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Health Assessment for Nursing Practice 6th Edition Wilson Test Bank

Chapter 17: Reproductive System and the Perineum Wilson: Health Assessment for Nursing Practice, 6th Edition MULTIPLE CHOICE 1. During the initial inspection of the female genitalia, the nurse recognizes which finding as

normal? a. The labia minora are hair-covered and lying within the labia majora. b. The cervical os in the multiparous woman has the shape of a small circle. c. The vaginal vestibule lies between the labia minora and contains the urinary

meatus. d. The openings of Skene and Bartholin glands are visible posteriorly. ANS: C

Option C is of normal female anatomy. The labia majora, rather than the labia minora, are covered with hair. The os of parous women is the shape of a slit. The opening of these glands is on either side of the vaginal vestibule. DIF: Cognitive Level: Understand REF: p. 353 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 2. The pregnant patient tells the nurse that she has had three pregnancies and two live births to

date. How does the nurse record this in the patient’s history? a. Gravida 3, para 3 b. Gravida 3, para 2 c. Gravida 2, para 3 d. Gravida 2, para 2 ANS: B

Gravida 3, para 2 represents three pregnancies and two that reached 20 weeks or longer, which is consistent with what the patient reported. Gravida 3, para 3 represents three pregnancies and three that reached 20 weeks or longer. Gravida 2, para 3 represents two pregnancies and three that reached 20 weeks or longer, which is not possible. Gravida 2, para 2 represents two pregnancies and two that reached 20 weeks or longer. DIF: Cognitive Level: Apply REF: p. 361 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 3. A mother asks a nurse when her daughter should get immunized again for human papilloma

virus (HPV). What is the nurse’s most appropriate response to this question? a. “Your daughter does not need this immunization until she becomes sexually active.” b. “The recommended age for this immunization is between 25 and 30 years of age.” c. “Between the ages of 11 and 26 years is the recommended time for this immunization.” d. “When she begins having menstrual periods is the best time for this

Health Assessment for Nursing Practice 6th Edition Wilson Test Bank immunization.” ANS: C

Option C is the recommendation from the Centers for Disease Control and Prevention (CDC). Options A, B, and D are not the recommendations of the CDC. DIF: Cognitive Level: Apply REF: p. 360 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs 4. A patient asks when she should make an appointment for her first Pap (Papanicolaou) test to

screen for cervical cancer. What is the nurse’s most appropriate response? a. “There is no need for Pap tests until after you have become pregnant.” b. “All women should have the first Pap test after reaching menarche.” c. “All women should have the first Pap test after they are 19 years of age.” d. “All women should have the first Pap test when they become sexually active or at age 21.” ANS: D

Option D is the recommendation from the U.S. Preventive Services Task Force. All females should be screened when they become sexually active or age 21, whichever happens first. Recommendations A and B are when females become sexually active or 21 years old. All females should be screened when they become sexually active or 21 years old, whichever happens first. DIF: Cognitive Level: Apply REF: p. 364 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs 5. A patient asks when she can stop having Pap (Papanicolaou) tests. What is the nurse’s most

appropriate response? a. “Until you are no longer sexually active.” b. “Through age 65.” c. “Until you begin menopause.” d. “Through the end of menopause.” ANS: B

Option B is the recommendation from the U.S. Preventive Services Task Force. All females should be screened after the onset of sexual activity through age 65. The recommendation from the U.S. Preventive Services Task Force is through age 65. DIF: Cognitive Level: Apply REF: p. 364 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Health Promotion Programs 6. When performing a well woman examination, the nurse expects what findings? a. The inner surface of the vestibule is deep pink and moist with a smooth texture. b. The inguinal skin appears wrinkled and moist with sparse hair distribution. c. The labia minora is deeply pigmented, and the tissue is ragged and asymmetrical. d. Pubic hair is distributed evenly over the mons and shaped as a triangle with the

apex over the mons.

Health Assessment for Nursing Practice 6th Edition Wilson Test Bank ANS: A

Option A is a normal finding of female external genitalia. The inguinal area would normally not be wrinkled. The labia minora is not normally ragged and asymmetric. Normally the base of the triangle is over the mons. DIF: Cognitive Level: Understand REF: p. 366 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 7. The nurse documents which finding as expected on inspection of the anus? a. Skin tone darker and coarser than that of the surrounding skin b. Sphincter lightly closed when the patient is relaxed c. Large amount of stiff, curling hair surrounding the anus d. Slight protrusion under the skin when the patient strains or bears down ANS: A

Option A is the normal finding. The anal sphincter should be tight. The anus is typically hairless. A protrusion may be a hemorrhoid, which is not an expected finding. DIF: Cognitive Level: Understand REF: p. 367 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 8. On inspection of the internal structure of the vagina, the nurse notes a rounded protrusion on

the posterior wall of the vagina. How does the nurse document this finding? a. Rectocele b. Cystocele c. Bartholin cyst d. Nabothian cyst ANS: A

Rectocele is a hernia type of protrusion of the rectum against the posterior wall of the vagina. Cystocele is a hernia type of protrusion of the bladder against the posterior wall of the vagina. The Bartholin glands are external structures. Nabothian cysts appear on the cervix. DIF: Cognitive Level: Understand REF: p. 388 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 9. After a rectal examination of a patient with obstructive jaundice, the nurse expects the stool to

be what color? Tan Pale yellow Black Bright red

a. b. c. d.

ANS: A

Health Assessment for Nursing Practice 6th Edition Wilson Test Bank Tan stool indicates a lack of bile caused by obstructive jaundice. Pale yellow stools indicate a malabsorption syndrome. Black stools indicate upper intestinal tract bleeding or excessive iron or bismuth ingestion. Bright red indicates bleeding from the lower rectum or hemorrhoids. DIF: Cognitive Level: Understand REF: p. 369 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 10. On inspection of the external male genitalia, the nurse notes which finding as abnormal? a. The scrotum is covered with dark rugous skin. b. The skin covering the penis is hairless and loose. c. The urinary meatus is located on the upper surface of the penis. d. The left side of the scrotum hangs slightly lower than the right. ANS: C

Option C is called epispadias. Options A, B, and D are normal findings. DIF: Cognitive Level: Understand REF: p. 373 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 11. The nurse observes that the urinary meatus is located on the undersurface of the penis. How

does the nurse document this finding? a. Balanitis b. Phimosis c. Epispadias d. Hypospadias ANS: D

Hypospadias occur when the urinary meatus is on the undersurface of the penis. Balanitis is inflammation of the glans that occurs in patients with phimosis. Phimosis is a very tight foreskin that cannot be retracted over the glans. Epispadias occur when the urinary meatus is on the upper (dorsum) surface of the penis. DIF: Cognitive Level: Understand REF: p. 373 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 12. In inspecting the scrotum, the nurse documents which finding as normal? a. The epididymides are round, solid nodular masses. b. The scrotum is deeply pigmented with a rugous surface. c. The scrotal skin is a lighter color than the body skin. d. The vas deferens is palpable bilaterally. ANS: B

Option B is an expected finding. Normally the epididymis is a tubular, comma-shaped structure. Normally the scrotal skin is more deeply pigmented than the body skin. Normally the vas deferens is not palpable.

Health Assessment for Nursing Practice 6th Edition Wilson Test Bank

DIF: Cognitive Level: Understand REF: p. 373 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 13. Which assessment technique does a nurse use to assess the inguinal region and femoral area of

a male patient as he is standing and straining? a. Palpates the femoral artery b. Palpates the inguinal lymph nodes c. Observes for a bulge through the inguinal region d. Observes for discoloration of the inguinal ring ANS: C

The nurse observes for a bulge that may indicate a hernia; the normal finding is no bulge. The nurse palpates the femoral artery when the patient is lying supine. The nurse palpates the inguinal lymph nodes when the patient is lying supine. The nurse cannot see the inguinal ring; it must be palpated. DIF: Cognitive Level: Understand REF: p. 374 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments

a. b. c. d.

The epididymis is located on the posterolateral surface of each testis. The epididymis feels like a tubular, comma-shaped structure. The epididymis collapses on palpation. The epididymis has an irregular, nodular surface.

ANS: D

The surface should be smooth and nontender. Options A to C are expected findings. DIF: Cognitive Level: Understand REF: p. 375 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 15. When does a nurse use transillumination of the scrotum? a. When the patient has tortuosity of the veins along the spermatic cord b. When the patient has an indirect hernia c. When there is a mass or fluid in the epididymis d. When there is twisting of the testicle and spermatic cord ANS: C

Option C is a description of a spermatocele, which does transilluminate, as does a hydrocele. Option A is a description of a varicocele, which does not transilluminate. Hernias do not transilluminate. Option D is a description of testicular torsion. DIF: Cognitive Level: Understand REF: p. 383 | p. 384 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body

Health Assessment for Nursing Practice 6th Edition Wilson Test Bank Systems 16. What procedure does a nurse use to assess the inguinal ring of a male patient for a hernia? a. Asks the patient to lie supine, lifts the scrotum, asks the patient to take a deep

breath, and observes for a bulge b. Asks the patient to lean over the examination table, inserts a gloved finger into the

lower part of the scrotum into the inguinal canal, asks the patient to cough, and palpates for a bulge c. Asks the patient to lie on the side not being assessed, inserts a gloved finger into the lower part of the scrotum into the inguinal canal, asks the patient to exhale completely, and palpates for a bulge d. Asks the patient to stand, inserts a gloved finger into the lower part of the scrotum into the inguinal canal, asks the patient to cough, and palpates for a bulge ANS: D

Option D describes the correct procedure. Option A has the patient in the wrong position with the wrong technique and wrong instruction given. Option B has the patient in the wrong position. Option C has the patient in the wrong position with the wrong instruction given. DIF: Cognitive Level: Understand REF: p. 377 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 17. The nurse places a male patient in which position for rectal examination? a. Lithotomy position b. Prone with the knees fully extended c. Bending over the table, with feet everted d. Left lateral position with knees and hips flexed ANS: D

Option D is the appropriate position for a rectal examination for a male patient. Option A is the appropriate position for a rectal examination for a female patient. Position B is not used; a knee chest position may be used instead. Option C is the appropriate position of a rectal examination for a male patient, except that the feet are inverted, rather than everted. DIF: Cognitive Level: Understand REF: pp. 375-376 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: System Specific Assessments 18. During an internal examination of a patient’s anus, the nurse notes that the patient has a

hypertonic sphincter. What is the most relevant action for the nurse to take at this time? a. Ask the patient about anxiety or pain related to the examination. b. Inquire if the patient has had any neurologic injury that causes a hypertonic

sphincter. c. Refer the patient to the physician for evaluation. d. Question the patient about a history of anal trauma. ANS: A

Health Assessment for Nursing Practice 6th Edition Wilson Test Bank Option A is the relevant action for the nurse to collect more data from the patient about the reaction to the examination. Option B probably would have been gathered during the history, so that the nurse would have anticipated an abnormal finding. Option C is not the action of most importance at this time. The nurse needs to collect more data from the patient before considering a referral. Option D is not the action of most importance at this time. The nurse needs to collect more data from the patient before asking about trauma. DIF: Cognitive Level: Apply REF: p. 369 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 19. A 50-year-old patient asks the nurse about her risk of developing a cancer of the reproductive

system. What is the appropriate response by the nurse? a. “Human papilloma virus infection and cigarette smoking are major risk factors for cervical cancer.” b. “Some of the risk factors for endometrial cancer include being age 40 or older and having a history of infertility.” c. “Ovarian cancer is not often seen in women under age 50 or those who have a family history of breast cancer.” d. “Women who have had menstrual irregularities for many years are at lower risk of developing any of the reproductive system cancers.” ANS: A

Human papilloma virus infection and cigarette smoking are risk factors for cervical cancer. These are not risk factors for endometrial cancer. These are not risk factors for ovarian cancer. These are not risk factors for gynecologic cancers. DIF: Cognitive Level: Understand REF: p. 359 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 20. The nurse recognizes which patient has the highest risk of endometrial cancer? a. A 24-year-old woman with menarche at age 9 b. A 30-year-old woman who started menstruating at age 19 c. A 42-year-old woman who reached menopause at age 40 d. A 64-year-old woman who had irregular, heavy menstrual cycles ANS: A

Early menarche is a risk factor. Option B is not a risk factor for endometrial cancer. Option C is not a risk factor for endometrial cancer. Patients who have late onset menopause are at risk. An irregular, heavy menstrual cycle is not a risk factor for endometrial cancer. DIF: Cognitive Level: Understand REF: p. 361 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems 21. Which patient does the nurse recognize as having the highest risk for ovarian cancer? a. A 24-year-old nulliparous woman who has a history of multiple sexual partners b. A 32-year-old woman who has had six live births and a history of human

Health Assessment for Nursing Practice 6th Edition Wilson Test Bank papilloma virus (HPV) infection c. A 55-year-old woman who reached menarche at age 12 and menopause at age 54 d. A 64-year-old nulliparous woman who has taken hormone replacement therapy for

8 years ANS: D

Patient D has a risk factor for ovarian cancer. Patient A has no risk factor for ovarian cancer. Patient B has a risk factor for cervical cancer (HPV), but not ovarian cancer. Patient C has no risk factors for ovarian cancer. DIF: Cognitive Level: Understand REF: p. 360 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 22. The nurse correlates which factor to an increased risk of endometrial cancer in women with

early menarche or late menopause? a. Total number of ovulatory cycles b. Less hormone stimulation c. Need for estrogen replacement in these patients d. Extended duration of the menstrual cycle in these patients ANS: A

More ovulatory cycles increases risk. These risk factors represent an increased cumulative exposure to estrogen. Hormone stimulation does not increase risk in endometrial cancer. Estrogen replacement does not increase risk in endometrial cancer. Extended duration of the menstrual cycle is not a risk factor. DIF: Cognitive Level: Understand REF: p. 361 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment 23. A patient complains of dysuria, yellow-green vaginal discharge, and vulvar itching. The nurse

suspects which sexually transmitted disease? a. Syphilis b. Gonorrhea c. Genital warts d. Chlamydia ANS: B

Gonorrhea causes a yellow or green vaginal discharge, dysuria, pelvic or abdominal pain, and vaginal itching and burning. Primary syphilis produces a single, firm, painless open sore or chancre with indurated borders at the site of entry on the genitals. Genital warts appear as soft, papillary, pink to brown, elongated lesions that may occur singularly or in clusters on the internal genitalia, the external genitalia, and the anal-rectal region. Chlamydia infection is asymptomatic in up to 75% of women because it often does not cause enough inflammation to produce symptoms. DIF: Cognitive Level: Apply REF: p. 379 TOP: Nursing Process: Assessment MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical

Health Assessment for Nursing Practice 6th Edition Wilson Test Bank Assessment 24. In assessing a patient with suspected Chlamydia, the nurse’s actions are guided by which

characteristic of this disease? Chlamydia is frequently asymptomatic and requires screening. Chlamydia is associated with a yellow-green vaginal discharge. Chlamydia is accompanied by heavy bleeding and headache. Chlamydia is ...