NR 304 Final Exam questions and answer with detailed rationales

Techniques used in musculoskeletal asessment include _____ and ______

inspection

palpation

Which factors have a positive impact on bone health? Select all that apply.

Vitamin D

Exercise

Calcium

Proteins

A nurse is evaluating a right ankle injury. Which should be included as part of the musculoskeletal assessment of the right extremity?

Neurovascular

Which information obtained during the health history of a healthy 40-year-old client may indicate the risk of musculoskeletal problems?

The client does not exercise.

Joints

Inspect for size, symmetry, color, swelling, masses, deformities, and alignment

Muscles

Inspect for size, swelling or wasting, tremors, and masses

Bones

Inspect for deformities

Which statements describe a proper musculoskeletal assessment? Select all that apply.

Comparing one side to the other

Demonstrate expected movements

Stopping if client reports pain

The 5 Ps of Neurovascular Assessment

Pain

Pulses

Pallor

Paresthesia

Paralysis

Dupuytren's contracture

inability to extend the fourth and fifth fingers

Degenerative joint disease

thickened synovial fluid, fragmented connective tissue, and scarring with joint calcification

Carpal tunnel syndrome

pain, tingling, numbness of the thumb and forefinger, weakness when grasping or making a fist​

Bursitis

localized joint pain with swelling, heat, and redness

Gout

a type of arthritis caused by uric acid crystal deposits in the joints

Scleroderma

damage to the skin, blood vessels, and joints caused by collagen build-up

Ulnar deviation

metacarpophalangeal and interphalangeal joint inflammation, leading to the hand turning outward

Hallux valgus

big toe abnormally adducted at the metatarsophalangeal joint

A client presents to the emergency department (ED) with an obvious deformity of the right forearm due to an accident. Which items should the nurse include in the neurovascular assessment? Select all that apply.

Sensation

Skin color

Pulses

Age Related Findings:

Older Adults

Osteoporosis

Osteoarthritis

Kyphosis

Age Related Findings:

Children

Scoliosis

Age Related Findings:

Pregnancy

Softening of pubis joints

Waddling gait

What assessment finding is illustrated in this picture? spine is curved

scoliosis

What are the signs or symptoms of idiopathic scoliosis? Select all that apply.

Asymmetry of shoulder blades

Back pain

Poor posture

Uneven gait

A client with scoliosis asks the nurse how physical therapy will help with breathing. Which response by the nurse is correct?

"Certain exercises can help expand the rib cage, increasing lung capacity."

Which treatment interventions could be considered for scoliosis depending on the severity of spinal curvature? Select all that apply.

Pain medication

Physical therapy

Spinal fusion

Brace

A client with mild scoliosis is being observed at this time with no further treatment recommendations. What may indicate to the client that the scoliosis is worsening? Select all that apply.

The client experiences increased shortness of breath.

​The client notes an increased height of one shoulder compared to the other.​

The client notes muscle spasms located in the back.

The client experiences increased back pain.

A 16-year-old client is at a yearly physical and the nurse assesses their spine. Which findings are indicative of mild scoliosis? Select all that apply.

Curved spinal column

Prominence of one scapula

Prominence of one scapula

Which x-ray image would the nurse expect to see in a client with moderate thoracic and lumbar scoliosis?

Slight curve in the middle and lower back

Which assessment findings would the nurse expect for a client with moderate thoracic and lumbar scoliosis? Select all that apply.

Muscle spasms

Chronic back pain

Family history of scoliosis

Which treatments are anticipated for a client with moderate scoliosis (35 degrees)? Select all that apply.

Counseling

Physical therapy

Brace

Pain medication

Which question is important to ask an adult female during a urinary health history?

"Do you urinate after having sexual intercourse?"

The nurse is performing a focused reproductive interview with a 28-year-old female client. Which statement by the client is unexpected?

"My breasts seem swollen all the time."​

The female reproductive organs include

the vagina, uterus, fallopian tubes, and ovaries.

The female urinary system include

the urethra, bladder, ureters, renal pelvis, and kidneys

Normal finding when palpating the lymphatic system include

nonpalpable and nontender nodes

Normal findings of the inspection of the breasts include

even color and slight asymmetry

Which tests could provide valuable information about the female reproductive and genitourinary systems?

Blood urea nitrogen BUN

Ultrasound

Creatinine

Cytoscopy

Breast self examination BSE can be taught to be performed...

5 days after the start of the mentrual period

When should a clinical breast examination be preformed?

Every 3 years when women are in their 30s and 40s

Fibrocystic Breast Disease

Lumps, breast pain, or tenderness, and nipple discharge. Treatment includes pain relievers and hormones

Bacterial Vaginitis

Creamy gray to white discharge that has a fishy odor. The client may also experience burning, itching, pain, and dysuria. Treatment includes antibiotics

Fibroadenoma

Asymptomatic; usually occurs as a single tumor near the nipple

Cystocel/Rectocele

The bladder or rectum starts protruding out of the vagina

Atrophic Vaginitis

Estrogen deficiency in postmenopausal females results in dryness, itching, and burning.

Incontinence

the uncontrollable leakage of urine from the bladder. Caused by bladder muscle weakness

Urinary Tract Infection UTI

usually caused by bacterial overgrowth in the bladder, which can spread to the kidney.

Renal Calculi

Urinary stones are produced, which causes blockage of the ureters or urethra

The client reports a consistent, achy pain in their lower back and suprapubic regions. The nurse interprets that this finding could indicate a problem of which structure?

Bladder

The nurse is assessing a client admitted for oliguria of unknown origin. Which factors affect urine output? Select all that apply.

Medications

Fluid intake

Bladder size

The nurse observes a reddened, painless sore on the client's labia. This is consistent with which sexually transmitted infection?

Syphilis

The nurse is planning to assess the external genitals of an adult female. What should be done first?​

Provide for privacy and display empathy.

Which finding most likely causes symptoms, including erythema, pain, and enlargement of one of Bartholin's glands?

Cyst

The _____ is located at the opening of the uterus and can be seen with a ____ examination.

cervix

pelvic

Which genitourinary changes are expected as a female ages? Select all that apply.

Reduced vaginal lubrication

Decrease in pubic hair

Decreased estrogen production

What would a nurse expect to find in an older adult client with a urinary tract infection?

dysuria

frequency

urgency

bacteriuria

During a pelvic exam, which position should the client be placed in for the best evaluation?

Lithotomy position

When assessing a young adult male, which statement made by the client indicates the need for more education?

"Condoms are unnecessary as long as the female partner is taking birth control pills."

The nurse is performing a focused reproductive interview with a 55-year-old male client. Which client statement indicates a need for more male reproductive health education?

"Because I am circumcised, I am at higher risk of getting sexually transmitted infections."

It is recommended to do a testicular self-exam _____. Adolescent males should begin self exams by the age of ____

monthly

14

You are a school nurse, and a transgender child is in your office reporting urgency and burning with urination. Which questions would you ask when assessing the child? Select all that apply.

"How much water do you drink during the day?"

"Do you feel comfortable using the school bathroom?"

"When did the urgency and burning begin?"

Phimosis

In an uncircumcised male, the foreskin is retracted and cannot be returned. This can result in strangulation of the glans (head of the penis). Symptoms include pain, venous engorgement, and edema of the glans. Treatment includes circumcision. This can be a urological emergency.​

Inguinal Hernia

The small bowel is pushed through the inguinal canal into the scrotum.

Testicular Torsion

This occurs when the testicles rotate, reducing or stopping the blood flow to the testicle. This is an emergent problem and requires immediate surgery. Symptoms include severe pain. ​

Prostatitis

inflammation of the prostate is usually caused by a sexually transmitted infection or other bacteria. Symptoms include pain with defecation and difficulty urinating.

HPV

known as genital warts, mostly asymptomatic, though a painless lesion may be present

syphilis

nontender lesions appear as round reddened ulcers

Herpes

Small vesicles appear in clusters and are painful

Gonorrhea

Yellow or green discharge caused by bacteria

Chlamydia

Dysuria, frequency, or urgency caused by bacteria

Trichomoniasis

Parasites cause irritation during urination.

Which factors should the nurse consider when providing contraceptive education to a client?

Age

Religious Beliefs

In an uncircumcised male, the foreskin is retracted and cannot be returned. This can result in strangulation of the glans (head of the penis). This describes which condition?

Paraphimosis

Which condition is a common cause of urinary retention in an older male adult?

Prostate enlargement

Which factor demonstrates culturally competent care during a reproductive assessment?​

The nurse asks a male colleague to perform the examination, as requested.

What is a common cause of anorexia nervosa in an adolescent?

Negative body image

Which items are risk factors for benign prostatic hypertrophy? Select all that apply.

Advanced age

Male gender

Which assessment technique assesses the size of the prostate?

Rectal exam

A client living with benign prostatic hypertrophy was started on the alpha-adrenergic blocking medication tamsulosin. Which statement best describes how this medication works?

Tamsulosin relaxes the muscles in the prostate and bladder.

What symptom is consistent with badder cancer?

Hematuria

Which radiologic examinations are used to visualize the bladder and prostate?

Computerized tomography (CT)

Magnetic resonance imaging (MRI)

What is the most common cue to indicate a client is at risk of clinical deterioration?

Change in one or more vital signs

Changes in which assessment data may indicate failure to rescue?

Oxygen saturation

Heart rate

Level of consciousness

Which key attributes contribute to the failure to rescue? Select all that apply.

Lack of clinical decision-making

Failing to communicate changes

Omission of care

Overlooking changes in the client's status

Which nursing action is most likely to prevent failure to rescue?

Recognizing early signs of clinical deterioration

Which factor is most important for the nurse to consider when deciding how to respond to a reduction in a client's physical condition?

Severity of decline