Chapter 22 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 22

Question 1

Type: HOTSPOT

A teenaged client has been brought to the clinic with complaints of pain. After an examination it was determined that the client has an inflamed Bartholins cyst. After the examination the client and her mother ask the nurse to show them the location of the gland involved. Mark an X on the location of the Bartholins gland.

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Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The Bartholins glands, or greater vestibular glands, are located posteriorly at the base of the vestibule and produce mucus, which is released into the vestibule.

Global Rationale:

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22.1: Describe the anatomy and physiology of the female reproductive system.

Question 2

Type: HOTSPOT

The nurse is caring for a pregnant client. The nurse notes the healthcare provider has documented the client has a positive Goodells sign. Mark an X on the area to which this refers.

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Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : Goodells sign refers to the softening of the cervix during pregnancy.

Global Rationale:

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22.1: Describe the anatomy and physiology of the female reproductive system.

Question 3

Type: MCMA

The nurse is preparing to assess a female clients external genitalia. The structures included in this assessment would be:

Standard Text: Select all that apply.

1. Vagina

2. Cervix

3. Clitoris

4. Labia majora

5. Labia minora

Correct Answer: 3,4,5

Rationale 1: Vagina. The internal female reproductive organs are the vagina, uterus, cervix, fallopian tubes, and ovaries.

Rationale 2: Cervix. The internal female reproductive organs are the vagina, uterus, cervix, fallopian tubes, and ovaries.

Rationale 3: Clitoris. Female external genitalia include the mons pubis, labia, glands, clitoris, and perianal area.

Rationale 4: Labia minora. Female external genitalia include the mons pubis, labia, glands, clitoris, and perianal area.

Rationale 5: Labia majora. Female external genitalia include the mons pubis, labia, glands, clitoris, and perianal area.

Global Rationale: The female external genitalia include the clitoris, labia majora, and the labia minora. The vagina and cervix are considered to be internal genitalia.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22.1: Describe the anatomy and physiology of the female reproductive system.

Question 4

Type: MCSA

The nurse notes a forward-tilted uterus with a downward-tilted cervix when examining a female client. The nurse would correctly document which of the following findings in this situation?

1. Anteflexion

2. Retroflexion

3. Anteversion

4. Midposition

Correct Answer: 3

Rationale 1: The uterus in anteflexion is folded forward at a 90-degree angle with the cervix is tilted downward.

Rationale 2: The retroverted uterus is tilted backward with the cervix tilted upward.

Rationale 3: Normal variations of uterine position include anteversion in which the uterus is tilted forward, the cervix is tilted downward.

Rationale 4: The uterus in midposition lies parallel to the tailbone with the cervix pointed straight.

Global Rationale: Normal variations of uterine position include anteversion (the uterus is tilted forward, the cervix is tilted downward), midposition (the uterus lies parallel to the tailbone, the cervix is pointed straight), and retroversion (the uterus is tilted backward, the cervix is tilted upward). Abnormal variations of uterine position include anteflexion (the uterus is folded forward at a 90-degree angle, the cervix is tilted downward), and retroflexion (the uterus is folded backward at a 90-degree angle, the cervix is tilted upward).

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 22.1: Describe the anatomy and physiology of the female reproductive system.

Question 5

Type: MCSA

The nurse notes that the uterus is folded backward with the cervix tilted upward when examining a female client. The nurse would correctly document which of the following findings in this situation.

1. Retroversion

2. Retroflexion

3. Midposition

4. Anteflexion

Correct Answer: 2

Rationale 1: The retroversion positioned uterus is tilted backward with the cervix tilted upward.

Rationale 2: The retroflexion uterus is folded backward at a 90-degree angle with the cervix tilted upward.

Rationale 3: The midposition uterus lies parallel to the tailbone, the cervix is pointed straight.

Rationale 4: The anteversion uterus is tilted forward with the cervix tilted downward.

Global Rationale: Normal variations of uterine position include anteversion (the uterus is tilted forward, the cervix is tilted downward), midposition (the uterus lies parallel to the tailbone, the cervix is pointed straight), and retroversion (the uterus is tilted backward, the cervix is tilted upward). Abnormal variations of uterine position include anteflexion (the uterus is folded forward at a 90-degree angle, the cervix is tilted downward), and retroflexion (the uterus is folded backward at a 90-degree angle, the cervix is tilted upward). Fibroids are benign tumors located within the uterine walls.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 22.1: Describe the anatomy and physiology of the female reproductive system.

Question 6

Type: HOTSPOT

The nurse is reviewing the technique utilized to obtain an endocervical specimen on a client. Mark with an X the location from which the specimen will be obtained.

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Standard Text: Select the correct area on the image.

Correct Answer:

Rationale : The comprehensive pap smear will include swabbed specimens from the endocervical region.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 21.2: Explain client preparation for the assessment of the reproductive system.

Question 7

Type: MCMA

The nurse is preparing to examine the female reproductive system of a client. The nurse would anticipate using which of the following assessment techniques?

Standard Text: Select all that apply.

1. Inspection

2. Palpation

3. Percussion

4. Auscultation

5. Aspiration

Correct Answer: 1,2

Rationale 1: Inspection. When completing the assessment of the female reproductive system the examiner will inspect the external genitalia.

Rationale 2: Palpation. Palpation will be used in the examination of the female reproductive system. The abdomen will be palpated to assess for the size and shape of the internal organs.

Rationale 3: Percussion. Percussion will not be employed in the assessment of the female reproductive system. Percussion will be used to assess the gastrointestinal and pulmonary systems.

Rationale 4: Auscultation. Auscultation will not be used to assess the female reproductive system. Auscultation will be used to assess the cardiovascular, pulmonary, and gastrointestinal systems.

Rationale 5: Aspiration. Aspiration will not be used to assess the female reproductive system. Aspiration may be performed to obtain a sample.

Global Rationale: The physical assessment techniques of inspection and palpation are used in the examination of the female reproductive system. When completing the assessment of the female reproductive system the examiner will inspect the external genitalia. Palpation will be used in the examination of the female reproductive system. The abdomen will be palpated to assess for the size and shape of the internal organs. Percussion will not be employed in the assessment of the female reproductive system. Percussion will be used to assess the gastrointestinal and pulmonary systems. Auscultation will not be used to assess the female reproductive system. Auscultation will be used to assess the cardiovascular, pulmonary, and gastrointestinal systems. Aspiration will not be used to assess the female reproductive system. Aspiration may be performed to obtain a sample.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 21.2: Explain client preparation for the assessment of the reproductive system.

Question 8

Type: MCSA

The nurse is examining a 65 year old and palpates a mobile, smooth, round-shaped mass in the left lower abdominal quadrant. The nurse would correctly choose which of the following actions next?

1. Ask the client if she is menstruating.

2. Report the findings to the healthcare provider.

3. Re-examine the area using a vaginal speculum.

4. Ask the client if she could be pregnant.

Correct Answer: 2

Rationale 1: The client in this scenario is elderly. Menstruation is not a viable option.

Rationale 2: In women who have been postmenopausal for more than 2.5 years, palpable ovaries are considered abnormal as the ovaries would normally atrophy with the decrease in estrogen.

Rationale 3: The ovary cannot be viewed with a vaginal speculum.

Rationale 4: The age of the client would not support a likely pregnancy for the client in the scenario. In addition, the pregnant uterus would not be palpated in the area described.

Global Rationale: In women who have been postmenopausal for more than 2.5 years, palpable ovaries are considered abnormal as the ovaries would normally atrophy with the decrease in estrogen. The ovary cannot be viewed with a vaginal speculum, and a pregnant uterus would not be palpated in this area. Menstruation is not relevant to this situation.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 22.3: Develop questions to be used when conducting the focused interview.

Question 9

Type: MCSA

The nurse is performing a gynecological examination and is ready to insert the speculum. The nurse would correctly insert the speculum at which of the following angles with the client in the lithotomy position?

1. 90 degrees

2. 45 degrees

3. Straight down

4. Straight up

Correct Answer: 2

Rationale 1: The speculum should be inserted at a 45-degree downward angle. This angle matches the downward slope of the vagina when the client is in the lithotomy position.

Rationale 2: The speculum should be inserted at a 45-degree downward angle. This angle matches the downward slope of the vagina when the client is in the lithotomy position.

Rationale 3: The speculum should be inserted at a 45-degree downward angle. This angle matches the downward slope of the vagina when the client is in the lithotomy position.

Rationale 4: The speculum should be inserted at a 45-degree downward angle. This angle matches the downward slope of the vagina when the client is in the lithotomy position.

Global Rationale: The speculum should be inserted at a 45-degree downward angle. This angle matches the downward slope of the vagina when the client is in the lithotomy position.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22.4: Describe techniques required for assessment of the female reproductive system.

Question 10

Type: MCMA

The nurse is preparing to perform an endocervical swab and needs to choose the most effective equipment to collect this specimen. The nurse would have which of the following ready for this procedure?

Standard Text: Select all that apply.

1. Microscopic slides

2. Saline

3. Cytobrush

4. Cotton applicator

5. Fixative

Correct Answer: 1,3,5

Rationale 1: Microscopic slides. The slides will be used to place the specimen on.

Rationale 2: Saline. Saline is used to moisten a cotton tipped applicator but is not needed with the cytobrush.

Rationale 3: Cytobrush. The cytobrush is preferred to obtain the endocervical cells.

Rationale 4: Cotton applicator. The use of the cotton application is not as highly recommended as the cytobrush. The endocervical cells will not adhere as well to the cotton-tipped applicator.

Rationale 5: Fixative. A fixative is a solution used to secure the specimen.

Global Rationale: When preparing to obtain an endocervical swam specimen the nurse will need to have microscopic slides, cytobrush, and a fixative. The slides will be used to place the specimen on. The cell specimens are obtained using a cytobrush. The cotton applicator will not be used in place of the cytobrush as it is not as effective in obtaining cells. Saline is used to moisten a cotton-tipped applicator but not used with the cytobrush.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 22.4: Describe techniques required for assessment of the female reproductive system.

Question 11

Type: MCSA

The nurse is performing a vaginal examination on a client who has had a hysterectomy. Which of the following would the nurse choose to do in this situation?

1. Defer the cervical scrape.

2. Use the vaginal wall for the cervical scrape.

3. Tell the client an examination is not needed.

4. Use the surgical stump for the cervical scrape.

Correct Answer: 4

Rationale 1: Clients who have had hysterectomies should have the surgical stump scraped as part of the examination. Deferring the cervical assessment could result in the omission of important information for the comprehensive care of the client.

Rationale 2: Specimens from the vaginal walls are indicated but do not replace the need to have cells obtained from the cervical stump.

Rationale 3: Clients that have had hysterectomies should have the surgical stump scraped as part of the examination.

Rationale 4: Clients that have had hysterectomies should have the surgical stump scraped as part of the examination.

Global Rationale: Clients who have had hysterectomies should have the surgical stump scraped as part of the examination. Deferring the scrape, using the walls of the vagina, or telling the client the examination is not needed would reduce the clients ability to have a comprehensive pelvic examination. Important cellular specimens must be obtained from the cervical stump.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 22.4: Describe techniques required for assessment of the female reproductive system.

Question 12

Type: MCSA

The nurse assisting the healthcare provider who is performing a bimanual examination on an extremely obese client. The healthcare provider is unable to palpate the uterus. Which of the following actions would most likely be selected in this situation?

1. Defer the examination.

2. Schedule an X-ray.

3. Schedule an ultrasound.

4. Ask the client if she has had recent problems.

Correct Answer: 3

Rationale 1: Forgoing an examination as a result of difficulties encountered is not a responsible action. The nurse has a responsibility to utilize other methods available as indicated.

Rationale 2: The use of an X-ray is not the best diagnostic test to review the condition of soft tissue organs and surrounding tissue.

Rationale 3: In an obese female palpation of the uterus may be difficult. An ultrasound would allow for examination of the female reproductive organs.

Rationale 4: The size of the client is the most likely cause of the inability to palpate the uterus. A discussion of recent problems is a part of the assessment but it does not reduce the need to discuss obtaining the ultrasound.

Global Rationale: In the obese female, it may be difficult to clearly differentiate the uterine structures and an ultrasound may be needed. Obtaining an ultrasound can only be done after consulting with the healthcare provider about the findings. The remaining choices are incorrect for this situation. An X-ray is not the best diagnostic test to review the condition of soft tissue organs and surrounding tissue. Deferring the examination does not meet the needs of the client. Determining the clients recent health history does not meet the needs of the client in having the uterus evaluated.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 22.4: Describe techniques required for assessment of the female reproductive system.

Question 13

Type: MCSA

The nurse is examining a pregnant client and notes the cervix is soft in texture and nontender. The nurse would correctly document which of the following conditions in this situation?

1. Nabothian cyst

2. Chadwicks sign

3. Hegars sign

4. Goodells sign

Correct Answer: 4

Rationale 1: Nabothian cysts are yellow and nodular and are benign areas that may appear after childbirth.

Rationale 2: Chadwicks sign, also occurring during pregnancy, is the appearance of a bluish-purple coloration of the cervix due to vascular congestion.

Rationale 3: Hegars sign refers to the softening of the lower uterine segemt during pregnancy.

Rationale 4: During pregnancy, the vascularity of the cervix increases and contributes to the softening of the cervix. This is a normal finding called Goodells sign.

Global Rationale: During pregnancy, the vascularity of the cervix increases and contributes to the softening of the cervix. This is a normal finding called Goodells sign. Chadwicks sign, also occurring during pregnancy, is the appearance of a bluish-purple coloration of the cervix due to vascular congestion. Hegars sign refers to a softening of the lower uterine segment during pregnancy. Nabothian cysts are yellow and nodular and are benign areas that may appear after childbirth.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system.

Question 14

Type: MCSA

The nurse is examining a pregnant client and notes the cervix has a bluish-purple change in coloration. The nurse would correctly document which of the following conditions in this situation?

1. Nabothian cyst

2. Goodells sign

3. Chadwicks sign

4. Bloody show

Correct Answer: 3

Rationale 1: Nabothian cysts are yellow and nodular and are benign areas that may appear after childbirth.

Rationale 2: Vascularity of the cervix also contributes to the softening of the cervix, and is called Goodells sign.

Rationale 3: Chadwicks sign appears during pregnancy and is the appearance of a bluish-purple coloration of the cervix due to vascular congestion.

Rationale 4: Expulsion of the mucous plug at the endocervical canal produces a bloody show at the initiation of labor.

Global Rationale: Chadwicks sign appears during pregnancy and is the appearance of a bluish-purple coloration of the cervix due to vascular congestion. Nabothian cysts are yellow and nodular and are benign areas that may appear after childbirth. Vascularity of the cervix also contributes to the softening of the cervix, and is called Goodells sign. Nabothian cysts are yellow and nodular and are benign areas that may appear after childbirth. Expulsion of the mucous plug at the endocervical canal produces a bloody show at the initiation of labor.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system.

Question 15

Type: MCSA

The nurse notes reddened areas on the labia and a discharge that is white and curd-like in the vaginal canal when examining a female client. The nurse would suspect which of the following conditions in this situation.

1. Contact dermatitis

2. Yeast infection

3. Herpes infection

4. Venereal warts

Correct Answer: 2

Rationale 1: Contact dermatitis is characterized by reddened lesions that weep and form crusts.

Rationale 2: Yeast infections are the most common female genital infection and can produce redness, pruritis, and cheese-like discharge.

Rationale 3: Herpes infection causes small, red, painful ulcerations.

Rationale 4: Venereal warts appear as cauliflower-shaped, raised, moist papules.

Global Rationale: Yeast infections are the most common female genital infection and can produce redness, pruritis, and cheese-like discharge. Contact dermatitis is characterized by reddened lesions that weep and form crusts. Herpes infection causes small, red, painful ulcerations. Venereal warts appear as cauliflower-shaped, raised, moist papules.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system.

Question 16

Type: MCSA

The nurse is examining a female client and notes a greenish discharge with a foul odor. The client also exhibits guarding of the abdomen. The nurse would suspect which of the following conditions in this situation?

1. Trichomoniasis

2. Herpes infection

3. Gonorrhea

4. Bacterial vaginosis

Correct Answer: 3

Rationale 1: Frothy yellow-green discharge is seen in trichomoniasis.

Rationale 2: Herpes infection produces red, painful vesicles with localized swelling.

Rationale 3: Green discharge that has a foul smell is associated with gonorrhea, which may spread to the abdominal cavity to cause pelvic inflammatory disease.

Rationale 4: Bacterial vaginosis presents with a creamy-gray to white discharge that has a fishy odor.

Global Rationale: Green discharge that has a foul smell is associated with gonorrhea, which may spread to the abdominal cavity to cause pelvic inflammatory disease. Frothy yellow-green discharge is seen in trichomoniasis. Herpes infection produces red, painful vesicles with localized swelling. Bacterial vaginosis presents with a creamy-gray to white discharge that has a fishy odor.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system.

Question 17

Type: MCSA

The nurse is examining the external genitalia of a female client and notes raised, cauliflower-shaped papules. The nurse would suspect which of the following conditions in this situation?

1. Genital warts

2. Herpes infection

3. Bartholins abscess

4. Contact dermatitis

Correct Answer: 1

Rationale 1: Genital warts present as raised, cauliflower-shaped papules.

Rationale 2: Herpes infection produces red, painful vesicles with localized swelling.

Rationale 3: Bartholins abscess produces inflammatory signs such as redness and warm skin. Bartholins abscess produces inflammatory signs such as redness and warm skin.

Rationale 4: Contact dermatitis produces red, weepy rashes.

Global Rationale: Genital warts present as raised, cauliflower-shaped papules as described. Herpes infection produces red, painful vesicles with localized swelling. Bartholins abscess produces inflammatory signs such as redness and warm skin. Contact dermatitis produces red, weepy rashes.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system.

Question 18

Type: MCSA

The nurse notes documentation in the clients history and physical of a nontender protrusion into the anterior vaginal wall. The nurse would suspect which of the following conditions in this situation?

1. Inflammation of the Skenes gland

2. Prolapsed uterus

3. Rectocele

4. Cystocele

Correct Answer: 4

Rationale 1: The Skenes glands are examined by palpation on both sides of the urethra.

Rationale 2: A prolapsed uterus may protrude from the vaginal wall, and may occur with or without straining.

Rationale 3: A rectocele is a hernia that is formed when the rectum pushes into the posterior vaginal wall.

Rationale 4: A cystocele is a hernia that is formed when the urinary bladder is pushed into the vaginal wall.

Global Rationale: A cystocele is a hernia that is formed when the urinary bladder is pushed into the vaginal wall. The Skenes glands are examined by palpation on both sides of the urethra. A prolapsed uterus may protrude from the vaginal wall, and may occur with or without straining. A rectocele is a hernia that is formed when the rectum pushes into the posterior vaginal wall.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system.

Question 19

Type: MCSA

The nurse is reading the history and physical and notes documentation of a protrusion into the posterior vaginal wall. The nurse would suspect which of the following conditions in this situation?

1. Ovarian cyst

2. Bartholins gland infection

3. Cystocele

4. Rectocele

Correct Answer: 4

Rationale 1: Ovarian cysts cause inflammation and tenderness upon examination.

Rationale 2: The Bartholins glands are palpated by gently squeezing the posterior region of the labia majora.

Rationale 3: A cystocele is a hernia that is formed when the urinary bladder is pushed into the vaginal wall.

Rationale 4: A rectocele is a hernia that is formed when the rectum pushes into the posterior vaginal wall.

Global Rationale: A rectocele is a hernia that is formed when the rectum pushes into the posterior vaginal wall. Ovarian cysts cause inflammation and tenderness upon examination. The Bartholins glands are palpated by gently squeezing the posterior region of the labia majora. A cystocele is a hernia that is formed when the urinary bladder is pushed into the vaginal wall.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system.

Question 20

Type: MCSA

The nurse is interviewing a female client that reports a grayish discharge with a fishy odor. The nurse would suspect which of the following conditions in this situation?

1. Bacterial vaginosis

2. Chlamydia

3. Genital warts

4. Gonorrhea

Correct Answer: 1

Rationale 1: Bacterial vaginosis presents with a creamy-gray to white discharge that has a fishy odor.

Rationale 2: A yellow discharge can be noted in a chlamydia infection.

Rationale 3: Genital warts are raised, moist, cauliflower-shaped papules.

Rationale 4: Gonorrhea is associated with a foul-smelling discharge.

Global Rationale: Bacterial vaginosis presents with a creamy-gray to white discharge that has a fishy odor. A yellow discharge can be seen in chlamydial infection. Genital warts are raised, moist, cauliflower-shaped papules. Green discharge that has a foul smell is associated with gonorrhea.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system.

Question 21

Type: MCSA

The nurse is interviewing a female client who reports a frothy, yellow-green discharge. The nurse would suspect which of the following conditions in this situation?

1. Vaginitis

2. Trichomoniasis

3. Gonorrhea

4. Chlamydia

Correct Answer: 2

Rationale 1: Vaginitis indicates a nonspecific inflammation of the vagina.

Rationale 2: Frothy yellow-green discharge is seen in trichomoniasis.

Rationale 3: Green discharge that has a foul smell is associated with gonorrhea.

Rationale 4: A yellow discharge can be seen in chlamydial infection.

Global Rationale: Frothy yellow-green discharge is seen in trichomoniasis. Vaginitis indicates a nonspecific inflammation of the vagina. Green discharge that has a foul smell is associated with gonorrhea. Green discharge that has a foul smell is associated with gonorrhea. A yellow discharge can be seen in chlamydial infection.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system.

Question 22

Type: MCSA

The nurse is examining the external genitalia of a female client and notes small vesicular lesions that are painful. The nurse would suspect which of the following conditions in this situation?

1. Genital warts

2. Herpes infection

3. Bartholins abscess

4. Contact dermatitis

Correct Answer: 2

Rationale 1: Genital warts produce cauliflower-like lesions.

Rationale 2: Herpes infection produces red, painful vesicles with localized swelling.

Rationale 3: Bartholins abscess produces inflammatory signs, such as redness and warm skin.

Rationale 4: Contact dermatitis produces red, weepy rashes.

Global Rationale: Herpes infection produces red, painful vesicles with localized swelling. Genital warts produce cauliflower-like lesions. Bartholins abscess produces inflammatory signs, such as redness and warm skin. Contact dermatitis produces red, weepy rashes.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system.

Question 23

Type: MCSA

The nurse is examining the external genitalia of a female client and notes draining papules. The nurse would suspect which of the following conditions in this situation?

1. Genital warts

2. Herpes infection

3. Syphilitic lesion

4. Contact dermatitis

Correct Answer: 3

Rationale 1: Genital warts produce cauliflower-like lesions.

Rationale 2: Herpes infection produces red, painful vesicles with localized swelling.

Rationale 3: Syphilitic lesions are painless papules that may begin to produce drainage.

Rationale 4: Contact dermatitis produces red, weepy rashes.

Global Rationale: Syphilitic lesions are painless papules that may begin to produce drainage. Genital warts produce cauliflower-like lesions. Herpes infection produces red, painful vesicles with localized swelling. Contact dermatitis produces red, weepy rashes.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 22.5: Differentiate normal from abnormal findings in physical assessment of the female reproductive system.

Question 24

Type: MCSA

The nurse is providing education on menopause to a group of female clients. Which of the following statements made by one of the clients would indicate the need for further instruction by the nurse?

1. My periods may be irregular and less frequent.

2. Night sweats and hot flashes are commonly experienced.

3. My mood changes are a normal part of menopause.

4. Vaginal dryness may occur during menopause.

Correct Answer: 1

Rationale 1: Menopause is said to have occurred when the female has not experienced a period in over one year.

Rationale 2: As estrogen levels decline, symptoms include night sweats, hot flashes, mood changes, and vaginal dryness, but if menstruation is still occurring, menopause is not complete.

Rationale 3: As estrogen levels decline, symptoms include night sweats, hot flashes, mood changes, and vaginal dryness, but if menstruation is still occurring, menopause is not complete.

Rationale 4: As estrogen levels decline, symptoms include night sweats, hot flashes, mood changes, and vaginal dryness, but if menstruation is still occurring, menopause is not complete.

Global Rationale: Menopause is said to have occurred when the female has not experienced a period in over one year. As estrogen levels decline, symptoms include night sweats, hot flashes, mood changes, and vaginal dryness, but if menstruation is still occurring, menopause is not complete.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 22.6: Describe developmental, cultural, psychosocial, and environmental variations in assessment and findings.

Question 25

Type: MCSA

The nurse is interviewing an elderly female client. Which of the following statements made by the client would cause intervention by the nurse?

1. I use a lubricant for sex to help with dryness.

2. I take hormone pills to help with my hot flashes.

3. My periods stopped for 5 years, but recently restarted.

4. I dont have a desire for sex very often, but neither does my husband.

Correct Answer: 3

Rationale 1: The use of lubrication for sexual intimacy is normal due to vaginal dryness, although libido may be diminished in both the male and female.

Rationale 2: The use of estrogen replacement therapy can alleviate symptoms related to night sweats, hot flashes, and mood changes.

Rationale 3: Women may assume that postmenopausal bleeding is normal and ignore it, but this may be suggestive of inadequate estrogen therapy or endometrial cancer, and follow-up is required.

Rationale 4: The use of lubrication for sexual intimacy is normal due to vaginal dryness, although libido may be diminished in both the male and female.

Global Rationale: Women may assume that postmenopausal bleeding is normal and ignore it, but this may be suggestive of inadequate estrogen therapy or endometrial cancer, and follow-up is required. The use of lubrication for sexual intimacy is normal due to vaginal dryness, although libido may be diminished in both the male and female. The use of estrogen replacement therapy can alleviate symptoms related to night sweats, hot flashes, and mood changes.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 22.6: Describe developmental, cultural, psychosocial, and environmental variations in assessment and findings.

Question 26

Type: MCMA

The nurse is examining an adolescent female and notes no pubic hair on the pubis area. The nurse would correctly choose which of the following actions?

Standard Text: Select all that apply.

1. Ask the client if she is menstruating.

2. Examine the client for breast buds.

3. Report the findings to the healthcare provider.

4. Document the findings as normal.

5. Assess the clients dietary intake.

Correct Answer: 1,2,3

Rationale 1: Ask the client if she is menstruating. The presence or absence of menstrual history will aid in the determination of hormonal function.

Rationale 2: Examine the client for breast buds. The presence or absence of breast buds will aid in the confirmation of the maturity of secondary sexual characteristics.

Rationale 3: Report the findings to the healthcare provider. Abnormalities may be indicative of endocrine pathology and need to be reported to the healthcare provider for follow-up.

Rationale 4: Document the findings as normal. According to Tanners Maturation Stages in the female, the findings in this situation are not normal for the adolescent female client. The adolescent female should have fine, sparse hair beginning at the labia and rising up the pubis.

Rationale 5: Assess the clients dietary intake. Dietary intake information in the client who presents with physical immaturities in the event they also exhibit signs of nutritional deficiencies. There is no supportive information indicating that there are nutritional needs unmet.

Global Rationale: According to Tanners Maturation Stages in the female, the findings in this situation are not normal for the adolescent female client. The adolescent female should have fine, sparse hair beginning at the labia and rising up the pubis. Abnormalities may be indicative of endocrine pathology and need to be reported to the healthcare provider for follow-up. Potentially related factors will need to be investigated. Subjective data related to menstruation are relevant to the situation. The presence or absence of menstrual history will aid in the determination of hormonal function. The presence or absence of breast buds will aid in the confirmation of the maturity of secondary sexual characteristics. Dietary intake information in the client who presents with physical immaturities may be reviewed in the event they also exhibit signs of nutritional deficiencies. There is no supportive information indicating that there are nutritional needs unmet.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 22.6: Describe developmental, cultural, psychosocial, and environmental variations in assessment and findings.

Question 27

Type: MCSA

The nurse is examining an adult female and notes thick, coarse pubic hair covering the pubis and extending to the thighs. The nurse would correctly choose which of the following actions?

1. Ask the client if she has started menstruation.

2. Report the findings to the healthcare provider.

3. Document the findings as normal.

4. Ask the client if she is sexually active.

Correct Answer: 3

Rationale 1: The clients physical appearance indicates the correct level of maturation. Information concerning menstruation is not needed.

Rationale 2: In the presence of normal findings the healthcare provider does not need notification.

Rationale 3: According to Tanners Maturation Stages in the female, the findings in this situation are appropriate for the adult female client. No further subjective information is required by the nurse. The nurse should document the findings.

Rationale 4: Information concerning the clients level of sexual activity is not relevant to the client in this scenario.

Global Rationale: According to Tanners Maturation Stages in the female, the findings in this situation are appropriate for the adult female client. No further subjective information is required by the nurse. The nurse should document the findings. The clients physical appearance indicates the correct level of maturation. Information concerning menstruation is not needed. In the presence of normal findings the healthcare provider does not need notification. Information concerning the clients level of sexual activity is not relevant to the client in this scenario.

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 22.6: Describe developmental, cultural, psychosocial, and environmental variations in assessment and findings.

Question 28

Type: MCSA

The community health nurse is preparing a presentation concerning the sexual health of teenaged girls. The objectives of Healthy People 2020 are being used as guidelines. When planning the offering which of the following should be included?

1. Increase the number of teens who are using oral contraceptives.

2. Increase the number of teens who utilize relationship counseling services.

3. Increase the number of teens who are tested for HIV.

4. Increase the number of teens who understand their reproductive functions.

Correct Answer: 3

Rationale 1: The goals of Healthy People 2020 seek to increase the proportion of adolescents who abstain from sexual intercourse or use condoms if sexually active and to increase the percentage of adolescents who have been tested for HIV. There are no provisions to dictate the use of oral contraceptives.

Rationale 2: Relationship counseling services are not included in the Healthy People 2020 objectives.

Rationale 3: The goals of Healthy People 2020 seek to increase the proportion of adolescents who abstain from sexual intercourse or use condoms if sexually active and to increase the percentage of adolescents who have been tested for HIV.

Rationale 4: The understanding of reproductive functions is not direct objectives of Healthy People 2020.

Global Rationale: The goals of Healthy People 2020 seek to increase the proportion of adolescents who abstain from sexual intercourse or use condoms if sexually active and to increase the percentage of adolescents who have been tested for HIV. There are no provisions to dictate the use of oral contraceptives. Relationship counseling services are not included in the Healthy People 2020 objectives. The understanding of reproductive functions is not a direct objective of Healthy People 2020.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 22.7: Discuss objectives related to womens health as stated in Healthy People 2020.

Question 29

Type: MCSA

The nurse suspects a gonorrheal infection in a client during an examination. Which of the following would be a priority action for the nurse?

1. Counsel regarding safe sex practices.

2. Obtain history of sexual contacts.

3. Obtain a culture.

4. Document the findings.

Correct Answer: 3

Rationale 1: The interaction between the nurse and client will include a discussion about safe sex practices. The discussion, however, of safe sexual practices is not a priority as the client has presented with a potential sexually transmitted infection.

Rationale 2: A listing of sexual contacts may be indicated in the event the disease is positively identified. At this time this step is premature pending the outcome of the diagnostic tests.

Rationale 3: Obtaining a culture of the potential infection is indicated as the priority. The findings of the culture will be used to determine the next actions of the nurse.

Rationale 4: The nurse will need to document the findings. It is most important to obtain the culture.

Global Rationale: The priority for the nurse in this situation is to obtain a culture of any discharge present so a definitive diagnosis can be made. The interaction between the nurse and client will include a discussion about safe sex practices. The discussion, however, of safe sexual practices is not a priority as the client has presented with a potential sexually transmitted infection. A listing of sexual contacts may be indicated in the event the disease is positively identified. At this time this step is premature pending the outcome of the diagnostic tests. The nurse will need to document the findings. It is most important to obtain the culture.

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 22.8: Apply critical thinking in selected simulations related to physical assessment of the female reproductive system.

Question 30

Type: MCSA

The nurse is caring for an adolescent female client who has come to the clinic for an annual physical examination. Which of the following questions would be best included in the data collection?

1. Do you have a boyfriend?

2. Do you need birth control?

3. Are you attracted to boys?

4. Are you sexually active at this time?

Correct Answer: 4

Rationale 1: The nurse should ask questions in a manner to place the client at ease. The questions should ideally be gender neutral. Asking specifically about boys may limit the clients response.

Rationale 2: It is more important to find out about the sexual activity than the birth control initially. A guided discussion may eventually lead to asking these questions.

Rationale 3: The nurse should ask questions in a manner to place the client at ease. The questions should ideally be gender neutral. Asking about the attraction to the opposite sex may appear judgmental to the client.

Rationale 4: It is more important to find out about the sexual activity than the birth control initially.

Global Rationale: The nurse should ask questions in a manner to place the client at ease. The questions should ideally be gender neutral. Asking specifically about boys may limit the clients response. It is more important to find out about the sexual activity than the birth control initially. Clients may feel they do not need birth control Asking about the attraction to the opposite sex may appear judgmental to the client.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 22.8: Apply critical thinking in selected simulations related to physical assessment of the female reproductive system.

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