Chapter 04: Assessment and Health Promotion
MULTIPLE CHOICE
1. Due to the effects of cyclic ovarian changes in the breast, when is the best time for breast
self-examination (BSE)?
a. Between 5 and 7 days after menses ceases
b. Day 1 of the endometrial cycle
c. Midmenstrual cycle
d. Any time during a shower or bath
ANS: A
The physiologic alterations in breast size and activity reach their minimal level
approximately 5 to 7 days after menstruation ceases. Therefore, BSE is best performed
during this phase of the menstrual cycle. Day 1 of the endometrial cycle is too early to
perform an accurate BSE. After the midmenstrual cycle, breasts are likely to become tender
and increase in size, which is not the ideal time to perform BSE. Lying down after a shower
or bath with a small towel under the shoulder of the side being examined is appropriate
teaching for BSE. A secondary BSE may be performed while in the shower.
PTS: 1 DIF: Cognitive Level: Applying
TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
2. Individual irregularities in N eR
thU arIiaN
ovS nG TeBn.
(m strCuO
alM
) cycle are most often caused by what?
a. Variations in the follicular (preovulatory) phase
b. Intact hypothalamic-pituitary feedback mechanism
c. Functioning corpus luteum
d. Prolonged ischemic phase
ANS: A
Almost all variations in the length of the ovarian cycle are the result of variations in the
length of the follicular phase. This information discounts the other options as being correct.
An intact hypothalamic-pituitary feedback mechanism would be regular, not irregular. The
luteal phase begins after ovulation. The corpus luteum is dependent on the ovulatory phase
and fertilization. During the ischemic phase, the blood supply to the functional endometrium
is blocked, and necrosis develops. The functional layer separates from the basal layer, and
menstrual bleeding begins.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
3. How would the physiologic process of the sexual response best be characterized?
a. Coitus, masturbation, and fantasy
b. Myotonia and vasocongestion
c. Erection and orgasm
d. Excitement, plateau, and orgasm
, ANS: B
Physiologically, sexual response can be analyzed in terms of two processes: vasocongestion
and myotonia. Coitus, masturbation, and fantasy are forms of stimulation for the physical
manifestation of the sexual response. Erection and orgasm occur in two of the four phases of
the sexual response cycle. Excitement, plateau, and orgasm are three of the four phases of
the sexual response cycle.
PTS: 1 DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
4. The nurse guides a woman to the examination room and asks her to remove her clothes and
put on an examination gown with the front open. The woman replies, “I have special
undergarments that I do not remove for religious reasons.” Which is the most appropriate
response from the nurse?
a. “You can’t have an examination without removing all your clothes.”
b. “I’ll ask the physician to modify the examination.”
c. “I’ll explain the examination procedure, and then we can discuss how you can
comfortably have your examination.”
d. “I have no idea how we can accommodate your beliefs.”
ANS: C
Explaining the examination procedure reflects cultural competence by the nurse and shows
respect for the woman’s religious practices. The nurse must respect the rich and unique
qualities that cultural diversity brings to individuals. The examination can be modified to
ensure that modesty is maintained. In recognizing the value of cultural differences, the nurse
can modify the plan of careNtU omRSeetItN
heGnTeeds
B.C M woman. Telling the client that her
ofOeach
religious practices are different or strange is inappropriate and disrespectful to the client.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
5. A woman tells the nurse that she thinks she has a vaginal infection, and has been using an
over-the-counter cream for the past 2 days to treat it. How should the nurse initially
respond?
a. Determine when she first noticed the symptoms.
b. Reassure the woman that using vaginal cream is not a problem for the
examination.
c. Ask the woman to describe the symptoms that indicate to her that she has a vaginal
infection.
d. Ask the woman to reschedule the appointment for the examination.
ANS: C
, An important element of the health history and physical examination is the client’s
description of any symptoms she may be experiencing. The best response is for the nurse to
inquire about the symptoms the woman is experiencing. While relevant, when the symptoms
began is not as important as what the symptoms are. Women should not douche, use
vaginal medications, or have sexual intercourse for 24 to 48 hours before obtaining a Pap
test. Although the woman may need to reschedule a visit for her Pap test, her current
symptoms should still be addressed.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
6. Preconception and prenatal care have become important components of women’s health.
What is the guiding principal of preconception care?
a. Ensure that pregnancy complications do not occur.
b. Identify the woman who should not become pregnant.
c. Encourage healthy lifestyles for families desiring pregnancy.
d. Ensure that women know about prenatal care.
ANS: C
Preconception counseling guides couples in how to avoid unintended pregnancies, how to
identify and manage risk factors in their lives and in their environment, and how to identify
healthy behaviors that promote the well-being of the woman and her potential fetus.
Preconception care does not ensure that pregnancy complications will not occur. In many
cases, problems can be identified and treated and may not recur in subsequent pregnancies.
For many women, counseling can allow behavior modification before any damage is done,
or a woman can make an informed decision about her willingness to accept potential
hazards. If a woman is seekNinUgRpS
reI
coNnG ptB
ceT io.nCcaOreM, then she is likely aware of prenatal care.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
7. Ovarian function and hormone production decline during which transitional phase?
a. Climacteric
b. Menarche
c. Menopause
d. Puberty
ANS: A
The climacteric phase is a transitional period during which ovarian function and hormone
production decline. Menarche is the term that denotes the first menstruation. Menopause
refers only to the last menstrual period. Puberty is a broad term that denotes the entire
transitional period between childhood and sexual maturity.
PTS: 1 DIF: Cognitive Level: Remember
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
8. Which statement indicates that a client requires additional instruction regarding breast
self-examination (BSE)?
a. “Yellow discharge from my nipple is normal if I’m having my period.”
MULTIPLE CHOICE
1. Due to the effects of cyclic ovarian changes in the breast, when is the best time for breast
self-examination (BSE)?
a. Between 5 and 7 days after menses ceases
b. Day 1 of the endometrial cycle
c. Midmenstrual cycle
d. Any time during a shower or bath
ANS: A
The physiologic alterations in breast size and activity reach their minimal level
approximately 5 to 7 days after menstruation ceases. Therefore, BSE is best performed
during this phase of the menstrual cycle. Day 1 of the endometrial cycle is too early to
perform an accurate BSE. After the midmenstrual cycle, breasts are likely to become tender
and increase in size, which is not the ideal time to perform BSE. Lying down after a shower
or bath with a small towel under the shoulder of the side being examined is appropriate
teaching for BSE. A secondary BSE may be performed while in the shower.
PTS: 1 DIF: Cognitive Level: Applying
TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
2. Individual irregularities in N eR
thU arIiaN
ovS nG TeBn.
(m strCuO
alM
) cycle are most often caused by what?
a. Variations in the follicular (preovulatory) phase
b. Intact hypothalamic-pituitary feedback mechanism
c. Functioning corpus luteum
d. Prolonged ischemic phase
ANS: A
Almost all variations in the length of the ovarian cycle are the result of variations in the
length of the follicular phase. This information discounts the other options as being correct.
An intact hypothalamic-pituitary feedback mechanism would be regular, not irregular. The
luteal phase begins after ovulation. The corpus luteum is dependent on the ovulatory phase
and fertilization. During the ischemic phase, the blood supply to the functional endometrium
is blocked, and necrosis develops. The functional layer separates from the basal layer, and
menstrual bleeding begins.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
3. How would the physiologic process of the sexual response best be characterized?
a. Coitus, masturbation, and fantasy
b. Myotonia and vasocongestion
c. Erection and orgasm
d. Excitement, plateau, and orgasm
, ANS: B
Physiologically, sexual response can be analyzed in terms of two processes: vasocongestion
and myotonia. Coitus, masturbation, and fantasy are forms of stimulation for the physical
manifestation of the sexual response. Erection and orgasm occur in two of the four phases of
the sexual response cycle. Excitement, plateau, and orgasm are three of the four phases of
the sexual response cycle.
PTS: 1 DIF: Cognitive Level: Knowledge
TOP: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
4. The nurse guides a woman to the examination room and asks her to remove her clothes and
put on an examination gown with the front open. The woman replies, “I have special
undergarments that I do not remove for religious reasons.” Which is the most appropriate
response from the nurse?
a. “You can’t have an examination without removing all your clothes.”
b. “I’ll ask the physician to modify the examination.”
c. “I’ll explain the examination procedure, and then we can discuss how you can
comfortably have your examination.”
d. “I have no idea how we can accommodate your beliefs.”
ANS: C
Explaining the examination procedure reflects cultural competence by the nurse and shows
respect for the woman’s religious practices. The nurse must respect the rich and unique
qualities that cultural diversity brings to individuals. The examination can be modified to
ensure that modesty is maintained. In recognizing the value of cultural differences, the nurse
can modify the plan of careNtU omRSeetItN
heGnTeeds
B.C M woman. Telling the client that her
ofOeach
religious practices are different or strange is inappropriate and disrespectful to the client.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
5. A woman tells the nurse that she thinks she has a vaginal infection, and has been using an
over-the-counter cream for the past 2 days to treat it. How should the nurse initially
respond?
a. Determine when she first noticed the symptoms.
b. Reassure the woman that using vaginal cream is not a problem for the
examination.
c. Ask the woman to describe the symptoms that indicate to her that she has a vaginal
infection.
d. Ask the woman to reschedule the appointment for the examination.
ANS: C
, An important element of the health history and physical examination is the client’s
description of any symptoms she may be experiencing. The best response is for the nurse to
inquire about the symptoms the woman is experiencing. While relevant, when the symptoms
began is not as important as what the symptoms are. Women should not douche, use
vaginal medications, or have sexual intercourse for 24 to 48 hours before obtaining a Pap
test. Although the woman may need to reschedule a visit for her Pap test, her current
symptoms should still be addressed.
PTS: 1 DIF: Cognitive Level: Apply
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
6. Preconception and prenatal care have become important components of women’s health.
What is the guiding principal of preconception care?
a. Ensure that pregnancy complications do not occur.
b. Identify the woman who should not become pregnant.
c. Encourage healthy lifestyles for families desiring pregnancy.
d. Ensure that women know about prenatal care.
ANS: C
Preconception counseling guides couples in how to avoid unintended pregnancies, how to
identify and manage risk factors in their lives and in their environment, and how to identify
healthy behaviors that promote the well-being of the woman and her potential fetus.
Preconception care does not ensure that pregnancy complications will not occur. In many
cases, problems can be identified and treated and may not recur in subsequent pregnancies.
For many women, counseling can allow behavior modification before any damage is done,
or a woman can make an informed decision about her willingness to accept potential
hazards. If a woman is seekNinUgRpS
reI
coNnG ptB
ceT io.nCcaOreM, then she is likely aware of prenatal care.
PTS: 1 DIF: Cognitive Level: Understand
TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
7. Ovarian function and hormone production decline during which transitional phase?
a. Climacteric
b. Menarche
c. Menopause
d. Puberty
ANS: A
The climacteric phase is a transitional period during which ovarian function and hormone
production decline. Menarche is the term that denotes the first menstruation. Menopause
refers only to the last menstrual period. Puberty is a broad term that denotes the entire
transitional period between childhood and sexual maturity.
PTS: 1 DIF: Cognitive Level: Remember
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
8. Which statement indicates that a client requires additional instruction regarding breast
self-examination (BSE)?
a. “Yellow discharge from my nipple is normal if I’m having my period.”
