NR509 FINAL EXAM QUESTIONS WITH 100% ACCURATE
SOLUTIONS & DETAILED RATIONALES.
1) A 63-year-old office worker comes to the clinic for her women's health exam.
Her last Pap smear was 5 years ago and was normal. She is married and has been
with the same sexual partner for the last 35 years. After performing the majority
of the exam, the clinician decides to do a speculum exam to collect cytology for
Pap smear. What is the correct position to have the patient in for her speculum
exam?
A) Sitting
B) Supine
C) Prone
D) Trendelenburg
E) Lithotomy -- Answer ✔✔ e. Lithotomy
- Rationale; Lithotomy or dorsal lithotomy position describes a patient lying on
an exam table supine but with the legs abducted with the feet in the stirrups.
This was named lithotomy because it is how doctors used to access the
urethra in both men and women to be able to remove stones with
instruments. This is the easiest position to visualize the cervix and do the
bimanual exam. Sitting is incorrect. Obviously the vagina and perineum cannot
be accessed in the sitting position. Supine is incorrect. A purely supine
position lying on the back with the legs adducted closed would provide no
, exposure to the female genitalia. Prone is incorrect. In the prone position,
the patient is laying on the stomach, and the genitalia are not accessible.
Trendelenburg is incorrect. In the Trendelenburg position, the patient is
supine and the legs are elevated higher than the level of the head. A reverse
Trendelenburg has the patient supine with the head higher than the level of
the feet.
2) A 68-year-old retired patient presents to the clinic complaining about feeling like
something is falling out of her vagina. She is a G6P6007 and had all her children
vaginally, even the twins. She went through menopause at age 55 years, and, for
the last few months, she has felt this falling sensation. On exam, an anterior bulge
in the vaginal wall is apparent when she bears down. Weakness in which muscle
would best account for the anterior bulge in the vaginal wall?
A) Levatori ani
B) Anal sphincter
C) Pubis symphysis
D) Ischiocavernosus muscle
E) Bulbocavernosus muscle -- Answer ✔✔ a. Levatori ani
- Rationale; The levatori ani muscle group consisting of the pubococcygeus
muscle and the iliococcygeus muscle is responsible for the support of the
pelvic floor. Weakening can cause prolapse of the pelvic organs. Weakness of
the anal sphincter is incorrect. Weakness of this muscle can lead to anal
incontinence of stool. Weakness of the pubis symphysis is incorrect. Although
there can be slight separation of the pubis symphysis following childbirth, it
usually returns to its normal state afterward and does not lead to weakening
of the pelvic musculature. Weakness of the ischiocavernosus or
bulbocavernosus muscles is incorrect. Weakness of these muscles can lead to
urinary incontinence.
3) . A 49-year-old male nurse experiences fecal incontinence after a motor vehicle
accident that left him paralyzed below the waist. He asks his rehabilitation
physician about the control of this function in a person without his injuries.
Which of the following is true regarding the muscle control of the anal sphincter?
A) The internal anal sphincter is under voluntary control, whereas the
external anal sphincter is under involuntary control.
, B) The internal anal sphincter is under involuntary control, whereas
the external anal sphincter is under voluntary control.
C) Both internal and external anal sphincter are under voluntary
control.
D) Both internal and external anal sphincter are under involuntary
control.
E) Control of the anal sphincters is variable between individuals. --
Answer ✔✔ b. The internal anal sphincter is under involuntary
control, whereas the external anal sphincter is under voluntary
control.
- Rationale; The internal anal sphincter is under involuntary control, whereas
the external anal sphincter is under voluntary control. Together, these two
muscles hold the anal sphincter closed until the individual is ready to
defecate. The internal anal sphincter is under voluntary control, whereas the
external anal sphincter is under involuntary control; both internal and
external anal sphincter are under voluntary control; and both internal and
external anal sphincter are under involuntary control are incorrect because,
as above, the internal anal sphincter is under involuntary control, whereas the
external anal sphincter is under voluntary control. Control of the anal
sphincters is variable between individuals is incorrect because this anatomic
and neurological arrangement is not typically variable between individuals,
although these pathways may be interrupted by derangements of normal
physiology such as spinal cord injuries.
4) A 45-year-old female executive reports to her primary care provider that she has
recently experienced a change in the patterns of her bowel movements. She
expresses a great concern as her family history includes a maternal aunt who died
of colon cancer at age 49 years; her mother has had colonoscopies every 3 years
with numerous adenomatous polyps removed. Which of the following historical
elements would be the most concerning for colon cancer in this patient?
A) Long-term history of hemorrhoids
B) Recent history of black, tarry stools
C) Remote history of anal pruritus
D) New-onset anal fissures
E) Recent onset of small-caliber stools -- Answer ✔✔ e. Recent onset
of small-caliber stools
, - Rationale; Small-caliber stools may be caused by narrowing of the colon due
to a mass. Colonoscopy should be performed to rule out such pathology,
especially in a patient with such a notable family history. Long-term history of
hemorrhoids is incorrect because hemorrhoids are not directly associated
with colon cancer. However, bleeding from hemorrhoids should be evaluated
carefully in high-risk patients, as bleeding attributed to hemorrhoids is
virtually indistinguishable from fresh blood from the lower gastrointestinal
(GI) tract. A low threshold for ordering colonoscopy should be maintained in
patients with risk factors for colon cancer, including age >50 years and strong
family history. Recent history of black, tarry stools is incorrect because black,
tarry stools ("melena") generally represent blood in the GI tract, whereas
melanotic stools usually have a source in the upper tract, not the colon.
Although this should be thoroughly investigated, it is not likely to have colon
cancer as a source. Remote history of anal pruritus is incorrect because it
may be due to hemorrhoids, proctitis, receptive anal intercourse, pinworms,
and a variety of other sources. Anal pruritus is not typically associated with
colon cancer. New-onset anal fissures is incorrect because anal fissures may
be associated with constipation and Crohn disease, but they are not generally
indicative of colon cancer.
5) A 53-year-old African American advertising agent 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 risk
and screening for prostate cancer?
A) The incidence of prostate cancer does not rise until age >65 years,
thus this patient needs no screening at this time.
B) Prostate cancer is always an aggressive neoplasm, thus the risks of
overdiagnosis with screening is outweighed by the benefits of early
case-finding.
C) This patient is at an elevated risk of prostate cancer due to his
family his-tory, thus screening modalities should be discussed
between the patient and provider.
D) This patient's race is a protective factor for prostate cancer, thus
reassurance is the only intervention necessary.
SOLUTIONS & DETAILED RATIONALES.
1) A 63-year-old office worker comes to the clinic for her women's health exam.
Her last Pap smear was 5 years ago and was normal. She is married and has been
with the same sexual partner for the last 35 years. After performing the majority
of the exam, the clinician decides to do a speculum exam to collect cytology for
Pap smear. What is the correct position to have the patient in for her speculum
exam?
A) Sitting
B) Supine
C) Prone
D) Trendelenburg
E) Lithotomy -- Answer ✔✔ e. Lithotomy
- Rationale; Lithotomy or dorsal lithotomy position describes a patient lying on
an exam table supine but with the legs abducted with the feet in the stirrups.
This was named lithotomy because it is how doctors used to access the
urethra in both men and women to be able to remove stones with
instruments. This is the easiest position to visualize the cervix and do the
bimanual exam. Sitting is incorrect. Obviously the vagina and perineum cannot
be accessed in the sitting position. Supine is incorrect. A purely supine
position lying on the back with the legs adducted closed would provide no
, exposure to the female genitalia. Prone is incorrect. In the prone position,
the patient is laying on the stomach, and the genitalia are not accessible.
Trendelenburg is incorrect. In the Trendelenburg position, the patient is
supine and the legs are elevated higher than the level of the head. A reverse
Trendelenburg has the patient supine with the head higher than the level of
the feet.
2) A 68-year-old retired patient presents to the clinic complaining about feeling like
something is falling out of her vagina. She is a G6P6007 and had all her children
vaginally, even the twins. She went through menopause at age 55 years, and, for
the last few months, she has felt this falling sensation. On exam, an anterior bulge
in the vaginal wall is apparent when she bears down. Weakness in which muscle
would best account for the anterior bulge in the vaginal wall?
A) Levatori ani
B) Anal sphincter
C) Pubis symphysis
D) Ischiocavernosus muscle
E) Bulbocavernosus muscle -- Answer ✔✔ a. Levatori ani
- Rationale; The levatori ani muscle group consisting of the pubococcygeus
muscle and the iliococcygeus muscle is responsible for the support of the
pelvic floor. Weakening can cause prolapse of the pelvic organs. Weakness of
the anal sphincter is incorrect. Weakness of this muscle can lead to anal
incontinence of stool. Weakness of the pubis symphysis is incorrect. Although
there can be slight separation of the pubis symphysis following childbirth, it
usually returns to its normal state afterward and does not lead to weakening
of the pelvic musculature. Weakness of the ischiocavernosus or
bulbocavernosus muscles is incorrect. Weakness of these muscles can lead to
urinary incontinence.
3) . A 49-year-old male nurse experiences fecal incontinence after a motor vehicle
accident that left him paralyzed below the waist. He asks his rehabilitation
physician about the control of this function in a person without his injuries.
Which of the following is true regarding the muscle control of the anal sphincter?
A) The internal anal sphincter is under voluntary control, whereas the
external anal sphincter is under involuntary control.
, B) The internal anal sphincter is under involuntary control, whereas
the external anal sphincter is under voluntary control.
C) Both internal and external anal sphincter are under voluntary
control.
D) Both internal and external anal sphincter are under involuntary
control.
E) Control of the anal sphincters is variable between individuals. --
Answer ✔✔ b. The internal anal sphincter is under involuntary
control, whereas the external anal sphincter is under voluntary
control.
- Rationale; The internal anal sphincter is under involuntary control, whereas
the external anal sphincter is under voluntary control. Together, these two
muscles hold the anal sphincter closed until the individual is ready to
defecate. The internal anal sphincter is under voluntary control, whereas the
external anal sphincter is under involuntary control; both internal and
external anal sphincter are under voluntary control; and both internal and
external anal sphincter are under involuntary control are incorrect because,
as above, the internal anal sphincter is under involuntary control, whereas the
external anal sphincter is under voluntary control. Control of the anal
sphincters is variable between individuals is incorrect because this anatomic
and neurological arrangement is not typically variable between individuals,
although these pathways may be interrupted by derangements of normal
physiology such as spinal cord injuries.
4) A 45-year-old female executive reports to her primary care provider that she has
recently experienced a change in the patterns of her bowel movements. She
expresses a great concern as her family history includes a maternal aunt who died
of colon cancer at age 49 years; her mother has had colonoscopies every 3 years
with numerous adenomatous polyps removed. Which of the following historical
elements would be the most concerning for colon cancer in this patient?
A) Long-term history of hemorrhoids
B) Recent history of black, tarry stools
C) Remote history of anal pruritus
D) New-onset anal fissures
E) Recent onset of small-caliber stools -- Answer ✔✔ e. Recent onset
of small-caliber stools
, - Rationale; Small-caliber stools may be caused by narrowing of the colon due
to a mass. Colonoscopy should be performed to rule out such pathology,
especially in a patient with such a notable family history. Long-term history of
hemorrhoids is incorrect because hemorrhoids are not directly associated
with colon cancer. However, bleeding from hemorrhoids should be evaluated
carefully in high-risk patients, as bleeding attributed to hemorrhoids is
virtually indistinguishable from fresh blood from the lower gastrointestinal
(GI) tract. A low threshold for ordering colonoscopy should be maintained in
patients with risk factors for colon cancer, including age >50 years and strong
family history. Recent history of black, tarry stools is incorrect because black,
tarry stools ("melena") generally represent blood in the GI tract, whereas
melanotic stools usually have a source in the upper tract, not the colon.
Although this should be thoroughly investigated, it is not likely to have colon
cancer as a source. Remote history of anal pruritus is incorrect because it
may be due to hemorrhoids, proctitis, receptive anal intercourse, pinworms,
and a variety of other sources. Anal pruritus is not typically associated with
colon cancer. New-onset anal fissures is incorrect because anal fissures may
be associated with constipation and Crohn disease, but they are not generally
indicative of colon cancer.
5) A 53-year-old African American advertising agent 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 risk
and screening for prostate cancer?
A) The incidence of prostate cancer does not rise until age >65 years,
thus this patient needs no screening at this time.
B) Prostate cancer is always an aggressive neoplasm, thus the risks of
overdiagnosis with screening is outweighed by the benefits of early
case-finding.
C) This patient is at an elevated risk of prostate cancer due to his
family his-tory, thus screening modalities should be discussed
between the patient and provider.
D) This patient's race is a protective factor for prostate cancer, thus
reassurance is the only intervention necessary.
