Chapter 40 My Nursing Test Banks

Osborn, Medical-Surgical Nursing, 2e
Chapter 40

Question 1

Type: MCMA

A 40-year-old male has reported to the clinic with complaints of impotence. The nurse is reviewing the patients health history. Which statements by the patient warrant further investigation?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. I take medications to control my blood pressure.

2. I had the mumps when I was a boy.

3. I had a vasectomy 4 years ago.

4. I have had diabetes for several years.

5. My wife has a history of cervical cancer.

Correct Answer: 1,4

Rationale 1: Certain antihypertensive drugs may cause impotence.

Rationale 2: The mumps are a risk factor for male infertility, not impotence.

Rationale 3: A vasectomy results in sterility, not impotence.

Rationale 4: Diabetes mellitus over time may result in vascular damage, leading to impotence.

Rationale 5: The presence of cervical cancer in a partner is not linked to impotence.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 40-3

Question 2

Type: MCSA

The nurse is preparing to obtain a sexual history from a male patient. Which question is of the highest importance in this assessment?

1. Do you engage in same-sex activity?

2. Do you have sex frequently?

3. Do you enjoy sexual intercourse?

4. Do you engage in masturbation?

Correct Answer: 1

Rationale 1: Assessing for the risk of sexually transmitted infections and preventing sexually transmitted infections are a priority for this patient. Sexual intercourse with same-sex partners further increases the risk for HIV infection. Determination of same-sex activity by a man is key in assessing risk factors.

Rationale 2: The frequency of sexual intercourse is part of the data collection but does not have the same importance as the determination of risk factors.

Rationale 3: The enjoyment of sexual intercourse is part of the data collection but does not have the same importance as the determination of risk factors.

Rationale 4: Masturbation may be included in the data collection, but it is not as important as the assessment of risk factors.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 40-2

Question 3

Type: MCSA

The nurse is providing instruction to a patient who has been diagnosed with prostate cancer. Which statement by the patient would indicate understanding of the nurses instruction?

1. The prostate gland is where sperm are formed.

2. The prostate gland is located at the neck of my bladder.

3. The prostate gland produces semen.

4. The prostate gland is normally very small, only about a quarter of an inch long.

Correct Answer: 2

Rationale 1: Sperm are formed in the testes.

Rationale 2: The prostate gland is located at the bladder neck.

Rationale 3: Semen is produced by seminal vesicles.

Rationale 4: The normal size of the prostate gland is about 2.5 cm or about 1 inch.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 40-1

Question 4

Type: MCMA

A patient presents to the emergency department with swelling and pain in his scrotum. The nurse anticipates dysfunction in which structures?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Testes

2. Vas deferens

3. Epididymis

4. Seminal vesicle

5. Prostate

Correct Answer: 1,3

Rationale 1: The testes are contained in the scrotum.

Rationale 2: The vas deferens is located in the abdomen.

Rationale 3: The epididymis is located in the scrotum.

Rationale 4: The seminal vesicle is located behind the prostate.

Rationale 5: The prostate is located at the bladder neck.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 40-1

Question 5

Type: MCMA

The nurse is performing an assessment of a female patients breasts. Which findings indicate the need for further assessment?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. One breast is shaped differently from the other.

2. The breasts do not display prominent veins.

3. The nipples are a light tan in color.

4. There is clear discharge from one nipple.

5. There is an area of dimpled skin on one breast.

Correct Answer: 1,4,5

Rationale 1: Changes in contour may be revealed as a shape difference and should be further evaluated.

Rationale 2: The absence of prominent veining is normal.

Rationale 3: The nipple color may range from pink to brown.

Rationale 4: Nipple discharge should be further evaluated.

Rationale 5: Dimpling and abnormal contours should be further evaluated.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 40-4

Question 6

Type: MCMA

The nurse is conducting a presentation to a group of women concerning menopause. Which statements by a participant indicate good understanding of the process?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Lubrication for intercourse will not be as necessary after menopause.

2. My risk for vaginal infections is reduced once my estrogen levels decrease during menopause.

3. My ovaries will shrink in size after menopause.

4. The hair under my arms will thicken.

5. I can expect my pubic hair to turn gray.

Correct Answer: 3,5

Rationale 1: The loss of estrogen as a woman ages is responsible for the reduction in vaginal lubrication. Patients experiencing this loss may require lubricants to promote comfort.

Rationale 2: The vaginal dryness associated with menopause places the woman at an increased risk for the development of vaginal infections.

Rationale 3: The ovaries shrink in size as a result of menopause. A palpable ovary should be considered enlarged.

Rationale 4: Axillary hair becomes sparser.

Rationale 5: Pubic hair turns gray and becomes sparser.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 40-5

Question 7

Type: MCSA

During a vaginal examination of a 33-year-old patient, a nontender mass at the posterolateral portion of the labia majora is noted. The nurse anticipates which diagnosis?

1. Rectocele

2. Fistula

3. Bartholin cyst

4. Cyst of the Skenes gland

Correct Answer: 3

Rationale 1: A rectocele results when the walls between the rectum and the vagina become weakened.

Rationale 2: A fistula results when there is an opening between two separate organs.

Rationale 3: The Bartholin glands are located at the posterolateral labia majora. These glands are responsible for providing lubrication to the female genitalia. A swelling in this area is consistent with the diagnosis of a Bartholin cyst.

Rationale 4: The Skenes glands are located on either side of the urethral meatus.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 40-4

Question 8

Type: MCMA

The nurse is preparing to examine a male patients reproductive organs. What nursing actions are part of preparing for this examination?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Secure a private examination room.

2. Use clean hands for the examination.

3. Ask the patient to lie down on the exam table.

4. Ask the patient put on a gown.

5. Make sure the room temperature is cool.

Correct Answer: 1,4

Rationale 1: The nurse ensures that the examining room is warm and private.

Rationale 2: The nurse puts on gloves before beginning and wears them throughout the examination.

Rationale 3: The assessment may be done with the patient sitting or standing.

Rationale 4: The nurse has the patient remove his clothing and put on a gown or drape.

Rationale 5: A cool temperature may be uncomfortable to the patient who is undressed.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 40-2

Question 9

Type: MCMA

During an assessment, a female patient asks why the nurse is feeling her armpit. Which responses are appropriate?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Im counting your ribs.

2. Dont you feel your own armpits?

3. Breast tissue extends into this area.

4. Im assessing hair distribution in this area.

5. The armpits should be part of your breast self-exam.

Correct Answer: 3,5

Rationale 1: Counting the ribs is unnecessary.

Rationale 2: This response does not address the patients question.

Rationale 3: Various palpation patterns may be used as long as every part of each breast is palpated, including the axillary tail, or the tail of Spence, which is the breast tissue that extends from the upper outer quadrant toward and into the axillae.

Rationale 4: Hair distribution would be assessed with visualization, not palpation.

Rationale 5: The nurse will explain breast self-exam (BSE) to the patient.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 40-2

Question 10

Type: MCSA

The nurse is assessing for a left inguinal hernia in a male patient. Which technique should the nurse use?

1. Palpate for a structure that feels like a bag of worms.

2. Use the left forefinger to examine the inguinal ring.

3. Ask the patient to cough during the assessment.

4. Have the patient face a table and lean over it.

Correct Answer: 3

Rationale 1: The structure that feels like a bag of worms is a varicocele.

Rationale 2: The right forefinger is used to examine the left inguinal ring.

Rationale 3: The nurse asks the patient to cough which brings the bulging hernia down against the nurses finger.

Rationale 4: This position is used for palpation of the prostate.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 40-4

Question 11

Type: MCSA

A female patient is admitted with a painful swelling in the perineal body. Where would the nurse look to assess this lesion?

1. Between the anus and the fourchette

2. Just lateral to the urethral meatus

3. Just anterior to the clitoris

4. Just anterior to the opening to the vagina

Correct Answer: 1

Rationale 1: The perineal body is located between the fourchette in the front and the anus in the back.

Rationale 2: The structure just lateral to the urethral meatus is the labium minus.

Rationale 3: The structure just anterior to the clitoris is the prepuce.

Rationale 4: The structure just anterior to the vagina orifice is the urethral meatus.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 40-2

Question 12

Type: MCSA

The nurse is reviewing the laboratory analysis of a female patients hormones. Increases in which hormone levels would indicate ovulation is occurring?

1. Estrogen

2. Luteinizing hormone

3. Progesterone

4. Gonadotropin-releasing hormone

Correct Answer: 2

Rationale 1: Estrogen levels peak prior to the release of the hormone necessary for ovulation.

Rationale 2: When the luteinizing hormone peaks, ovulation occurs.

Rationale 3: Increases in the progesterone level occur after ovulation.

Rationale 4: The gonadotropin-releasing hormone stimulates the anterior pituitary to release the follicle-stimulating hormone, which occurs prior to ovulation.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 40-1

Question 13

Type: MCSA

A patient with a menstrual cycle of 28 days asks about the timing of ovulation. The nurse would respond that ovulation would most likely occur on which days?

1. 14 to 16

2. 20 to 22

3. 10 to 12.

4. 1 to 2

Correct Answer: 1

Rationale 1: Ovulation occurs at mid-cycle. Because there are 28 days in the patients menstrual cycle, ovulation would occur on day 14 to 16.

Rationale 2: Days 20 to 22 follow the time of ovulation for this patient.

Rationale 3: Days 10 to 12 precede the likely ovulation time for this patient.

Rationale 4: Days 1 to 2 are the first days of menstruation, at the beginning of the cycle. Ovulation will not occur for several more days.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 40-1

Question 14

Type: MCSA

A patient is having a routine prostate examination. Which question is an important part of this examination?

1. Do you have polyuria in the morning?

2. Do you take laxatives or stool softeners?

3. Do you have difficulty with urination?

4. Do you experience constipation?

Correct Answer: 3

Rationale 1: Polyuria in the morning is not a sign of prostate disease.

Rationale 2: Taking laxatives or stool softeners does not affect the function of the prostate.

Rationale 3: When the prostate is enlarged, it disrupts urinary flow and causes several urinary symptoms.

Rationale 4: Experiencing constipation is not associated with the prostate gland.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 40-4

Question 15

Type: MCSA

The nurse is assessing the medication history of a patient with an enlarged prostate. The nurse would inquire about the use of which herbal supplement?

1. Ginkgo

2. Saw palmetto

3. Green tea

4. Fish oil

Correct Answer: 2

Rationale 1: Ginkgo is not used to improve prostate health.

Rationale 2: Saw palmetto is an herbal supplement sometimes suggested for use by patients with an enlarged prostate gland.

Rationale 3: Green tea is not associated with prostate health.

Rationale 4: Fish oil is not associated with prostate health.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 40-2

Question 16

Type: MCSA

During a physical examination, a male patient reports discharge from the urinary meatus. The discharge is not visible to the nurse. What is the first action the nurse would ask the patient to take?

1. Continue to watch for other signs of a sexually transmitted infection (STI).

2. Return to the clinic when the discharge occurs.

3. Strip the penis to bring discharge to the meatus for culture.

4. Go to the emergency department for further testing.

Correct Answer: 3

Rationale 1: Watching for other signs of an STI is premature because the nurse does not know if the discharge is related to an STI.

Rationale 2: Returning to the clinic when the discharge occurs is appropriate, but the initial action would be to attempt to obtain a culture of the fluid.

Rationale 3: The patient should strip (compress or milk) the penis to bring discharge to the meatus so that testing can be performed.

Rationale 4: Going to the emergency department is unnecessary because the patient can be further tested and treated during the examination.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 40-4

Question 17

Type: MCMA

The nurse is assisting the health care provider with a routine prostate examination. The nurse could assist the patient to which positions for this examination?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. On the left side with right knee drawn up

2. Leaning over the examination table

3. Standing in the most comfortable position

4. On the right side with both knees flexed

5. In the lithotomy position

Correct Answer: 1,2

Rationale 1: This is a correct anatomical position for a routine prostate examination.

Rationale 2: This is a correct anatomical position for a routine prostate examination.

Rationale 3: Standing does not allow access to the prostate.

Rationale 4: There is no reason for both knees to be drawn up, and this may make the patient more uncomfortable.

Rationale 5: The lithotomy position is used to examine the internal female reproductive organs. It is not recommended for prostate examination.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 40-2

Question 18

Type: MCMA

While obtaining a social history on a male patient regarding patterns of alcohol use, the nurse becomes aware that the patient may have a drinking problem. The nurse continues assessing the patient using the CAGE questionnaire. Which questions would the nurse ask?


Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Have you ever felt annoyed by criticism of your drinking?

2. Have you ever felt the desire to stop drinking?

3. Have you ever taken a drink first thing in the morning?

4. Have you ever felt the need to cut down on drinking?

5. Have you ever felt guilty about drinking?

Correct Answer: 1,3,4,5

Rationale 1: Annoyance at being criticized for drinking is one of the areas assessed by the CAGE questionnaire.

Rationale 2: This question is not part of the CAGE questionnaire.

Rationale 3: Asking about drinking first thing in the morning is part of the CAGE questionnaire.

Rationale 4: Asking about feeling the need to cut down on drinking is part of the CAGE questionnaire.

Rationale 5: Guilt about drinking is assessed by the CAGE questionnaire.

Global Rationale:

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 40-2

Question 19

Type: MCSA

A patient is having a breast examination and is asked by the nurse to position her arms at her sides, then to press her hands to her hips. The patient asks why she has to perform so many different positions for the examination. What rationale would the nurse provide for this request?

1. Several positions pull ligaments, causing dimpling if a tumor is present.

2. Having the patient move facilitates a neurological assessment along with the breast examination.

3. These movements help to determine the patients state of balance.

4. These movements help test motor strength.

Correct Answer: 1

Rationale 1: Several maneuvers move the breast and pull the suspensory ligaments in such a way that a tumor would cause dimpling or a bulge.

Rationale 2: Neurological assessment is not the rationale for maneuvering the extremities during a breast examination.

Rationale 3: Testing the state of balance is not the rationale for these movements.

Rationale 4: Testing motor strength is not the rationale for these movements.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 40-2

Question 20

Type: MCMA

During a routine breast examination of a patient, the nurse notes a small amount of nipple discharge. What nursing actions are indicated?


Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Tell the patient she may have cancer.

2. Send the specimen to the lab.

3. Ask the patient if she has noticed discharge before.

4. Collect a specimen on a slide.

5. Document the finding.

Correct Answer: 2,3,4,5

Rationale 1: Telling the patient she has cancer is inappropriate; discharge is not always a sign of cancer.

Rationale 2: The nipple drainage would be sent to the lab for analysis.

Rationale 3: The nurse would question if this discharge has occurred before and when it began.

Rationale 4: The drainage should be collected on a specimen slide.

Rationale 5: The nurse would document the finding so that future comparisons can be made if the drainage continues.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 40-4

Question 21

Type: MCMA

During a routine pelvic examination, the nurse instructs the patient to bear down. The nurse explains that this motion makes it easier to assess for which conditions?


Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Rectoceles

2. Prolapsed uterus

3. Vaginal tumors

4. Ovarian cysts

5. Cystoceles

Correct Answer: 1,2,5

Rationale 1: Rectocele, or relaxation of the posterior vaginal wall over the rectum, is assessed by asking the patient to bear down so that the health care provider can determine the presence of the structures through the vagina.

Rationale 2: Prolapsed uterus, or the protrusion of the uterus into the vaginal wall, is assessed by asking the patient to bear down so that the health care provider can determine the presence of the structures through the vagina.

Rationale 3: Vaginal tumors may be detected by visual inspection of the pelvis through a speculum device.

Rationale 4: Ovarian cysts are palpated manually, and the patient does not have to bear down to determine their presence.

Rationale 5: Cystocele, or relaxation of the anterior vaginal wall under the urinary bladder, is assessed by asking the patient to bear down so that the health care provider can determine the presence of the structures through the vagina.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 40-4

Question 22

Type: MCMA

The nurse is instructing a female patient about changes in sexual functioning that may result from the aging process. Which nursing diagnoses would the nurse incorporate into the plan of care for this patient regarding sexual intercourse?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Risk for Injury

2. Risk for Infection

3. Impaired Skin Integrity

4. Altered Tissue Perfusion

5. Alteration in Comfort

Correct Answer: 1,2,3,5

Rationale 1: The patient could be at risk of injury due to thinning vaginal tissues.

Rationale 2: With intercourse, the vaginal tissue may tear, and infection of the disrupted tissue could result.

Rationale 3: Impaired Skin Integrity may result because of the thinning of the vaginal mucosa and loss of adipose tissue.

Rationale 4: The aging process does not reduce the perfusion of the vaginal mucosa.

Rationale 5: Intercourse may be painful because of the estrogen loss and drying of the vaginal mucosa.

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 40-5

Question 23

Type: MCSA

A female patient who is experiencing hot flashes during menopause asks the nurse how long they will last. Which information should the nurse provide?

1. Hot flashes do not occur after the first year of menopause.

2. Hot flashes usually occur once a month.

3. The patient may have hot flashes for up to 5 years.

4. Hot flashes generally disappear after the first 2 years of menopause.

Correct Answer: 3

Rationale 1: Hot flashes are unpredictable and may last longer than 1 year.

Rationale 2: There is no indication that hot flashes occur only once a month.

Rationale 3: Hot flashes are unpredictable and may last up to 5 years, especially if the patient is not taking hormone replacement therapy.

Rationale 4: Hot flashes may last longer than 2 years.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 40-5

Question 24

Type: MCSA

A young adult male asks the nurse about the recommended frequency of testicular self-exams. How should the nurse respond?

1. The more frequently exams are performed, the more beneficial they are.

2. You should have been taught to self-examine starting at age 12.

3. Not all experts believe that testicular self-examination is necessary or beneficial for young men.

4. It is essential that you perform this exam each month.

Correct Answer: 3

Rationale 1: Guidelines do not indicate that testicular self-exams are beneficial the more they are performed.

Rationale 2: There is no indication that a 12-year-old should be taught testicular self-examination.

Rationale 3: Testicular self-exams for adolescents and young men have been shown to cause more harm than benefit, according to the United States Preventive Service Task Force (USPSTF). USPSTF guidelines state that routine exams should not be performed.

Rationale 4: Not all experts believe that testicular exams are necessary for adolescents and young men.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 40-6

Question 25

Type: MCSA

A 20-year-old female asks the nurse when she should begin having pelvic examinations. Which question should the nurse ask before responding?

1. Are you on any medications?

2. Do you have a boyfriend?

3. Are you sexually active?

4. Are you asking because you think you are pregnant?

Correct Answer: 3

Rationale 1: Asking about medications is too broad a question and does not give the nurse information about the patients sexual practices.

Rationale 2: Having a boyfriend does not always indicate sexual activity.

Rationale 3: The United States Preventive Services Task Force (USPSTF) recommends that pelvic examinations begin about 3 years after the initiation of sexual intercourse but no later than 21 years of age.

Rationale 4: Pregnancy is a reason for a pelvic examination, but it is not the only reason. The nurse should also not assume that the patient may be pregnant.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 40-6

Question 26

Type: MCSA

The patient asks why the nurse is asking questions about her mothers obstetrical history. Which rationale for this questioning should the nurse provide?

1. If your mother smoked while she was pregnant with you, your risk of lung cancer is higher.

2. Use of medications to prevent miscarriage may have an impact on your health.

3. The government wants to know for a genetic study.

4. If your mother had bleeding after delivery, you should avoid aspirin if you become pregnant.

Correct Answer: 2

Rationale 1: There is no correlation between smoking during pregnancy and the development of lung cancer in the child.

Rationale 2: Daughters of women who took diethylstilbesterol (DES) are at higher risk of developing cancer of the vagina and cervix.

Rationale 3: This is not a reason to collect this information.

Rationale 4: All pregnant women should avoid aspirin. There is no correlation between their mothers obstetric history and the need to avoid aspirin.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 40-3

Question 27

Type: MCSA

Which statement by a patient offers the nurse information about moliminal symptoms?

1. I have headaches if I dont eat regularly.

2. When I was pregnant, my feet and ankles were swollen every day.

3. My last boyfriend gave me hepatitis.

4. I get terrible cramps with my periods.

Correct Answer: 4

Rationale 1: Headaches that occur when meals are missed may be due to hypoglycemia. This is not a moliminal symptom.

Rationale 2: Swelling of the feet and ankles during pregnancy is not a moliminal symptom.

Rationale 3: Hepatitis is not associated with moliminal symptoms.

Rationale 4: Symptoms associated with menses are moliminal symptoms.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 40-2

Question 28

Type: MCSA

On assessment the nurse notes that a patients urinary opening is on the ventral side of the penis. How should the nurse document this finding?

1. Hypospadias

2. Hydrocele

3. Cryptorchidism

4. Varicocele

Correct Answer: 1

Rationale 1: In hypospadias, the urinary opening is on the ventral or bottom side of the penis.

Rationale 2: A hydrocele is swelling due to fluid accumulation in the scrotum.

Rationale 3: Cryptorchidism is the presence of an undescended testicle.

Rationale 4: Varicocele is varicosities of the veins of the scrotum.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 40-4

Question 29

Type: MCSA

Which precautions should the nurse conducting an assessment of the reproductive system take to avoid the cremasteric reflex?

1. Ask the patient to cough during the exam for inguinal hernia.

2. Ask the patient to breathe in slowly through the nose and out through the mouth.

3. Conduct the examination in a warm room.

4. Lubricate the finger used for the prostate exam.

Correct Answer: 3

Rationale 1: Coughing during the exam for inguinal hernia intensifies the bulging. This is not the cremasteric reflex.

Rationale 2: Slow breathing does not eliminate the cremasteric reflex.

Rationale 3: The cremasteric reflex, in which the testicles rise in the scrotum to the abdominal cavity, can be reduced by conducting the exam in a warm room.

Rationale 4: The cremasteric reflex is not related to the prostate exam.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 40-2

Question 30

Type: MCSA

During assessment, the nurse notes a third nipple about 4 inches below the patients costal margin. What nursing action is indicated?

1. Ask the patient when this nipple appeared.

2. Document this normal variant.

3. Discuss the finding with the health care provider because these nipples are commonly malignant.

4. Look for additional nipples on the patients back.

Correct Answer: 2

Rationale 1: Patients are born with this condition.

Rationale 2: Supernumerary nipples are normal variants but should be documented in the medical record.

Rationale 3: This is a benign condition.

Rationale 4: These extra nipples appear down the milk lines that run from the axilla across the nipple and down the abdomen to the groin. They are not found on the back.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 40-1

 

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