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Perry: Maternal Child Nursing Care, 4th Edition

Chapter 5: Health Assessment Test Bank MULTIPLE CHOICE 1. The two primary functions of the ovary are: a Normal female development and sex hormone release. . b Ovulation and internal pelvic support. . c Sexual response and ovulation. . d Ovulation and hormone production. . ANS: D The two functions of the ovaries are ovulation and hormone production. The presence of ovaries does not guarantee normal female development. The ovaries produce estrogen, progesterone, and androgen. Ovulation is the release of a mature ovum from the ovary; the ovaries are not responsible for interval pelvic support. Sexual response is a feedback mechanism involving the hypothalamus, anterior pituitary gland, and the ovaries. Ovulation does occur in the ovaries. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment 2. The uterus is a muscular, pear-shaped organ that is responsible for: a Cyclic menstruation. c Fertilization. . . b Sex hormone production. d Sexual arousal. . . ANS: A The uterus is an organ for reception, implantation, retention, and nutrition of the fertilized ovum; it also is responsible for cyclic menstruation. Hormone production and fertilization occur in the ovaries. Sexual arousal is a feedback mechanism involving the hypothalamus, the pituitary gland, and the ovaries. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 66 REF: 68

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2 3. Unique muscle fibers make the uterine myometrium ideally suited for: a Menstruation. c Ovulation. . . b The birth process. d Fertilization. . . ANS: B The myometrium is made up of layers of smooth muscle that extend in three directions. These muscles assist in the birth process by expelling the fetus, ligating blood vessels after birth, and controlling the opening of the cervical os. PTS: 1 DIF: Cognitive Level: Application OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 66

4. The hormone responsible for maturation of mammary gland tissue is: a Estrogen. c Prolactin. . . b Testosterone. d Progesterone. . . ANS: D Progesterone causes maturation of the mammary gland tissue, specifically acinar structures of the lobules. Estrogen increases the vascularity of the breast tissue. Testosterone has no bearing on breast development. Prolactin is produced after birth and released from the pituitary gland. It is produced in response to infant suckling and emptying of the breasts. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 68

5. Because of the effect of cyclic ovarian changes on the breast, the best time for breast selfexamination (BSE) is: a Five to 7 days after menses ceases. c Midmenstrual cycle. . . b Day 1 of the endometrial cycle. d Any time during a shower or bath. . . ANS: A The physiologic alterations in breast size and activity reach their minimal level about 5 to 7 days after menstruation stops. Therefore, all women should perform BSE during this phase of the menstrual cycle.

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Test Bank

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PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Planning 6. Menstruation is periodic uterine bleeding: a That occurs every 28 days. . b In which the entire uterine lining is shed. . c That is regulated by ovarian hormones. . d That leads to fertilization. .

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ANS: C Menstruation is periodic uterine bleeding that is controlled by a feedback system involving three cycles: endometrial, hypothalamic-pituitary, and ovarian. The average length of a menstrual cycle is 28 days, but variations are normal. During the endometrial cycle, the functional two thirds of the endometrium is shed. Lack of fertilization leads to menstruation. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 71

7. Individual irregularities in the ovarian (menstrual) cycle are most often caused by: a Variations in the follicular (preovulatory) phase. . b An intact hypothalamic-pituitary feedback mechanism. . c A functioning corpus luteum. . d A prolonged ischemic phase. . ANS: A Almost all variations in the length of the ovarian cycle are the result of variations in the length of the follicular phase. An intact hypothalamic-pituitary feedback mechanism is regular, not irregular. The luteal phase begins after ovulation. The corpus luteum depends on the ovulatory phase and fertilization. During the ischemic phase the blood supply to the functional endometrium is blocked, and necrosis develops. The functional layer separates from the basal layer, and menstrual bleeding begins.

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4 PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 73

8. Prostaglandins are produced in most organs of the body, including the uterus. Other source(s) of prostaglandins is/are: a Ovaries. c Menstrual blood. . . b Breast milk. d The vagina. . . ANS: C Menstrual blood is a potent source of prostaglandins. Prostaglandins are produced in most organs of the body and in menstrual blood. The ovaries, breast milk, and vagina are neither organs nor a source of prostaglandins. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 73

9. Physiologically sexual response can be characterized by: a Coitus, masturbation, and fantasy. c Erection and orgasm. . . b Myotonia and vasocongestion. d Excitement, plateau, and orgasm. . . ANS: B Physiologically, according to Masters (1992), sexual response can be analyzed in terms of two processes: vasocongestion and myotonia. Coitus, masturbation, and fantasy are forms of stimulation for the physical manifestation of the sexual response. Erection and orgasm occur in two of the four phases of the sexual response cycle. Excitement, plateau, and orgasm are three of the four phases of the sexual response cycle. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 74

10. Before beginning the health history interview, the nurse should perform all actions except: a Smile and ask the client whether she has any special concerns. . b Speak in a relaxed manner with an even, nonjudgmental tone. . c Make the client comfortable.

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Test Bank . d Tell the client her questions are irrelevant. . ANS: D The woman should be assured that all of her questions are relevant and important. Smiling and asking about special concerns, speaking in a relaxed manner, and making the client comfortable are all appropriate actions for the nurse to perform before beginning the health history. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 75

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11. The nurse guides a woman to the examination room and asks her to remove her clothes and put on an examination gown with the front open. The woman states, I have special undergarments that I do not remove for religious reasons. The most appropriate response from the nurse would be: a You cant have an examination without removing all your clothes. . b Ill ask the doctor to modify the examination. . c Tell me about your undergarments. Ill explain the examination procedure, and . then we can discuss how you can have your examination comfortably. d What? Ive never heard of such a thing! That sounds different and strange. . ANS: C This statement reflects cultural competence by the nurse and shows respect for the womans religious practices. The nurse must respect the rich and unique qualities that cultural diversity brings to individuals. In recognizing the value of these differences, the nurse can modify the plan of care to meet the needs of each woman. PTS: 1 DIF: Cognitive Level: Application OBJ: Client Needs: Psychosocial Integrity TOP: Nursing Process: Planning REF: 75, 76

12. A 62-year-old woman has not been to the clinic for an annual examination for 5 years. The recent death of her husband reminded her that she should come for a visit. Her family doctor has retired, and she is going to see the womens health nurse practitioner for her visit. To facilitate a positive health care experience, the nurse should: a Remind the woman that she is long overdue for her examination and that she . should come in annually. b Listen carefully and allow extra time for this womans health history interview.

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6 . c Reassure the woman that a nurse practitioner is just as good as her old doctor. . d Encourage the woman to talk about the death of her husband and her fears about . her own death. ANS: B The nurse has an opportunity to use reflection and empathy while listening and to ensure open and caring communication. Scheduling a longer appointment time may be necessary because older women may have longer histories or may need to talk. A respectful and reassuring approach to caring for women over age 50 can help ensure that they continue to seek health care. Reminding the woman about her overdue examination, reassuring the woman that she has a good practitioner, and encouraging conversation about the death of her husband and her own death are not the best approaches with women in this age group. PTS: 1 DIF: Cognitive Level: Application OBJ: Client Needs: Psychosocial Integrity TOP: Nursing Process: Planning REF: 75

13. During a health history interview, a woman states that she thinks that she has bumps on her labia. She also states that she is not sure how to check herself. The correct response would be to: a Reassure the woman that the examination will not reveal any problems. . b Explain the process of vulvar self-examination to the woman and reassure her . that she should become familiar with normal and abnormal findings during the examination. c Reassure the woman that bumps can be treated. . d Reassure her that most women have bumps on their labia. . ANS: B During the assessment and evaluation the responsibility for self-care, health promotion, and enhancement of wellness is emphasized. The pelvic examination provides a good opportunity for the practitioner to emphasize the need for regular vulvar selfexamination. Providing reassurance to the woman concerning the bumps would not be an accurate response. PTS: 1 DIF: Cognitive Level: Application REF: 81, 82 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Assessment

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Test Bank

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14. A woman arrives at the clinic for her annual examination. She tells the nurse that she thinks she has a vaginal infection and she has been using an over-the-counter cream for the past 2 days to treat it. The nurses initial response should be to: a Inform the woman that vaginal creams may interfere with the Papanicolaou (Pap) . test for which she is scheduled. b Reassure the woman that using vaginal cream is not a problem for the . examination. c Ask the woman to describe the symptoms that indicate to her that she has a . vaginal infection. d Ask the woman to reschedule the appointment for the examination. . ANS: C An important element of the history and physical examination is the clients description of any symptoms she may be experiencing. Although vaginal creams may interfere with the Pap test, the best response is for the nurse to inquire about the symptoms the client is experiencing. Women should not douche, use vaginal medications, or have sexual intercourse for 24 to 48 hours before obtaining a Pap test. Although the woman may need to reschedule a visit for her Pap test, her current symptoms should still be addressed. PTS: 1 DIF: Cognitive Level: Application REF: 78 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Assessment 15. The transition phase during which ovarian function and hormone production decline is called: a The climacteric. c Menopause. . . b Menarche. d Puberty. . . ANS: A The climacteric is a transitional phase during which ovarian function and hormone production decline. Menarche is the term that denotes the first menstruation. Menopause refers only to the last menstrual period. Puberty is a broad term that denotes the entire transitional stage between childhood and sexual maturity. PTS: 1 DIF: Cognitive Level: Knowledge REF: 74 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Assessment 16. Which statement would indicate that the client requires additional instruction about breast self-examination? a Yellow discharge from my nipple is normal if Im having my period. . b I should check my breasts at the same time each month, like after my period.

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8 . c I should also feel in my armpit area while performing my breast examination. . d I should check each breast in a set way, such as in a circular motion. . ANS: A Discharge from the nipples requires further examination from a health care provider. I should check my breasts at the same time each month, like after my period, I should also feel in my armpit area while performing my breast examination, and I should check each breast in a set way, such as in a circular motion all indicate successful learning. PTS: 1 DIF: Cognitive Level: Analysis OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 71

17. A 20-year-old client calls the clinic to report that she has found a lump in her breast. The nurses best response is: a Dont worry about it. Im sure its nothing. . b Wear a tight bra, and it should shrink. . c Many women have benign lumps and bumps in their breasts. However, to make . sure that its benign, you should come in for an examination by your physician. d Check it again in 1 month and call me back if its still there. . ANS: C Try to ease the clients fear, but provide a time for a thorough evaluation of the lump because it may indicate abnormal changes in the breast. Discrediting the clients findings may discourage her from continuing with breast self-examination. Wearing a tight bra may irritate the skin and will not cause the lump to shrink. Delaying treatment may allow proliferation of abnormal cells. PTS: 1 DIF: Cognitive Level: Analysis REF: 79 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Assessment 18. The female reproductive organ(s) responsible for cyclic menstruation is/are the: a Uterus. c Vaginal vestibule. . . b Ovaries. d Urethra. . .

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Test Bank

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ANS: A The uterus is responsible for cyclic menstruation. It also houses and nourishes the fertilized ovum and the fetus. The ovaries are responsible for ovulation and production of estrogen; the uterus is responsible for cyclic menstruation. The vaginal vestibule is an external organ that has openings to the urethra and vagina; the uterus is responsible for cyclic menstruation. The urethra is not a reproductive organ, although it is found in the area; the uterus is responsible for cyclic menstruation. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 66

19. The body part that both protects the pelvic structures and accommodates the growing fetus during pregnancy is the: a Perineum. c Vaginal vestibule. . . b Bony pelvis. d Fourchette. . . ANS: B The bony pelvis protects and accommodates the growing fetus. The perineum covers the pelvic structures; the bony pelvis protects and accommodates the growing fetus. The vaginal vestibule contains openings to the urethra and vagina; the bony pelvis protects and accommodates the growing fetus. The fourchette is formed by the labia minor; the bony pelvis protects and accommodates the growing fetus. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 68

20. A fully matured endometrium that has reached the thickness of heavy, soft velvet describes the _____ phase of the endometrial cycle. a Menstrual c Secretory . . b Proliferative d Ischemic . . ANS: C

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10 The secretory phase extends from the day of ovulation to approximately 3 days before the next menstrual cycle. During this phase the endometrium becomes fully mature. During the menstrual phase the endometrium is being shed; the endometrium is fully mature again during the secretory phase. The proliferative phase is a period of rapid growth, but the endometrium becomes fully mature again during the secretory phase. During the ischemic phase the blood supply is blocked, and necrosis develops. The endometrium is fully mature during the secretory phase. PTS: 1 DIF: Cognitive Level: Comprehension OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 73

21. The stimulated release of gonadotropin-releasing hormone and follicle-stimulating hormone is part of the: a Menstrual cycle c Ovarian cycle . . b Endometrial cycle d Hypothalamic-pituitary cycle . . ANS: D The menstrual, endometrial, and ovarian cycles are interconnected. However, the cyclic release of hormones is the function of the hypothalamus and pituitary glands. PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 73

22. Certain fatty acids classified as hormones that are found in many body tissues and that have roles in many reproductive functions are known as: a Gonadotropin-releasing hormone (GnRH). . b Prostaglandins (PGs). . c Follicle-stimulating hormone (FSH). . d Luteinizing hormone (LH). . ANS: B PGs affect smooth muscle contraction and changes in the cervix. GnRH, FSH, and LH are part of the hypothalamic-pituitary cycle, which responds to the rise and fall of estrogen and progesterone. PTS: 1 DIF: Cognitive Level: Knowledge REF: 73

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Test Bank OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment 23. Which statement about female sexual response is NOT accurate? a Women and men are more alike than different in their physiologic response to . sexual arousal and orgasm. b Vasocongestion is the congestion of blood vessels. . c The orgasmic phase is the final state of the sexual response cycle. . d Facial grimaces and spasms of hands and feet are often part of arousal. .

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ANS: C The final state of the sexual response cycle is the resolution phase after orgasm. Men and women are surprisingly alike. Vasocongestion causes vaginal lubrication and engorgement of the genitals. Arousal is characterized by increased muscular tension (myotonia). PTS: 1 DIF: Cognitive Level: Knowledge OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Assessment REF: 74

24. As part of their participation in the gynecologic portion of the physical examination, nurses should: a Take a firm approach that encourages the client to facilitate the examination by . following the physicians instructions exactly. b Explain the procedure as it unfolds and continue to question the client to get . information in a timely manner. c Take the opportunity to explain that the trendy vulvar self-examination is only for . women at risk for cancer. d Help the woman relax through proper placement of her hands and proper . breathing during the examination. ANS: D Breathing techniques are important relaxation techniques that can help the client during the examination. The nurse should encourage the client to participate in an active partnership with the care provider. Explanations during the procedure are fine, but many women are uncomfortable answering questions in the exposed and awkward position of the examination. Vulvar self-examination on a regular basis should be encouraged and taught during the examination. PTS: 1 DIF: Cognitive Level: Application OBJ: Client Needs: Safe and Effective Care Environment REF: 80

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12 TOP: Nursing Process: Implementation 25. The microscopic examination of scrapings from the cervix, endocervix, or other mucous membranes to detect premalignant or malignant cells is called: a Bimanual palpation. c A Papanicolaou (Pap) test. . . b Rectovaginal palpation. d A four As procedure. . . ANS: C The Pap test is a microscopic examination for cancer that should be performed regularly, depending on the clients age. Bimanual palpation is a physical examination of the vagina. Rectovaginal palpation is a physical examination performed through the rectum. The four As is an intervention procedure to help a client stop smoking. PTS: 1 DIF: Cognitive Level: Knowledge REF: 83 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Implementation 26. As a girl progresses through development, she may be at risk for a number of age-related conditions. While preparing a 21-year-old client for her first adult physical examination and Papanicolaou (Pap) test, the nurse is aware of excessiveness shyness. The young woman states that she will not remove her bra because, There is something wrong with my breasts; one is way bigger. What is the best response by the nurse in this situation? a Please reschedule your appointment until you are more prepared. . b It is okay; the provider will not do a breast examination. . c I will explain normal growth and breast development to you. . d That is unfortunate; this must be very stressful for you. . ANS: C

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Test Bank

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During adolescence one breast may grow faster than the other. Discussion regarding this aspect of growth and development with the client will reassure her that there may be nothing wrong with her breasts. Female teenagers usually enter the health system for screening (Pap tests begin at age 21 or 3 years after first sexual activity). Situations such as these can produce great stress for the teenager, and the nurse and health care provider should treat her carefully. Asking her to reschedule will likely result in the clients not returning for her appointment at all. A breast examination at her age is part of the complete physical examination. Young women should be taught about normal breast development and begin doing breast self-examinations. This response is inappropriate. Although this shows empathy on the part of the nurse and acknowledges the client's stress, it will not correct the clients deficient knowledge related to normal growth and development. PTS: 1 DIF: Cognitive Level: Application OBJ: Client Needs: Health Promotion and Maintenance TOP: Nursing Process: Diagnosis TRUE/FALSE 1. Diethylstilbestrol (DES) was a drug commonly used to prevent miscarriage and premature birth between 1938 and 1971. Most nurses who provide gynecologic care are aware of the increased risk of adenocarcinoma to the vagina and cervix for the daughters of women who used DES. Fortunately there were no known side effects to their sons. ANS: F Sons of women who took DES have an increased risk of noncancerous epididymal cysts. Grandsons of these women are 20 times more likely to have hypospadias. PTS: 1 DIF: Cognitive Level: Application REF: 83 OBJ: Client Needs: Physiologic Integrity TOP: Nursing Process: Planning REF: 70

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