NSG6020- FINAL EXAM REVIEW
QUESTIONS AND ANSWERS
A5565-year-
old55patient55remarks55that55she55just55can't55believe55that55her55breast55sag55so55much.
55She55states55it55must55be55from55lack55of55exercise.55What55explanation55should55the5
5nurse55offer55her?55-55answer--
After55menopause,55the55glandular55and55fat55tissue55atrophies,55causing55breast55size5
5and55elasticity55to55diminish,55resulting55in55breasts55that55sag.
The55mother55of55a5510-year-
old55boy55asks55the55nurse55to55discuss55the55recognition55of55puberty.55The55nurse55sh
ould55reply55by55saying:55-55answer--
The55first55sign55of55puberty55is55enlargement55of55the55testes
A55patient55has55bilateral55pitting55edema55of55the55feet.55While55assessing55the55periph
eral55vascular55system,55the55nurse's55primary55focus55should55be:55-55answer--
Venous55function55of55the55lower55extremities
During55an55examination,55the55nurse55notes55severe55nystagmus55in55both55eyes55of55
a55patient.55Which55of55the55following55conclusions55is55correct?55-55answer--
This55may55indicate55disease55of55the55cerebellum55or55brainstem
When55performing55a55musculoskeletal55assessment,55the55nurse55knows55the55correct5
5approach55for55the55examination55should55be:55-55answer--proximal55to55distal
A5543-year-
old55woman55is55at55the55clinic55for55a55routine55examination.55She55reports55that55she55
has55had55a55breast55lump55in55her55right55breast55for55years.55Recently,55it55has55begu
n55to55change55in55consistency55and55is55becoming55harder.55She55reports55that55555yea
rs55ago55her55physician55evaluated55the55lump55and55determined55that55it55"was55nothin
g55to55worry55about."55the55examination55validates55the55presence55of55a55mass55in55the
55right55upper55outer55quadrant55at55155o'clock55approximately55555cm55from55the55nipple
.55It55is55firm,55mobile,55non-
tender,55with55borders55that55are55not55well55defined.55The55nurse's55recommendation55t
o55her55is:55-55answer--
, Because55of55the55change55in55consistency55of55the55lump,55it55should55be55further55eva
luated55by55a55physician.
The55nurse55practitioner55is55examining55a553-month-
old55infant.55While55holding55the55thumbs55on55the55infant's55inner55-
mid55thighs55and55the55fingers55outside55on55the55hips,55touching55the55greater55trochan
ter,55the55nurse55practitioner55adducts55the55legs55until55the55nurse55practitioner's55thum
b55touch55and55then55abducts55the55legs55until55the55infant's55knees55touch55the55table.5
5The55nurse55practitioner55does55not55note55any55"clunking"55sounds55and55is55confident
55to55record55a"55-55answer--Negative55Ortolani's55sign
A55patient's55mother55has55noticed55that55her55son,55who55has55been55to55a55new55baby
sitter55has55some55blisters55and55scabs55on55his55face55and55buttocks.55On55examinatio
n,55the55nurse55notices55moist,55thin-
roofed55vesicles55with55a55thin55erythematous55base55and55suspects:55-55answer--
Impetigo
The55nurse55is55testing55superficial55reflexes55on55a55adult55patient.55When55stroking55u
p55the55lateral55side55of55the55sole55and55across55the55ball55of55the55foot,55the55nurse55n
otices55the55plantar55flexion55of55the55toes.55How55would55the55nurse55document55this55fi
nding?55-55answer--Plantar55reflex55present
A55woman55is55in55the55family55planning55clinic55seeking55birth55control55information.55S
he55states55that55her55breast55"change55all55month55long"55and55that55she55is55worried55t
hat55this55is55unusual.55What55is55the55nurse's55best55response?55-55answer--
Tell55her55that,55because55of55the55changing55hormones55during55the55monthly55menstru
al55cycle,55cyclic55breast55changes55are55common
A55patient55states55during55the55interview55that55she55noticed55a55new55breast55lump55in
55the55shower55a55few55days55ago.55It55was55on55her55left55breast55near55her55axilla.55Th
e55RN55should55plan55to:55-55answer--palpate55the55unaffected55breast55first
A5516-year-
old55girl55is55being55seen55at55clinic55for55gastrointestinal55complaints55and55weight55loss
.55Nurse55determines55that55many55of55her55complaints55may55be55related55to55erratic55e
ating55patterns,55eating55predominantly55fast55foods,55and55high55caffeine55intake.55In55t
his55situation,55which55is55most55appropriate55when55collecting55current55dietary55intake5
5information?55-55answer--
Have55the55patient55complete55a55food55diary55for55355day=55255weekdays55+55255weeke
nd55day.
To55assess55the55head55control55of55a554-month-
old55infant,55the55nurse55lifts55the55infant55up55in55a55prone55position55while55supporting5
5his55chest.55The55nurse55looks55for55what55normal55response?55-55answer--
Raises55head55and55arches55back
QUESTIONS AND ANSWERS
A5565-year-
old55patient55remarks55that55she55just55can't55believe55that55her55breast55sag55so55much.
55She55states55it55must55be55from55lack55of55exercise.55What55explanation55should55the5
5nurse55offer55her?55-55answer--
After55menopause,55the55glandular55and55fat55tissue55atrophies,55causing55breast55size5
5and55elasticity55to55diminish,55resulting55in55breasts55that55sag.
The55mother55of55a5510-year-
old55boy55asks55the55nurse55to55discuss55the55recognition55of55puberty.55The55nurse55sh
ould55reply55by55saying:55-55answer--
The55first55sign55of55puberty55is55enlargement55of55the55testes
A55patient55has55bilateral55pitting55edema55of55the55feet.55While55assessing55the55periph
eral55vascular55system,55the55nurse's55primary55focus55should55be:55-55answer--
Venous55function55of55the55lower55extremities
During55an55examination,55the55nurse55notes55severe55nystagmus55in55both55eyes55of55
a55patient.55Which55of55the55following55conclusions55is55correct?55-55answer--
This55may55indicate55disease55of55the55cerebellum55or55brainstem
When55performing55a55musculoskeletal55assessment,55the55nurse55knows55the55correct5
5approach55for55the55examination55should55be:55-55answer--proximal55to55distal
A5543-year-
old55woman55is55at55the55clinic55for55a55routine55examination.55She55reports55that55she55
has55had55a55breast55lump55in55her55right55breast55for55years.55Recently,55it55has55begu
n55to55change55in55consistency55and55is55becoming55harder.55She55reports55that55555yea
rs55ago55her55physician55evaluated55the55lump55and55determined55that55it55"was55nothin
g55to55worry55about."55the55examination55validates55the55presence55of55a55mass55in55the
55right55upper55outer55quadrant55at55155o'clock55approximately55555cm55from55the55nipple
.55It55is55firm,55mobile,55non-
tender,55with55borders55that55are55not55well55defined.55The55nurse's55recommendation55t
o55her55is:55-55answer--
, Because55of55the55change55in55consistency55of55the55lump,55it55should55be55further55eva
luated55by55a55physician.
The55nurse55practitioner55is55examining55a553-month-
old55infant.55While55holding55the55thumbs55on55the55infant's55inner55-
mid55thighs55and55the55fingers55outside55on55the55hips,55touching55the55greater55trochan
ter,55the55nurse55practitioner55adducts55the55legs55until55the55nurse55practitioner's55thum
b55touch55and55then55abducts55the55legs55until55the55infant's55knees55touch55the55table.5
5The55nurse55practitioner55does55not55note55any55"clunking"55sounds55and55is55confident
55to55record55a"55-55answer--Negative55Ortolani's55sign
A55patient's55mother55has55noticed55that55her55son,55who55has55been55to55a55new55baby
sitter55has55some55blisters55and55scabs55on55his55face55and55buttocks.55On55examinatio
n,55the55nurse55notices55moist,55thin-
roofed55vesicles55with55a55thin55erythematous55base55and55suspects:55-55answer--
Impetigo
The55nurse55is55testing55superficial55reflexes55on55a55adult55patient.55When55stroking55u
p55the55lateral55side55of55the55sole55and55across55the55ball55of55the55foot,55the55nurse55n
otices55the55plantar55flexion55of55the55toes.55How55would55the55nurse55document55this55fi
nding?55-55answer--Plantar55reflex55present
A55woman55is55in55the55family55planning55clinic55seeking55birth55control55information.55S
he55states55that55her55breast55"change55all55month55long"55and55that55she55is55worried55t
hat55this55is55unusual.55What55is55the55nurse's55best55response?55-55answer--
Tell55her55that,55because55of55the55changing55hormones55during55the55monthly55menstru
al55cycle,55cyclic55breast55changes55are55common
A55patient55states55during55the55interview55that55she55noticed55a55new55breast55lump55in
55the55shower55a55few55days55ago.55It55was55on55her55left55breast55near55her55axilla.55Th
e55RN55should55plan55to:55-55answer--palpate55the55unaffected55breast55first
A5516-year-
old55girl55is55being55seen55at55clinic55for55gastrointestinal55complaints55and55weight55loss
.55Nurse55determines55that55many55of55her55complaints55may55be55related55to55erratic55e
ating55patterns,55eating55predominantly55fast55foods,55and55high55caffeine55intake.55In55t
his55situation,55which55is55most55appropriate55when55collecting55current55dietary55intake5
5information?55-55answer--
Have55the55patient55complete55a55food55diary55for55355day=55255weekdays55+55255weeke
nd55day.
To55assess55the55head55control55of55a554-month-
old55infant,55the55nurse55lifts55the55infant55up55in55a55prone55position55while55supporting5
5his55chest.55The55nurse55looks55for55what55normal55response?55-55answer--
Raises55head55and55arches55back
