RAMs), finger-to-nose (F→N), heel-to-shin (H→S) intact. Gait with normal stance and stride. Sensory: Pinprick, light touch, position, and vibration intact. Romberg— maintains balance with eyes closed. Reflexes: 2+ and symmetric with plantar reflexes downgoing. Which of the following is the most accurate interpretation of these findings? These findings suggest no abdnormalities Which cranial nerve (CN) is being assessed by the examiner in this image? ADA Description: Examiner's hands placed on anterior shoulders while patient shrugs both shoulders upward against hands. CNXI What assessment test is being performed in this image? ADA Description: Tuning fork on top of the head. Weber test A 74-year-old man presents to the clinic for a scheduled annual examination. He has a history of hypertension and diabetes, both controlled with medication. He denies any complaints. The NP performed a fundoscopic examination. Identify the abnormal assessment findings in this image. ADA Description: Accumulations of axoplasmic debris within adjacent bundles of unmyelinated ganglion cell axons of the retina. Cotton wool spots A 66-year-old female presents to the office for a focused visit to discuss hypertension management strategies. During the interview, the patient asks the NP if she could be screened today for cervical cancer/HPV. Review of her medical record reveals she was screened at ages 57, 60, and 63, with no abnormal findings, and no history of cancer. What is the best action the NP should take regarding the patient's request for screening? Deny her request, inform the patient that she has had three negative screenings in the last 10 years and no longer requires screening, and focus on the reason for the visit. Of the following statements, which is true regarding the human papillomavirus (HPV) vaccine? The vaccine can protect against anogenital lesions A 21-year-old female presents for her first annual exam. She reports concern because her female partner was recently diagnosed with condyloma acuminata and wonders if she could also be infected. If true, what physical assessment findings would the NP expect to find during the speculum examination? Raised friable or lobed lesions An 18-year-old female presents to the clinic complaining of a thick and yellow vaginal discharge along with recent pelvic pain. Her history is significant for pelvic inflammatory disease (PID). During the speculum examination, the NP would expect to find purulent discharge in the following area(s) which is consistent with the diagnosis of PID? Cervical os A 23-year-old female presents to the clinic. She has decided to discontinue using condoms and would like a different birth control option. Her last pelvic exam was 2 years ago when she had a negative Pap smear and STI screening. Her LMP was 2 days ago, and she is still spotting. She last had sex with her boyfriend 1 week ago. Condoms were used. The NP elects to postpone her speculum exam during this office encounter. What is the best evidence-based rationale for the decision to postpone her exam? She is on her menses A 24-year-old female presents to the clinic for an annual exam. The NP proceeds to perform a Pap smear and understands that the most important area on the cervix to obtain cells for the Pap smear is where? Transformation zone A 45-year-old female presents to the clinic for heavy periods and pelvic pain during her menses. She reached menarche at age 13 years and has had regular periods except during her pregnancies. She is a G4P3013 and does not use birth control as her husband has had a vasectomy. She states this has been going on for about a year but seems to be getting worse. Her LMP was 1 week ago. On a bimanual exam, a large midline mass halfway to the umbilicus is palpated. Each adnexal area is nonpalpable. Her rectal exam is normal. Her body mass index (BMI) is 27. Which of the following is the most likely interpretation of these findings? These findings suggest uterine fibroids A 48-year-old female presents to the clinic with complaints of heavy vaginal discharge and severe itching for 1 week. On visualization of the vulva, a thick, white, curdy discharge is seen at the introitus. On speculum examination, there is a copious amount of this discharge. The pH of the discharge is 4.1 and the KOH whiff test is negative, with no unusual smell. Wet prep shows budding hyphae. Which of the following is the most accurate interpretation of these findings? These findings suggest candida vaginitis Cervical motion tenderness and/or adnexal tenderness are hallmarks of all the following conditions, EXCEPT? Bacterial vaginosis A 30-year-old female presents to the clinic with complaints of a bad-smelling vaginal discharge with some mild itching for about 3 weeks. She denies pain with urination or with sexual intercourse. She also reports that the smell increased after intercourse and during her period last week. After a careful history and physical assessment, the NP documents the following pelvic and anorectal examination findings: Bilateral shotty inguinal adenopathy. External genitalia without erythema or lesions. Vaginal mucosa and cervix coated with thin white homogeneous discharge with a mild fishy odor. After swabbing the cervix, no discharge is visible in the cervical os. Uterus midline; no adnexal masses. Rectal vault without masses. Stool brown and negative for fecal blood. pH of vaginal discharge 4.5. Which of the following is the most accurate interpretation of these findings? These findings suggest bacterial vaginosis The NP knows it is possible to palpate multiple structures in relation to the inguinal canal and related hernias while performing a physical examination on male patients. Which of the following is not palpable during an external examination of the abdominal wall or inguinal region? Internal inguinal rings What are the most predominant risk factors for prostate cancer? Age Ethnicity Family history A patient presents with right-upper quadrant (RUQ) pain but does not have any tenderness on palpation in the RUQ. The NP is suspicious of acute cholecystitis. The NP knows to perform which assessment test next? Murphy Sign Pain in the right-lower quadrant (RLQ) during deep, even palpation of the left-lower quadrant (LLQ) then quickly withdrawing your fingers indicates what positive assessment finding? Blumberg sign The NP suspects a patient has appendicitis. Identify the physical examination maneuver done by applying pressure halfway between the umbilicus and the anterior spine of the ilium? McBurney Sign Which assessment finding would be most suggestive of a diagnosis of biliary colic? Associated right shoulder pain Which of the following physical assessment finding is most suggestive of peritonitis secondary to a ruptured appendix? Pressing down onto the abdomen firmly and quickly withdrawals the hand produces pain A 76-year-old female presents to the office for an annual physical. Upon reviewing her history, she had a positive FOBT on one occasion at age 66 years. Subsequent colonoscopy revealed internal hemorrhoids and sigmoid diverticuli only. She has no firstdegree relatives with a history of colorectal cancer or adenomatous polyps. What is the U.S. Preventive Services Task Force (USPSTF) screening recommendation for this particular patient? Do not screen routinely A 30-year-old male is admitted to the hospital for abdominal pain. He reports steady, aching pain that began suddenly around his naval and now involves the lower abdomen. He also reports a decreased appetite with nausea but no vomiting. After a careful history and physical examination, the NP documents the following abdominal findings: The abdomen is flat, firm, and rigid, with increased tenderness and guarding in the right lower quadrant. No bowel sounds heard. Liver percusses to 7 cm in the midclavicular line; edge not felt. Spleen and kidneys not felt. No palpable masses. No CVA tenderness. Psoas sign positive. Blumberg sign positive. Which of the following is the most accurate interpretation of these findings? These findings suggest acute peritonitis The NP student is precepting with a provider in a geriatric-based clinic. The provider asks the student if he is familiar with the 10-Minute Geriatric Screener. Which of the following statements best demonstrates that the NP understands this assessment tool? The tool assesses for functional deficits which are strong predictors of patient outcomes in the elderly. The NP conducted a physical assessment on a 79-year-old male who lives independently in subsidized housing. The documentation for the Head, Eyes, Ears, Nose, Throat (HEENT) findings are as follows: Scalp without lesions. Skull NC/AT. Conjunctiva pink, sclera muddy. Pupils 2 mm constricting to 1 mm, round, regular, equally reactive to light and accommodation. Extraocular movements intact. Disc margins sharp, without hemorrhages or exudates. Mild arteriolar narrowing. TMs with good cone of light. Weber midline. AC BC. Nasal mucosa erythematous, septum deviated to the right, turbinates mildly enlarged. No sinus tenderness. Oral mucosa pink. Dentition fair. Caries present. Tongue midline, slight beefy redness. Pharynx is mildly erythematous with cobblestoning. Which of the following is the most accurate interpretation of the findings? The patient has chronic allergies The staff NP in a nursing home is conducting a physical assessment on an 84-year-old male resident who is pleasant, active, and cooperative. The skin findings in this image are observed during the examination. The staff and patient deny any known injury or trauma. The NP should document these findings as consistent with which of the following? ADA Description: Extensor surface of the right forearm with emphasis on well-demarcated vividly purple macules and patches Actinic purpura An 80-year-old woman who lives alone at home presents with concerns about maintaining her independent living status. She continues to drive and care for herself and her pet dog but reports two falls over the past 4 months. During one fall, she struck her head, causing a contusion over the right eye. She attributes these episodes to environmental factors. Once she tripped over a rug, and once she misjudged the depth of the curb while crossing the street. Which of the following would be the best approach to this patient? Perform a comprehensive assessment of fall risk and plan preventive interventions Concerning alcohol consumption in older adults, which of the following is true? The CAGE screening for alcohol abuse retains the same sensitivity and specificity it has for younger populations Which of the following statements are true about the presentation of pain and pain assessment in the older adult? Select all that apply Older patients are less likely to report pain symptoms than younger patients The American Geriatrics Society (AGS) prefers the term "persistent pain" over the term "chronic pain". Which of the following physical assessment findings regarding blood pressure is consistent with the normal aging process and not a sign of cardiovascular disease? A net increase in pulse pressure with an increase in systolic pressure and a decrease in diastolic pressure Which of the following statements best demonstrates that the NP understands their role in caring for the aging population? I will evaluate geriatric conditions in terms of functionality and quality of life rather than via traditional disease models. Which of the following physiologic and psychologic changes are expected assessment findings with the normal aging process? Select all that apply A 25-year-old female presents to the clinic after a positive home pregnancy test. She confides in you that her live-in, male partner has been verbally threatening her. She denies interest in involving law enforcement. Additionally, she reports that she has a 3- year-old daughter who lives in the home. What is the appropriate next step by the NP? Ask open-ended questions, allow her to make decisions that she feels are best for herself given the circumstance, and provide immediate or long-term referrals to domestic violence resources A 42-year-old female is at 39-weeks gestation. She reports no major issues except swelling in her feet and shortness of breath which she assumed is normal for pregnancy. On exam, the NP notes a diastolic murmur. Which of the following is true about her presentation and the appropriate next step by the NP? A diastolic murmur during pregnancy is likely pathological; further investigation and work-up is warranted A 32-year-old primigravid woman is at 27 weeks gestation. She presents with nausea, vomiting, urinary frequency, discomfort in the lower abdomen, tenderness over the suprapubic area, and severe constipation. Which of the following is true regarding these pregnancy symptoms? Iron supplementation, hormonal changes, slowed intestinal transit, physical pressure from the gravid uterus, and increased blood volume all contribute to abdominal symptoms in pregnant women. A 24-year-old female presents to the clinic concerned that she may be pregnant. Her LMP was 7-weeks ago, and the urine human chorionic gonadotropin (HCG) test is positive. What can the NP expect to find on physical examination, assuming a normal pregnancy? Select all that apply an internal cervical os closed to the width of a fingertip a bluish hue to the cervix A 20-year-old female presents to the clinic with symptoms of fatigue, nausea, and an increase in urination. She is sexually active, and her male partner uses condoms occasionally. A urine pregnancy test is positive. Her last menstrual period was 3 months ago (6/20/2021). Using the Naegele rule, what is the estimated date of delivery (EDD, or due date)? 3/27/22 The NP is conducting a physical assessment on a woman in her 26th week of pregnancy. Which of the examination finding is worrisome for a potential, emergent condition? Facial edema The NP is documenting the obstetric history of a patient. Her history includes two spontaneous miscarriages at 16- and 24-weeks' gestation, four living children (one set of twins) who were delivered at term, and a current pregnancy. How would this be documented? G6P3024 An 11-month-old infant male is accompanied to the clinic by his father. The father is concerned about the skin rash on this son's arms represented in this image. Family history is significant for a 4-year-old sibling with atopic dermatitis and asthma. Which of the following is the best documentation of the integument findings? Erythematous, patches and plaques involving the extensor surfaces of the bilateral antecubital fossa. Mild, secondary excoriations present with serous exudate. No streaking. Scant purulent drainage A mother brings her 15-day-old female infant to the outpatient clinic for evaluation of a rash that appeared suddenly after visiting family in Florida. It is August and the house did not have air conditioning. The infant is afebrile, eating and drinking well, and does not appear to be in distress. The physical assessment findings are represented in this image. Based on the history and examination findings, what is the likely etiology? ADA Description: Infant with a red, facial rash. miliaria rubra The NP assesses for the Moro Reflex as part of an infant routine physical examination. The NP should suspect a neurologic disease if the reflex has not disappeared by what specific timeframe? 16 weeks A 2-month-old female is accompanied by her parents for her first visit to the practice. When reviewing the hospital medical records of her birth, the NP notes documentation regarding significantly edematous hands and feet present at birth. Upon physical examination of the infant, the NP finds skin folds that run along the sides of the neck down to the shoulders. Which of the following should be assessed and monitored by the NP and parents related to these findings? Select all that apply. The infant's growth chart with concern for height and length. The infant's ability to properly latch during breastfeeding. The infant's fluid gain or loss. The NP is observing a female pediatric patient during a routine physical. She can jump in place and balance on one foot. She speaks in full sentences and her mother states that she can feed herself. Based on your observations and the history, determine her developmental age 4 years The NP is observing a full-term infant male. He can pull to a stand, use "mama" and "dada" specifically, and indicates his wants by vocalization and pointing. Based on your observations, determine his developmental age. 12 months Of the following statements, which is accurate regarding growth and assessment charts published by the National Center for Health Statistics? Select all that apply. All charts include height, weight, and head circumference for children up to 36 months. Growth charts are available for children with specific conditions such as Down syndrome or Turner syndrome. Growth charts are available for use in infants born prematurely. A 25-year-old male presents to the clinic with a complaint of severe rectal pain during defecation. The pain is so severe he waits several days before having a bowel movement. He has a history of ulcerative colitis (UC). He also reports being in an active sexual new relationship with a male partner. After conducting a history and physical exam, the NP documents the following anorectal findings: Perirectal area inflamed; no ulcerations, open sores, fissures, or verruca. Scant, whiteyellow, mucoid, rectal discharge noted. Unable to examine external sphincter, rectal vault, or prostate because of spasm of the external sphincter and marked inflammation and tenderness of anal canal. Which of the following is the most accurate interpretation of these findings? These findings suggest infectious proctitis A 54-year-old female with a history of migraines since childhood presents to the clinic with chronic intermittent, progressive pulsatile headaches which are similar in nature to prior attacks and precipitated by current life stressors. The headaches are accompanied by nausea and vomiting. She denies constitutional symptoms. On examination, she has elevated blood pressure but otherwise a normal cardiovascular, neurologic, and fundoscopic examination. Based on the history and physical examination findings, which diagnoses are appropriate for the differential diagnosis (DDx) list? Select all that apply. Migraine Tension A 50-year-old female presents to the clinic for evaluation of neck stiffness and aching pain. She was a restrained driver in a low-speed, rear-end, motor vehicle collision 1 day ago. The pain started several hours after the accident. On physical examination, you note muscle spasms over the paraspinous muscles on the left side of the neck, as well as pain reported during active range of motion of the cervical spine. No neurological deficits are noted. Which of the following is the most accurate interpretation of these findings? These findings suggest cervical strain Which muscle(s) are being assessed during active rotation of the neck? Sternocleidomastoid A 34-year-old female presents to the office with left elbow pain following rigorous training for a tennis match. Tenderness is noted with palpation in the area on the image marked by the red circle. What correlative diagnosis does this assessment finding indicate? ADA Description: Left elbow with emphasis on the small, tuberculated eminence, curved a little forward, about 1 cm from the joint. lateral epicondylitis A 35-year-old male presents to the clinic for a routine physical examination. His only complaint is a feeling of heaviness in his scrotum. He denies injury or trauma. After conducting a history and physical, the NP documents the following genitourinary (GU) findings: Uncircumcised penis; prepuce easily retractable. No penile discharge or lesions. No scrotal swelling or discoloration. Testes descended bilaterally; right testicle smooth; 1 × 1 cm firm, fixed, nontender, nodule on the left lateral testicle. Epididymis nontender. No inguinal or femoral hernias. Negative CVA tenderness. Which of the following is the most accurate interpretation of these findings? These findings suggest testicular cancer A 26-year-old female presents to the Emergency Department with intense abdominal pain for 6 hours, light-headedness, and a fainting episode that finally prompted her to seek medical attention. She has a history of gallstones and is concerned that she is having another gallbladder attack. She denies nausea and vomiting, and her last normal bowel movement was this morning. She reports that her LMP was 10 weeks ago. Vital signs: pulse 118; blood pressure, 86/68; respiratory rate, 20/min; oxygen saturation, 99%; and temperature, 37.3ºC orally. A β-human chorionic gonadotropin (β-hCG) blood test is pending. The NP performs an abdominal exam prior to her pelvic exam and, on palpation of her abdomen, finds involuntary rigidity and rebound tenderness. Which of the following is the most likely etiology for these assessment findings? Ruptured ectopic pregnancy A 42-year-old female presents to the office for her annual well-woman examination. She has a history of fibrocystic breast changes since her mid-20s, so she did not report any new issues except that her right breast feels "heavier" than usual. After a careful history and physical examination, the NP documents the following breast findings: Breasts pendulous with diffuse fibrocystic changes. Single firm 1 × 1 cm mass, mobile, and nontender, with overlying peau d'orange appearance in the right breast, upper outer quadrant at 11 o'clock, 2 cm from the nipple. Which of the following is the most accurate interpretation of these findings? These findings suggest a cyst An NP student conducted a clinical breast examination on a 27-year-old female with a history of fibroadenomas. The NP palpated a rubbery, mobile, nontender mass in the right breast. The mass was located 3 cm proximal to and 3 cm to the left of the nipple. Which of the following would be the most appropriate way to document the physical assessment findings? rubbery, mobile, nontender mass located in the right breast, in the 10:30 position from the nipple A 24-year-old male presents to the office for evaluation of a lump under his left nipple. He reports no other symptoms, denies trauma or injury, and reports no known family history of a first-degree relative with breast cancer. On examination, the NP notes a firm, 2-cm mass under his areola. What is the most likely etiology for these findings? Breast cancer A 34-year-old female arrives at the clinic for a prenatal, second-trimester appointment. During the interview, her behavior is concerning for intoxication, and she smells of alcohol and cigarettes. She reveals a history of intravenous drug use "10-years ago". How should the NP counsel this patient? Select all that apply If a pregnant patient does not intend to quit tobacco, cutting down is still considered beneficial to the pregnancy and should be encouraged. Pregnant women are not routinely screened for hepatitis C, but this test should be added to the panel of prenatal blood tests for patients with a history of intravenous drug use A 27-year-old female presents to the outpatient clinic with acute abdominal pain and uterine bleeding. Her last menstrual period was 6-weeks ago. She and her husband have been trying to conceive for almost one year. On physical examination, the NP palpates an ill-defined, adnexal mass in the left lower quadrant. The urine pregnancy test results are pending. Based on the history and examination findings, what is the most likely etiology? Ectopic pregnanct The NP knows measurement of growth is one of the most important indicators of infant health. Deviations may provide an early indication of an underlying problem. What is the minimum variation that indicates a more detailed evaluation is needed? Beyond 2 standard deviations for age range A 44-year-old female mathematician presents to clinic with a complaint of a mass in the right breast. Her partner noticed this mass 2 days ago, and the patient feels guilty because she has only had one mammogram and does not engage in breast self-examination (BSE) on any regular basis. She has no family history of breast cancer, and her prior mammogram was ordered as a routine screening test at age 43 years after a brief discussion with her primary care provider. After a thorough investigation reveals a benign cyst, what advice should be given to this patient about screening for breast cancer in her age group? a. BSE is well evidenced, and all recommending agencies agree that it should be taught and reinforced. b. Clinical breast examination (CBE) is superior to BSE and should be a routine part of annual examinations starting at age 30 years. c. This patient was in compliance with the U.S. Preventive Services Task Force (USPSTF) recommendations for her age group and risk factors prior to her current complaint. d. Mammography is most sensitive and specific for women in their 40s, when breast tissue is still dense enough to image accurately. e. Breast cancer screening is extremely well studied, and no controversy exists on the recommended norms for screening and follow-up. c. This patient was in compliance with the U.S. Preventive Services Task Force (USPSTF) recommendations for her age group and risk factors prior to her current complaint. A 42-year-old female website developer presents for an annual preventive examination with questions about breast cancer screening. She is concerned about the radiation exposure associated with mammography and is interested in magnetic resonance imaging (MRI) as a possible alternative for routine screening. She is otherwise healthy with no family history of breast, ovarian, or colon cancer. Which of the following is true about MRI as a screening modality for breast cancer in the general population? a. Breast cancer screening by MRI has been well studied in the general population. b. Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity. c. This patient is an ideal candidate for screening via breast MRI based on current evidence. d. Women at low lifetime risk of breast cancer (20%) are recommended to undergo screening MRI. e. Known BRCA1 or BRCA2 mutation is insufficient criteria to justify screening with breast MRI. b. Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity. A 35-year-old G0P0 woman presents to clinic with a complaint of bilateral nipple discharge. This discharge started several weeks ago and has occurred at irregular intervals since that time. She does not complain of local tenderness, redness, fever, or any other systemic symptoms aside from slightly irregular periods over the last few months. On examination, she is able to express a small amount of discharge, which is sent to the laboratory and found to be consistent with breast milk but without any signs of blood or pus. Screening laboratories are also sent, which reveal a normal blood count, metabolic panel, thyroid-stimulating hormone, and human chorionic gonadotropin (HCG) level. Further laboratories are still pending. Which of the following is the most likely diagnosis? a. Mastitis b. Ductal carcinoma in situ c. Paget disease of the breast d. Occult pregnancy e. Prolactinoma e. Prolactinoma A 22-year-old G0P0 undergraduate student presents to clinic after finding a breast mass on breast self-examination (BSE) at home. The mass is nontender without skin changes, erythema, or overlying swelling. She has heard that most breast cancers are found by patients themselves, and she is very concerned that she may have breast cancer. Which of the following is true about BSE and self-detection of breast cancer? a. Most masses that women find at home and bring to a provider's attention turn out to be malignant. b. This patient is more likely to find a fibroadenoma than a cancer on self-examination. c. The most likely breast mass this patient is likely to find in herself is an abscess complicating underlying mastitis. d. Because of this patient's age, breast masses should not be pursued with imaging and diagnosis because the risk of cancer is so low. e. BSE is universally recommended because of very high sensitivity and specificity for finding cancerous lesions. b. This patient is more likely to find a fibroadenoma than a cancer on self-examination. A 48-year-old female psychologist presents to clinic with concerns about her breast cancer risk after an age-matched cousin was recently diagnosed with this disease. This cousin is the third family member on her father's side in as many years to be diagnosed with breast cancer, including the patient's own father, who had surgery and subsequent treatment 3 years ago for breast cancer. The patient has little other knowledge of her family history, only that her grandparents independently arrived from Eastern Europe near the end of World War II and were among very few members of their family that survived the war. The patient has read about testing for the breast cancer genes (BRCA1 and BRCA2) and desires further information about whether this would be appropriate for her. Which of the following is true about this patient's indications for BRCA testing? a. Her familial lineage is irrelevant to her risk of BRCA genes and should be discounted in assessing her risk for these genes. b. Breast cancer in a male relative does not add significant weight to the decision to test for the BRCA genes in this patient. c. The BRCAPRO calculator does not add any further clinical information to this patient's risk for carrying the BRCA gene. d. This patient carries several risk factors that together justify BRCA testing. e. Even if this patient is BRCA positive, no changes in screening or treatment are recommended for patients with this genetic mutation, so the test is not recommended. d. This patient carries several risk factors that together justify BRCA testing. A 68-year-old former paleontologist presents to clinic with concerns about her breast cancer risk. Her mother developed the disease in her 50s and died from it in her 60s. A younger cousin developed the disease a few years ago before the age of 50 years, but this individual was not tested for the BRCA1 and BRCA2 genes. In addition, the patient suffered from lymphoma in her 20s and had radiation to the chest. She did take hormone replacement therapy for a few years before data emerged that this may contribute to breast cancer risk. She has had several abnormal mammograms in her 50s for persistently dense breasts with subtle findings, but follow-up biopsies never showed any malignant pathology. Which of the following is true regarding magnetic resonance imaging (MRI) screening of this patient? a. No agency recommends breast MRI for a patient such as this one, who has moderately but not extraordinary risk factors for breast cancer. b. The U.S. Preventive Services Task Force (USPSTF) recommends against screening with MRI for patients with such risk factors. c. Regardless of recommendations, the high sensitivity of breast MRI comes at the expense of markedly decreased specificity (i.e., the ability to rule out disease in healthy breasts). d. Mammograms are not affected by breast density and thus density is not a factor in choosing MRIs over mammograms in patients such as this individual. e. History of chest radiation is not a risk factor for breast cancer and is thus not relevant to deciding whether MRI is appropriate in this patient. c. Regardless of recommendations, the high sensitivity of breast MRI comes at the expense of markedly decreased specificity (i.e., the ability to rule out disease in healthy breasts). A 66-year-old female museum curator presents for a routine annual examination. On examination, a notably enlarged supraclavicular lymph node is appreciated on the right side. The lymph node is nontender and feels firm and rubbery. She denies any localized or systemic symptoms such as breast lumps, fevers, or night sweats. She has been taking conjugated estrogen tablets for 9 years since menopause, though she has not taken progestin compounds since she had a hysterectomy for heavy bleeding at age 45 years. Which of the following is true about this presentation of lymphadenopathy? a. Breast cancer always presents with axillary lymphadenopathy because the lymphatics of the breast uniformly drain into the axilla. b. Supraclavicular nodes are generally considered benign and require no further evaluation or follow-up. c. Supraclavicular nodes are found along the anterior edge of the trapezius muscle in the neck. d. Firm, rubbery lymph nodes are generally considered to be benign. e. Metastatic breast cancer cells may spread directly into the infraclavicular and then supraclavicular nodes without first causing notable changes in the axillary nodes. e. Metastatic breast cancer cells may spread directly into the infraclavicular and then supraclavicular nodes without first causing notable changes in the axillary nodes. A 24-year-old graphic designer presents to clinic with a concern for a breast mass. A rubbery, mobile, nontender mass is palpated in the right breast as described by the patient, which is consistent with a firbroadenoma. In describing the location of the mass, the examiner notes that it is 3 cm proximal to and 3 cm to the left of the nipple. Which of the following would be the most appropriate way to report this finding? a. "Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from the nipple" b. "Rubbery, mobile, nontender mass located in right breast, in the lower outer quadrant" c. "Rubbery, mobile, nontender mass located in right breast, in the upper inner quadrant" d. "Rubbery, mobile, nontender mass located in the left breast, upper outer quadrant" e. "Rubbery, mobile, nontender mass located in right breast, in the 1:30 position from the nipple" a. "Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from the nipple" A 54-year-old female dietician presents for a routine annual examination. On review of systems, she reports that she has had many breast findings over several years, including one biopsy with normal pathology. She feels that her breasts have become far less lumpy since she underwent menopause 3 years ago. Which of the following is true regarding changes in the breasts with menopause? a. Transformation of breasts to primarily fatty tissue with menopause decreases the sensitivity and specificity of mammograms. b. Estrogen in hormone replacement therapy (HRT) has no effect on breast density after menopause. c. Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the number of lobules. d. Breast density has no genetic component and is entirely due to estrogen dose from endogenous and exogenous sources over the lifetime. e. Mammography performs most poorly in the menopausal and postmenopausal age group and should be limited for that reason. c. Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the number of lobules. An overweight 26-year-old public servant presents to the Emergency Department with 12 hours of intense abdominal pain, light-headedness, and a fainting episode that finally prompted her to seek medical attention. She has a strong family history of gallstones and is concerned about this possibility. She has not had any vomiting or diarrhea. She had a normal bowel movement this morning. Her β-human chorionic gonadotropin (β-hCG) is positive at triage. She reports that her last period was 10 weeks ago. Her vital signs at triage are pulse, 118; blood pressure, 86/68; respiratory rate, 20/min; oxygen saturation, 99%; and temperature, 37.3ºC orally. The clinician performs an abdominal exam prior to her pelvic exam and, on palpation of her abdomen, finds involuntary rigidity and rebound tenderness. What is the most likely diagnosis? a. Ruptured tubal (or ectopic) pregnancy b. Acute cholecystitis c. Ruptured appendix d. Perforated bowel wall e. Ruptured ovarian cyst a. Ruptured tubal (or ectopic) pregnancy A 63-year-old janitor with a history of adenomatous colonic polyps presents for a well visit. Basic labs are performed to screen for diabetes mellitus and dyslipidemia. Electrolytes and liver enzymes were also measured. His labs are all normal expect for moderate elevations of aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transferase, and alkaline phosphatase as well as a mildly elevated total bilirubin. He presents for a follow-up appointment and the clinician performs an abdominal exam to assess his liver. Which of the following findings would be most consistent with hepatomegaly? a. Liver span of 11 cm at the midclavicular line b. Liver span of 8 cm at the midsternal line c. Dullness to percussion over a span of 11 cm at the midclavicular line d. Dullness to percussion over a span of 8 cm at the midsternal line e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration A 63-year-old underweight administrative clerk with a 50-pack-year smoking history presents with a several month history of recurrent epigastric abdominal discomfort. She feels fairly well otherwise and denies any nausea, vomiting, diarrhea, or constipation. She reports that a first cousin died from a ruptured aneurysm at age 68 years. Her vital signs are pulse, 86; blood pressure, 148/92; respiratory rate, 16; oxygen saturation, 95%; and temperature, 36.2ºC. Her body mass index is 17.6. On exam, her abdominal aorta is prominent, which is concerning for an abdominal aortic aneurysm (AAA). Which of the following is her most significant risk factor for an AAA? a. Female gender b. History of smoking c. Underweight d. Family history of ruptured aneurysm e. Hypertension b. History of smoking A 76-year-old retired man with a history of prostate cancer and hypertension has been screened annually for colon cancer using high sensitivity fecal occult blood testing (FOBT). He presents for follow-up of his hypertension, during which the clinician scans his chart to ensure he is up to date with his preventive health care. He has a positive FOBT on one occasion at age 66 years and subsequently went for a colonoscopy. Internal hemorrhoids and sigmoid diverticuli were found on colonoscopy. He has no first-degree relatives with a history of colorectal cancer or adenomatous polyps. What are the U.S. Preventive Services Task Force (USPSTF) screening recommendations for this patient? a. Do not screen routinely b. Continue annual FOBT screening until age 80 years c. Continue annual FOBT screening until age 85 years d. Repeat colonoscopy this year e. Sigmoidoscopy every 5 years with FOBT every 3 years a. Do not screen routinely An otherwise healthy 31-year-old accountant presents to an outpatient clinic with a 3-year history of recurrent crampy abdominal pain that lasts for about 1-2 weeks each episode and is associated with onset of constipation. She describes infrequent, small hard stool that she finds very difficult to pass. She has tried to increase dietary fiber and water intake, but usually this is not sufficient and she resorts to over-the-counter laxatives, which she finds upset her stomach but do resolve the constipation. Symptoms typically gradually resolve with bowel movements. Which of the following is the most likely physiological mechanism for her constipation? a. A large, firm fecal mass in the rectum b. Decreased fecal bulk c. Functional change in bowel movement d. Spasm of the external sphincter e. Impairment of autonomic innervations c. Functional change in bowel movement A 23-year-old woman comes to the respirology clinic for follow-up of her chronic sinusitis and bronchiectasis that is associated with a rare congenital condition called Kartagener syndrome. The preceptor notes that she has situs inversus and asks for a physical exam. Which of the following descriptions best fits with findings on the abdominal exam? a. Tympany to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant b. Protuberant abdomen that has scattered areas of tympany and dullness; stool is felt on palpation c. Liver dullness in the right upper quadrant that is displaced downward by the low diaphragm due to chronic obstructive pulmonary disease d. Dullness to percussion of the left lower anterior chest wall roughly at the anterior axillary line e. A change in percussion from tympany to dullness in the left lower anterior chest wall on inspiration a. Tympany to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant An otherwise healthy 28-year-old lawyer presents to the Emergency Department with a 1-day history of severe abdominal pain. The emergency physician suspects appendicitis and general surgery is consulted. The resident believes the patient has signs of peritonitis on exam. Which of the following physical exam findings supports peritonitis? a. Voluntary contraction of the abdominal wall that persists over several examinations b. Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain c. Abdominal pain that increases with hip flexion d. Localized pain over McBurney point, which lies 2 inches from the anterior superior iliac spinous process on a line drawn from the umbilicus e. Pain with internal rotation of the right hip b. Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain A 58-year-old man with a history of diabetes and alcohol addiction has been sober for the last 10 months. He presents with a 4-month history of increasing weakness, recurrent epigastric pain radiating to his back, chronic diarrhea with stools 6-8 times daily, and weight loss of 18 lb over 4 months. What is the mechanism of his most likely diagnosis? a. Helicobacter pylori infection b. Inflammation of the gallbladder c. Inflammation of colonic diverticulum d. Reduced blood supply to the bowel e. Fibrosis of the pancreas e. Fibrosis of the pancreas A 46-year-old executive who is obese and otherwise healthy presents to a family medicine clinic with a 3-month course of recurrent severe abdominal pain that usually resolves on its own after a few hours. Her last episode was prolonged lasting 6 hours, and she is frustrated that she has had to leave or miss work on three separate occasions. She would like a diagnosis and the problem fixed. Which symptoms or signs would be most suggestive of a diagnosis of biliary colic? a. Exacerbating factor includes alcohol intake b. Positive McBurney point tenderness c. Poorly localized periumbilical pain d. Vomiting of bile e. Associated right shoulder pain e. Associated right shoulder pain A 67-year-old electronics technician with a history of hypertension and type 2 diabetes presents for his yearly physical examination and complains of progressively worsening erectile dysfunction (ED). While counseling him, the clinician mentions that multiple processes must take place to achieve an erection. Which of the following structures would be most affected by vascular deficiencies related to his preexisting medical conditions and is likely contributing to his symptoms? a. Corpora cavernosa b. Ejaculatory duct c. Epididymis d. Seminal vesicle e. Vas deferens Submit a. Corpora cavernosa A 29-year-old graduate student states that he is able to achieve an erection and ejaculate during sexual intercourse; however, he does not experience any pleasurable sensation of orgasm. He is otherwise healthy and is not on any medications. What is the most likely cause of his problem? a. Androgen insufficiency b. Endocrine dysfunction c. Peyronie disease d. Psychogenic e. Sexually transmitted infection (STI) d. Psychogenic Multiple processes must take place in order for a male to sustain an erection. Various cues stimulate sympathetic outflow from higher brain centers to the T11-L2 levels of the spinal cord and parasympathetic outflow from S2 to S4 reflex arcs. Local vasodilatation within the penis erectile tissue results from increased levels of which of the following? a. Follicle-stimulating hormone (FSH) b. Gonadotropin-releasing hormone (GRH) c. Luteinizing hormone (LH) d. Nitric oxide (NO) and cyclic guanosine monophosphate (cGMP) e. Testosterone d. Nitric oxide (NO) and cyclic guanosine monophosphate (cGMP) The human papillomavirus (HPV) can cause genital warts in males and females as well as cervical cancer in females. Vaccination against HPV is available and should be offered to males between what ages? a. 6-9 months b. 1-3 years c. 5-7 years d. 9-21 years e. 30-50 years d. 9-21 years A 32-year-old male complains of a painless, cystic mass just above his left testicle. During the physical examination, a strong flashlight is placed behind the scrotum through the area in question and transillumination is noted. What is the most likely diagnosis? a. Direct hernia b. Indirect hernia c. Spermatocele d. Testicular tumor e. Varicocele c. Spermatocele A 25-year-old graduate student presents to the clinic complaining of scrotal pain, which has been increasing over the past 2 days. He is sexually active and has had unprotected intercourse with multiple partners in the past couple of weeks. On examination, some mild to moderate swelling of the scrotum on the right and tenderness with palpation of the right testicle are notes. What is the most likely diagnosis? a. Acute epididymitis b. Hydrocele c. Primary syphilis d. Spermatocele e. Testicular cancer a. Acute epididymitis A 32-year-old elementary teacher requests a workup for infertility. He and his wife have been trying to conceive for the last 2 years. He reports that his wife has been evaluated and does not appear to have any infertility issues. The overall examination does not reveal any significant abnormalities. He is of average height and weight and has normal secondary sex characteristics of the genitalia. Of the following, which would be most likely be abnormal and causing male infertility? a. 5α-Dihydrotestosterone b. 5α-Reductase c. Follicle-stimulating hormone (FSH) d. Luteinizing hormone (LH) e. Thyroid-stimulating hormone (TSH) c. Follicle-stimulating hormone (FSH) While performing a physical examination on male patients, it is possible to palpate multiple structures in relation to the inguinal canal and related hernias. Which of the following is not palpable during an external examination of the abdominal wall or inguinal region? a. External inguinal ring b. Internal inguinal ring c. Pubic tubercle d. Anterior superior iliac spine e. Direct inguinal hernia b. Internal inguinal ring A 20-year-old college student presents for his annual physical examination. He recently became sexually active and is inquiring about the best means of preventing sexually transmitted infections (STIs). Of the following, which would be the most effective means of prevention? a. Early withdrawal b. Male condoms c. Spermicides d. Diaphragms e. Cervical caps b. Male condoms A 21-year-old college student presents to the student health clinic for a full physical examination. He is generally healthy; however, he reports that he has had sexual intercourse with multiple partners in the past couple of months. He noticed a small lesion on the shaft of his penis a few days ago. While performing the examination, he unwillingly achieves an erection. How should the clinician proceed at this point? a. Stop the examination immediately. b. Have him return to see another provider. c. Explain this is a normal response and finish the examination. d. Tell him the examination cannot proceed until the erection subsides. e. Assume that he is malingering. Submit c. Explain this is a normal response and finish the examination. A 45-year-old driver's education instructor presents to the clinic for heavy periods and pelvic pain during her menses. She reached menarche at age 13 years and has had regular periods except during her pregnancies. She is a G4P3013 and does not use birth control as her husband has had a vasectomy. She states this has been going on for about a year but seems to be getting worse. Her last period was 1 week ago. On bimanual exam, a large midline mass halfway to the umbilicus is palpated. Each adnexal area is nonpalpable. Her rectal exam is normal. Her body mass index (BMI) is 27. What is the best explanation for her physical finding? a. Large colonic stool b. Ovarian mass c. Fibroids d. 4-Month pregnancy e. Bartholin gland enlargement c. Fibroids A 32-year-old G0 woman comes for evaluation on why she and her husband have been unable to get pregnant. Her husband has been married before and has two other children, ages 7 and 4 years. The patient relates she began her periods at age 12 and has been fairly regular ever since. She began oral contraceptive pills from when she got married until last year, when she began to try for a pregnancy. Before this she had regular cycles for 10 years. She has had a history of five prior partners. She relates she was once treated for a severe genital infection when she was in college. Based on this patient's history, what is the best explanation for her infertility? a. Prior pelvic inflammatory disease (PID) b. Prior Bartholin gland infection c. Prior herpes infection d. Metabolic disorder with subsequent hormonal irregularities leading to anovulation e. Secondary amenorrhea a. Prior pelvic inflammatory disease (PID) A 24-year-old retail clerk presents to the clinic for an annual exam. Her last Pap was 3 years ago and was normal. She is a G0 and is currently not sexually active although she has had two lifetime partners. She is on oral contraceptive pills for cycle control and has no medical problems. Based on guidelines, the clinician proceeds to perform a Pap smear and places the speculum. There are two layers of cells, squamous and columnar. Where is the most important area to obtain cells for a Pap smear? a. Zona reticularis b. Transformation zone c. Squamous zone d. Columnar zone e. Linea nigra b. Transformation zone A 35-year-old grade school teacher presents for her annual exam. Her last Pap smear was 4 years ago and normal. She is a G1P1 with a 6-year-old child. She has had four lifetime partners but only one partner in the last 12 years. Otherwise she has no complaints. A speculum exam is done followed by a bimanual examination during which a rectovaginal mass is palpated. Which of the following exam findings would be most reassuring that this is not a colonic mass? a. No cervical motion tenderness b. No pus from the os c. The mass dents with digital pressure d. Both adnexa are nontender e. The perineum has no lesions c. The mass dents with digital pressure A 21-year-old college student presents for her first annual exam. She has been sexually active for 1 year and has had two partners. She is not aware of having had any sexually transmitted diseases (STIs). She is using condoms for birth control and STI prevention but admits to not always using them regularly. Her last menses was 2 weeks ago. On speculum exam, an unusual appearance is noted, which is diagnosed as warts. What is the best description for these lesions? a. Several shallow ulcers with a red base b. Translucent nodules c. Raised friable or lobed lesions d. Bright red, soft lesion arising from the cervical canal e. Strawberry cervix (small red granular spots or petechiae) c. Raised friable or lobed lesions A 23-year-old female comes to the clinic to discuss her birth control options. Although she has been sexually active since age 16 years, she has been with one partner for the last year. She has decided to discontinue condoms and would like a different birth control option. She has not had a pelvic exam for 2 years. She had a normal Pap smear that year and negative sexually transmitted infection (STI) testing. Her last menstrual period was 2 days ago. She states that she is still spotting. She also states that she last had sex with her boyfriend 1 week ago, so the clinician elects to postpone her speculum exam. What is the best explanation for the decision to postpone her exam? a. She is on her menses. b. She has only one current partner and does not need STI testing. c. She had a normal Pap smear within the last 3 years. d. She should not be sexually active. e. She has been using condoms. a. She is on her menses. An 18-year-old high school senior presents to the clinic complaining of a vaginal discharge. She states that it is thick and yellow and that she has had some recent pelvic pain. She is sexually active and is not using any type of birth control or sexually transmitted infection (STI) prevention. She denies any burning with urination, nausea, vomiting, or diarrhea. She has had some fever and chills with a temperature up to 101.5ºF. Her last menstrual period was last week. After a physical exam, she is diagnosed with pelvic inflammatory disease (PID). Visualization of purulent discharge in which of the following areas would best support a diagnosis of PID? a. Cervical os b. Posterior fornix c. Anterior fornix d. Skene gland opening e. Bartholin gland opening a. Cervical os A 27-year-old G0 bus driver presents to the clinic complaining of an itchy vaginal discharge for the last week. She reached menarche at age 12 years, became sexually active at age 18 years, and has had a total of five sexual partners. She has been with her current partner for 1 month. She is on oral contraceptive pills and does not use condoms as she is allergic to latex. Her last menstrual period was 3 weeks ago. She is not having any pelvic pain, fever, nausea, or vomiting. Her vitals are normal with a body mass index of 22. The clinician places the metal medium Graves speculum in the vagina but cannot find the cervix. What is the best next maneuver to visualize the cervix? a. Replace the speculum with a larger one (large Graves). b. Withdraw the speculum and do a bimanual exam to find the cervix. c. Withdraw the speculum slightly and reposition it on a different slope. d. Replace the sp