FREE Chapter 02: Assessment and Health Promotion My Nursing Test Banks

Lowdermilk: Maternity Nursing, 8th Edition

Chapter 02: Assessment and Health Promotion

Test Bank 

MULTIPLE CHOICE

1. The two primary functions of the ovary are:

a. Normal female development and sex hormone release.
b. Ovulation and internal pelvic support.
c. Sexual response and ovulation.
d. Ovulation and hormone production.

ANS: D

Feedback
A The presence of ovaries does not guarantee normal female development. The ovaries produce estrogen, progesterone, and androgen.
B Ovulation is the release of a mature ovum from the ovary; the ovaries are not responsible for internal pelvic support.
C Sexual response is a feedback mechanism involving the hypothalamus, anterior pituitary gland, and the ovaries. Ovulation does occur in the ovaries.
D The two functions of the ovaries are ovulation and hormone production.

DIF:Cognitive Level: KnowledgeREF:28

OBJ:Client Needs: Health Promotion and Maintenance

TOP: Nursing Process: Assessment

2. Because of the effect of cyclic ovarian changes on the breast, the best time for breast self-examination (BSE) is:

a. Five to 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

Feedback
A The physiologic alterations in breast size and activity reach their minimal level about 5 to 7 days after menstruation stops. Therefore BSE is best performed during this phase of the menstrual cycle.
B All women should perform BSE on a regular basis; however, the ideal time is when the breasts are not tender or swollen. This occurs at the end of menstruation.
C All women should perform BSE; however, the ideal time is 5 to 7 days after the menses ceases.
D The woman should be instructed that the best position for BSE is to lie down and place a pillow under the breast to be examined first.

DIF:Cognitive Level: KnowledgeREF:30

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning

3. Sexual assault is:

a. Limited to rape.
b. An act of force in which an unwanted and uncomfortable sexual act occurs.
c. A legal term for sexual violence.
d. An act of violence in which the partner is unknown.

ANS: B

Feedback
A Sexual assault is a broad term that encompasses a wide range of sexual victimization. It may include but is not limited to rape.
B Sexual assault encompasses a wide range of sexual victimization, including unwanted or uncomfortable touches, kisses, hugs, petting, intercourse, or other sexual acts.
C Sexual violence is a term for rape, not sexual assault, that includes a broader range of activities.
D A sexual act of violence, or rape, may be categorized as sexual assault. Statistically, the victim knows the assailant.

DIF:Cognitive Level: ComprehensionREF:44

OBJ: Client Needs: Psychosocial Integrity TOP: Nursing Process: Assessment

4. Individual irregularities in the ovarian (menstrual) cycle are most often caused by:

a. Variations in the follicular (preovulatory) phase.
b. An intact hypothalamic-pituitary feedback mechanism.
c. A functioning corpus luteum.
d. A prolonged ischemic phase.

ANS: A

Feedback
A Almost all variations in the length of the ovarian cycle are the result of variations in the length of the follicular phase.
B An intact hypothalamic-pituitary feedback mechanism is regular, not irregular.
C The luteal phase begins after ovulation. The corpus luteum depends on the ovulatory phase and fertilization.
D 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.

DIF:Cognitive Level: ComprehensionREF:34

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment

5. Prostaglandins are produced in most organs of the body, most notably the endometrium. Another/Other source(s) of prostaglandins is/are:

a. Ovaries.
b. Breast milk.
c. Menstrual blood.
d. The vagina.

ANS: C

Feedback
A Prostaglandins are produced in most organs of the body and in menstrual blood. The ovaries are not a source of prostaglandins.
B Prostaglandins are produced in most organs of the body and in menstrual blood. Breast milk is not a source of prostaglandins.
C Menstrual blood is a potent source of prostaglandins.
D Prostaglandins are produced in most organs of the body and in menstrual blood. The vagina is not a source of prostaglandins.

DIF:Cognitive Level: KnowledgeREF:34

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment

6. Physiologically, sexual response can be characterized by:

a. Coitus, masturbation, and fantasy.
b. Myotonia and vasocongestion.
c. Erection and orgasm.
d. Excitement, plateau, and orgasm.

ANS: B

Feedback
A Coitus, masturbation, and fantasy are forms of stimulation that illicit the physical manifestation of the sexual response.
B Physiologically, according to Masters (1992), sexual response can be analyzed in terms of two processes: vasocongestion and myotonia.
C Erection and orgasm occur in two of the four phases of the sexual response cycle.
D Excitement, plateau, and orgasm are three of the four phases of the sexual response cycle.

DIF:Cognitive Level: KnowledgeREF:35

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment

7. One purpose of preconception care is to:

a. Ensure that pregnancy complications do not occur.
b. Identify women who should not become pregnant.
c. Encourage healthy lifestyles for families desiring pregnancy.
d. Ensure that women know about prenatal care.

ANS: C

Feedback
A 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.
B In many instances, counseling can allow behavior modification before damage is done, or a woman can make an informed decision about her willingness to accept potential hazards.
C Preconception counseling guides couples in how to avoid unintended pregnancies, how to identify and manage risk factors in their lives and their environment, and how to identify healthy behaviors that promote the well-being of the woman and her potential fetus.
D If a woman is seeking preconception care, she likely is aware of prenatal care.

DIF:Cognitive Level: ComprehensionREF:36

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning

8. Concerning the use and abuse of legal drugs or substances, nurses should be aware that:

a. Although cigarette smoking causes a number of health problems, it has little direct effect on maternity-related health.
b. Women ages 21 to 34 have the highest rates of specific alcohol-related problems.
c. Coffee is a stimulant that can interrupt body functions and has been related to birth defects.
d. Prescription psychotherapeutic drugs taken by the mother do not affect the fetus; otherwise they would not have been prescribed.

ANS: B

Feedback
A Cigarette smoking impairs fertility and is a cause of low birth weight.
B Although a very small percentage of childbearing women have alcohol-related problems, alcohol abuse during pregnancy has been associated with a number of negative outcomes.
C Caffeine consumption has not been related to birth defects.
D Psychotherapeutic drugs have some effect on the fetus, and that risk must be weighed against their benefit to the mother.

DIF:Cognitive Level: KnowledgeREF:40

OBJ: Client Needs: Psychosocial Integrity TOP: Nursing Process: Assessment

9. During a health history interview, a woman tells the nurse that her husband physically abuses her. The nurses first response should be to:

a. Advise the woman of mandatory state reporting laws pertaining to abuse and confidentiality.
b. Reassure the woman that the abuse is not her fault.
c. Give the woman referrals to local agencies and shelters where she can obtain help.
d. Formulate an escape plan for the woman that she can use the next time her husband abuses her.

ANS: A

Feedback
A Many states have mandatory reporting laws for health care providers. It is important to inform the patient that you may need to report this.
B Although all of these responses are appropriate when dealing with an abused woman, the nurse first should discuss the legal implications of this type of situation.
C Although all of these responses are appropriate when dealing with an abused woman, the nurse first should discuss the legal implications of this type of situation.
D Although all of these responses are appropriate when dealing with an abused woman, the nurse first should discuss the legal implications of this type of situation.

DIF:Cognitive Level: ApplicationREF:45

OBJ: Client Needs: Safe and Effective Care Environment TOP: Nursing Process: Planning

10. As a powerful central nervous system stimulant, which of these substances can lead to miscarriage, preterm labor, premature separation of the placenta, and stillbirth?

a. Heroin
b. Alcohol
c. PCP
d. Cocaine

ANS: D

Feedback
A Heroin is an opiate. Its use in pregnancy is associated with preeclampsia, intrauterine growth restriction, miscarriage, premature rupture of membranes, infections, breech presentation, and preterm labor.
B The most serious effect of alcohol use in pregnancy is fetal alcohol syndrome.
C The major concerns regarding PCP use in pregnant women are its association with polydrug abuse and the neurobehavioral effects on the neonate.
D Cocaine is a powerful central nervous system stimulant. Effects on pregnancy associated with cocaine use include abruptio placentae, preterm labor, precipitous birth, and stillbirth.

DIF:Cognitive Level: ComprehensionREF:40

OBJ: Client Needs: Psychosocial Integrity TOP: Nursing Process: Assessment

11. Kegel exercises, or pelvic muscle exercises:

a. Were developed to control or reduce incontinent urine loss.
b. Are the best exercises for a pregnant woman because they are so pleasurable.
c. Help to manage stress.
d. Are ineffective without sufficient calcium in the diet.

ANS: A

Feedback
A Kegel exercises help control the urge to urinate.
B Kegel exercises may be fun for some, but the most important matter is the control they provide over incontinence.
C Kegel exercises help manage urination, not stress.
D Calcium in the diet is important but is not related to Kegel exercises.

DIF:Cognitive Level: KnowledgeREF:54

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning

12. During the past 20 years, the prevalence of obesity has increased dramatically in the United States, with one-third of women older than 20 years of age being obese. Body mass index is defined as the measure of an adults weight in relation to his or her height. This is currently the most accurate measure of weight. It is an important part of the health screening process because obesity is closely associated with:

a. The non-Hispanic Caucasian population.
b. A large number of chronic conditions.
c. Mostly acute illnesses.
d. Improved mental well-being.

ANS: B

Feedback
A In the United States, the prevalence of obesity is highest among non-Hispanic black women, followed by Hispanic women and non-Hispanic Caucasian women.
B Overweight and obesity are known risk factors for diabetes, heart disease, dyslipidemia, stroke, hypertension, arthritis, osteoporosis, and some types of cancer.
C Overweight and obesity are most frequently linked to chronic conditions.
D This is a myth. In fact, obesity is associated with depression and increased stress.

DIF:Cognitive Level: KnowledgeREF:41

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment

13. Before beginning the health history interview, the nurse should perform all actions except:

a. Smile and ask the patient whether she has any special concerns.
b. Speak in a relaxed manner with an even, nonjudgmental tone.
c. Make the patient comfortable.
d. Tell the patient her questions are irrelevant.

ANS: D

Feedback
A This action is appropriate for the nurse to do before beginning the health history.
B This action is appropriate for the nurse to do before beginning the health history.
C This action is appropriate for the nurse to do before beginning the health history.
D The woman should be assured that all of her questions are relevant and important.

DIF:Cognitive Level: ComprehensionREF:44

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment

14. During a health history interview, a woman states that she thinks that she has bumps on her labia. She also states that she is not sure how to check herself. The correct response would be to:

a. Reassure the woman that the examination will not reveal any problems.
b. Explain the process of vulvar self-examination to the woman and reassure her that she should become familiar with normal and abnormal findings during the examination.
c. Reassure the woman that bumps can be treated.
d. Reassure her that most women have bumps on their labia.

ANS: B

Feedback
A This statement is not accurate.
B During the assessment and evaluation, the responsibility for self-care, health promotion, and enhancement of wellness is emphasized. The pelvic examination provides a good opportunity for the practitioner to emphasize the need for regular vulvar self-examination.
C This statement is not accurate.
D This statement is not accurate.

DIF:Cognitive Level: ApplicationREF:50

OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Assessment

15. Women with severe and persistent mental illness are likely to be more vulnerable to being involved in controlling and/or violent relationships. However, many women develop mental health problems as a result of long-term abuse. The psychologic consequences of continued abuse do not include:

a. Substance abuse.
b. Posttraumatic stress disorder (PTSD).
c. Eating disorders.
d. Bipolar disorder.

ANS: D

Feedback
A Substance abuse is a common method of coping with long-term abuse. The abuser is also more likely to use alcohol and other chemical substances.
B PTSD is the most prevalent mental health sequela of long-term abuse. The traumatic event is persistently reexperienced through distress recollection and dreams.
C Eating disorders, depression, psychophysiologic illness, and anxiety reactions are all mental health problems associated with repeated abuse.
D Bipolar disorder is a specific illness (also known as manic depressive disorder) not related to abuse.

DIF:Cognitive Level: AnalysisREF:44

OBJ: Client Needs: Psychosocial Integrity TOP: Nursing Process: Diagnosis

16. A woman arrives at the clinic for her annual examination. She tells the nurse that she thinks she has a vaginal infection and she has been using an over-the-counter cream for the past 2 days to treat it. The nurses initial response should be to:

a. Inform the woman that vaginal creams may interfere with the Papanicolaou (Pap) test for which she is scheduled.
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

Feedback
A Although this statement is true, the best response is for the nurse to inquire about the symptoms the woman is experiencing.
B Women should not douche, use vaginal medications, or have sexual intercourse for 24 to 48 hours before obtaining a Pap test.
C An important element of the history and physical examination is the womans description of any symptoms she may be experiencing.
D Although the woman may need to reschedule a visit for her Pap test, her current symptoms should still be addressed.

DIF:Cognitive Level: ApplicationREF:48

OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Assessment

17. The transition phase during which ovarian function and hormone production decline is called:

a. The climacteric.
b. Menarche.
c. Menopause.
d. Puberty.

ANS: A

Feedback
A The climacteric is a transitional phase during which ovarian function and hormone production decline.
B Menarche is the term that denotes the first menstruation.
C Menopause refers only to the last menstrual period.
D Puberty is a broad term that denotes the entire transitional stage between childhood and sexual maturity.

DIF:Cognitive Level: KnowledgeREF:34

OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Assessment

18. What opiate causes euphoria, relaxation, drowsiness, and detachment from reality and has possible effects on the pregnancy, including preeclampsia, intrauterine growth restriction, and premature rupture of membranes?

a. Heroin
b. Alcohol
c. PCP
d. Cocaine

ANS: A

Feedback
A The opiates include opium, heroin, meperidine, morphine, codeine, and methadone. The signs and symptoms of heroin use are euphoria, relaxation, relief from pain, detachment from reality, impaired judgment, drowsiness, constricted pupils, nausea, constipation, slurred speech, and respiratory depression. Possible effects on pregnancy include preeclampsia, intrauterine growth restriction, miscarriage, premature rupture of membranes, infections, breech presentation, and preterm labor.
B Alcohol is not an opiate.
C PCP is not an opiate.
D Cocaine is not an opiate.

DIF:Cognitive Level: ComprehensionREF:40

OBJ: Client Needs: Psychosocial Integrity TOP: Nursing Process: Assessment

19. A 20-year-old patient calls the clinic to report that she has found a lump in her breast. The nurses best response is:

a. Dont worry about it. Im sure its nothing.
b. Wear a tight bra, and it should shrink.
c. Many women have benign lumps and bumps in their breasts. However, to make sure that its benign, you should come in for an examination by your physician.
d. Check it again in 1 month and call me back if its still there.

ANS: C

Feedback
A Discrediting the patients findings may discourage her from continuing with breast self-examination.
B Wearing a tight bra may irritate the skin and will not cause the lump to shrink.
C Try to ease the patients fear, but provide a time for a thorough evaluation of the lump because it may indicate abnormal changes in the breast.
D Delaying treatment may allow proliferation of abnormal cells.

DIF:Cognitive Level: AnalysisREF:31

OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Assessment

20. The body part that both protects the pelvic structures and accommodates the growing fetus during pregnancy is the:

a. Perineum.
b. Bony pelvis.
c. Vaginal vestibule.
d. Fourchette.

ANS: B

Feedback
A The perineum covers the pelvic structures; the bony pelvis protects and accommodates the growing fetus.
B The bony pelvis protects and accommodates the growing fetus.
C The vaginal vestibule contains openings to the urethra and vagina; the bony pelvis protects and accommodates the growing fetus.
D The fourchette is formed by the labia minor; the bony pelvis protects and accommodates the growing fetus.

DIF:Cognitive Level: KnowledgeREF:28

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment

21. A fully matured endometrium that resembles the thickness of heavy, soft velvet describes the _____ phase of the endometrial cycle.

a. Menstrual
b. Proliferative
c. Secretory
d. Ischemic

ANS: C

Feedback
A During the menstrual phase, the endometrium is being shed; the endometrium is fully mature again during the secretory phase.
B The proliferative phase is a period of rapid growth, but the endometrium becomes fully mature again during the secretory phase.
C The secretory phase extends from the day of ovulation to approximately 3 days before the next menstrual cycle. During this phase, the endometrium becomes fully mature.
D During the ischemic phase, the blood supply is blocked, and necrosis develops. The endometrium is fully mature during the secretory phase.

DIF:Cognitive Level: ComprehensionREF:34

OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment

22. The microscopic examination of scrapings from the cervix, endocervix, or other mucous membranes to detect premalignant or malignant cells is called:

a. Bimanual palpation.
b. Rectovaginal palpation.
c. A Papanicolaou (Pap) test.
d. The four As procedure.

ANS: C

Feedback
A Bimanual palpation is a physical examination of the vagina; the Pap test is a microscopic examination for cancer.
B Rectovaginal palpation is a physical examination performed through the rectum; the Pap test is a microscopic examination for cancer.
C The Pap test is a microscopic examination for cancer that should be performed regularly, depending on the patients age.
D The four As is an intervention procedure to help a patient stop smoking. The Pap test is a microscopic examination for cancer.

DIF:Cognitive Level: KnowledgeREF:50, 51

OBJ:Client Needs: Physiologic Integrity

TOP: Nursing Process: Implementation

23. While obtaining a detailed history from a woman who has recently emigrated from Somalia, the nurse recognizes that the woman has undergone female genital mutilation (FGM). The nurses best response to this woman is:

a. This is a very abnormal practice and rarely seen in the United States.
b. Do you know who performed this so that it can be reported to the authorities?
c. We will be able to fully restore your circumcision after delivery.
d. The extent of your circumcision will affect the potential for complications.

ANS: D

Feedback
A Although this practice is not prevalent in the United States, it is very common in many African and Middle Eastern countries for religious reasons. This response is culturally insensitive.
B The infibulation may have occurred during infancy or childhood. The woman will have little to no recollection of the event. She would have considered this to be a normal milestone during her growth and development.
C The International Council of Nurses has spoken out against this procedure as harmful to a womans health.
D This response is the most appropriate. The patient may experience pain, bleeding, scarring, or infection and may require surgery before childbirth. With the growing number of immigrants from countries where FGM is practiced, nurses will increasingly encounter women who have undergone the procedure.

DIF:Cognitive Level: AnalysisREF:38

OBJ: Client Needs: Psychosocial Integrity TOP: Nursing Process: Assessment

MULTIPLE RESPONSE

1. The nurse who is evaluating the woman for potential abuse should be aware that intimate partner violence includes (choose all that apply):

a. Physical abuse.
b. Sexual abuse.
c. Emotional abuse.
d. Psychologic abuse.
e. Economic abuse.

ANS: A, B, C, D, E

Feedback
Correct All of these types of abuse can be factors in intimate partner violence.
Incorrect None of the above.

DIF:Cognitive Level: ComprehensionREF:44

OBJ: Client Needs: Psychosocial Integrity TOP: Nursing Process: Assessment

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