NR-304 Health Assessment II - Set 5 - Part 1

Correct Answer: The bleeding arises above the dentate line.

Tissue above the dentate line carries autonomic innervation and is relatively insensitive to pain, so an internal hemorrhoid bleeds briskly without hurting. Bright red painless bleeding after defecation is the cardinal sign of internal hemorrhoids. Option b is incorrect because tissue distal to the dentate line has somatic sensory innervation and is exquisitely pain sensitive. A lesion arising there, such as a thrombosed external hemorrhoid, presents with pain rather than silent bleeding. Option c is incorrect because sensory nerves are certainly present; the canal below the dentate line is among the most pain sensitive areas of the body. Only the rectum above that line is relatively insensitive to cutting. Option d is incorrect because rectal mucosa is richly vascular, which is precisely why hemorrhoidal tissue bleeds so freely. Hemorrhoids are engorged vascular cushions of arterioles, venules and connective tissue rather than avascular folds.

Correct Answer: Obtain a specimen of the drainage for testing

Skene glands normally produce no visible discharge, so purulent material from a paraurethral duct signals infection, classically gonococcal. The nurse collects a specimen for culture or nucleic acid testing and reports the finding to the provider. Option a is incorrect because healthy paraurethral glands release only a small amount of clear mucus that is not visible on examination. Charting purulent drainage as expected would leave a treatable infection undetected. Option b is incorrect because lubricating mucus during intercourse is secreted by the Bartholin glands near the introitus, not by the paraurethral ducts. Reassurance also ignores pus, which is never a physiologic secretion. Option d is incorrect because heat does not treat a sexually transmitted urethral infection, and a week of delay allows organisms to ascend. Absence of dysuria does not exclude gonorrhea, which is often silent.

Correct Answer: A narrow Pederson speculum with generous water-based lubricant

Atrophic tissue and a narrowed introitus call for the smallest instrument that will show the cervix. The straight narrow Pederson blades fit where a wide curved Graves would cause pain and can tear friable mucosa. Option b is incorrect because warming the blades is correct technique but does not fix the size problem. A large Graves blade cannot be introduced comfortably through an atrophic introitus no matter what its temperature. Option c is incorrect because the wide curved Graves design suits the parous adult vault, and locking the blades before insertion is unsafe. Blades are opened only after they are fully advanced past the introitus. Option d is incorrect because omitting lubricant in dry atrophic tissue guarantees discomfort and bleeding. A small amount of water or water-based gel is used even when cytology is planned, since only excess gel degrades a specimen.

Correct Answer: Vitamin C may cause a falsely negative result.

Vitamin C above two hundred fifty milligrams daily blocks the oxidation reaction the guaiac card depends on, so the card can fail to turn positive even when blood is present. It is avoided for several days before testing. Option a is incorrect because the guaiac card detects the peroxidase activity of haem and reacts to animal haem as well. Red meat is avoided for about three days because it causes false positives. Option b is incorrect because ascorbic acid is an antioxidant and pushes the result toward a false negative rather than a false positive. Blood may be present in the stool yet go undetected. Option c is incorrect because nonsteroidal drugs such as ibuprofen and naproxen are stopped for about seven days beforehand. They can cause gastric bleeding, which shows on the card as a false positive.

Correct Answer: Continue nursing on demand from that breast

Mastitis begins with milk stasis, so keeping milk moving is the treatment. On-demand feeding from the affected breast is safe for the infant, and rest, fluids and anti-inflammatory analgesia complete supportive care. Option b is incorrect because stopping feeds on that side worsens the stasis that started the inflammation. If direct feeding hurts too much, the client expresses or pumps to keep the breast drained. Option c is incorrect because weaning is never the response to mastitis and the milk remains safe for the baby throughout. Abrupt weaning leaves the breast engorged and raises the risk of abscess. Option d is incorrect because binding compresses the breast and blocks drainage, the opposite of what this client needs. Tight garments are listed among the causes of stasis rather than among its remedies.

Correct Answer: Standing and leaning forward across the table.

Standing and leaning forward across the table is the preferred position for prostate palpation because it flattens the posterior surface of the gland against the examining finger and makes the upper border easier to reach. Option a is incorrect because the left lateral Sims position is the general default and the best tolerated choice for frail or mobility limited clients, but it does not present the prostate as favourably. Option b is incorrect because lithotomy is used chiefly for women when the rectal examination follows the vaginal examination or when a rectovaginal examination is performed. It offers no advantage for palpating a male gland. Option d is incorrect because knee-chest and prone jackknife positions are reserved for anoscopy and proctologic procedures. They are poorly tolerated during routine assessment and are not chosen simply to reach the prostate.

Correct Answer: Stage four, a secondary areolar mound

Tanner stage four is defined by elevation of the areola and nipple above the breast contour, creating the secondary mound often described as a double scoop. The mound recedes again at stage five. Option b is incorrect because stage two is the breast bud, a small amount of tissue palpable only under the areola with early widening of the areola. No secondary mound exists that early. Option c is incorrect because stage three has breast tissue extending beyond the areolar border, with breast and areola enlarging together and no separate areolar contour. The projecting mound described belongs to a later stage. Option d is incorrect because stage five is the adult form, in which the raised areolar mound settles back into a single smooth breast contour. Persistence of the mound means maturation is not yet complete.

Correct Answer: Serous fluid is present within the scrotum

Only clear fluid transmits light, so a red glow signals serous fluid such as a hydrocele or spermatocele. Normal contents, solid tumors and bowel-filled hernias are all tissue and block the beam. Option a is incorrect because a hernia in an adult carries bowel, which is tissue and stops the light. Absence of a glow, not its presence, is what suggests herniated intestine in the sac. Option b is incorrect because normal scrotal contents do not transmit light at all. A glow therefore always represents an abnormal fluid collection and calls for further evaluation rather than reassurance. Option c is incorrect because a testicular tumor is solid and opaque. Light stops at the mass, so a tumor is suspected when swelling stays dark, and imaging is then needed to confirm it.

Correct Answer: Uterus anteverted, smooth, firm, mobile and non-tender

Most uteri are anteverted and anteflexed, tipping forward over the bladder. The bimanual examination characterizes size, contour, consistency, mobility, position and tenderness, and the expected organ is smooth, firm, freely mobile and painless. Option b is incorrect because retroversion tips the uterus back toward the sacrum, which contradicts the forward position described. A uterus fixed in place suggests adhesions, endometriosis or malignancy rather than a normal variant. Option c is incorrect because an enlarged uterus with an irregular contour is the classic bimanual signature of fibroids. Irregularity is the discriminator, and a normal organ is pear-shaped with an even surface. Option d is incorrect because a soft, globular, enlarged uterus points toward pregnancy and calls for dating the last menstrual period and testing. Midposition also fails to describe an organ clearly tipped anteriorly.

Correct Answer: Varicocele of the pampiniform venous plexus

Dilated veins of the pampiniform plexus produce the classic bag of worms, felt above and behind the testis. Gravity empties them when the man lies flat and refills them when he stands again. Option a is incorrect because a hydrocele surrounds the testis with serous fluid, feels smooth and fluctuant, glows red on transillumination, and does not empty with a change of position. Option b is incorrect because a spermatocele is a discrete round cyst that stays the same size whatever the posture. It feels almost like a third testis and transmits light, unlike a nest of veins. Option d is incorrect because a scrotal hernia is soft and mushy but the examining fingers cannot reach above it, since the mass stays continuous with the abdomen through the inguinal canal.

Correct Answer: Report the finding promptly and arrange referral.

A firm or hard mass with an irregular shape or rolled edges may signify carcinoma, and any mass found on rectal examination must be reported promptly and referred for further evaluation. Option b is incorrect because charting the finding without escalating it leaves a possible malignancy unaddressed. Documentation is necessary, yet it is the referral that changes what happens to this client next. Option c is incorrect because delaying evaluation by a month allows a potentially curable lesion to advance. Early colorectal disease is commonly silent, so the absence of symptoms offers no reassurance at all. Option d is incorrect because telling a client a rectal mass is harmless is untrue and may stop him pursuing the workup. Honest information about the need for further examination is what he requires.

Correct Answer: Chart that reflexes were not assessed

When the maneuver cannot be added, the charting must shrink to match what was done. Reflexes not assessed is short, true and tells the next reader exactly what still needs doing, which a blank line does not. Option a is incorrect because an empty space is read as normal by whoever comes next, so it misleads without ever making a claim. Silence in a record is not the same as honesty. Option b is incorrect because a presumed value is still a fabricated measurement. If this client were hyporeflexic, the false baseline would hide a real change when the next nurse compares findings hours later. Option d is incorrect because relocating an untrue sentence to a different row leaves it untrue. Reflexes belong under neurological in this form anyway, so the row was never the difficulty being raised.

Correct Answer: Melena from bleeding proximal to the ligament of Treitz.

Black, tarry, sticky and foul smelling stool is melena, produced when hemoglobin is degraded by gastric acid and bacteria during transit. It indicates bleeding above the ligament of Treitz, commonly peptic ulcer disease. Option a is incorrect because hematochezia is the passage of bright red or maroon blood that has not been digested. Its source lies in the colon, rectum or anus rather than the upper tract. Option c is incorrect because absent bile pigment turns stool gray tan or clay coloured, not black. That pattern accompanies obstructive jaundice or hepatitis, and this client has neither jaundice nor pale stool. Option d is incorrect because excess fecal fat produces pale, yellow, greasy, frothy stool that is difficult to flush. Steatorrhoea reflects malabsorption of fat, which does not darken stool or make it tarry.

Correct Answer: It flattens and medially displaces breast tissue

The pad and the raised arm spread a thick mobile gland into a thin layer over the chest wall, flattening it and displacing it medially, so that any significant lump feels far more distinct. Option a is incorrect because muscle relaxation is not the aim and the breast contains essentially no muscle of its own. Pectoral contraction is used later, with hands on hips, to test fixation. Option b is incorrect because the axilla is examined with the client seated and the forearm supported, which relaxes the shoulder girdle and opens the apex. Supine positioning serves the breast tissue instead. Option c is incorrect because comfort is not the purpose of the pad, and all three depths of pressure are still applied at every point. Discomfort is minimized by technique, not by positioning.

Correct Answer: We can weigh the benefits and harms, then you decide.

For men aged fifty five to sixty nine, the decision to have periodic prostate specific antigen screening is an individual one made after discussing benefits and harms, incorporating the client's own values and preferences. Option b is incorrect because routine annual testing for all older men is no longer recommended by current guidance. Screening is offered through shared decision making, and clinicians should not screen men who express no preference for it. Option c is incorrect because the age threshold works the other way: screening is recommended against at seventy and older, while men in their late fifties and sixties are the group offered the discussion. Option d is incorrect because digital rectal examination is not recommended as a screening modality, since evidence of benefit is lacking. It remains part of evaluating a man who already reports symptoms.

Correct Answer: Fit his hearing aids and repeat the questions

Sensory deficits must be corrected before cognition is judged. A man who cannot hear the questions over a loud television is not necessarily disoriented, and charting him as confused creates a clinical error with lasting consequences. Option a is incorrect because documenting disorientation from an untested hearing channel records a conclusion the data cannot support. That label follows a client through every later handover and shapes how staff interpret him. Option b is incorrect because a screening instrument run under the same noisy conditions will produce the same false result. Fixing the listening environment costs seconds and must come before any formal cognitive testing. Option d is incorrect because collateral history is valuable but comes second, and it cannot substitute for repeating the questions under fair conditions. The immediate obstacle sits on the bedside table, not with the family.

Correct Answer: Notify the provider urgently for emergency foreskin reduction

The retracted foreskin acts as a tourniquet, and glans swelling tightens it further, risking vascular compromise and necrosis. Paraphimosis is a urologic emergency requiring immediate reduction, with a dorsal slit if manual compression fails. Option a is incorrect because the constricting ring worsens minute by minute as edema builds. Waiting for the next round allows ischemia to progress toward tissue death in an entirely preventable situation. Option c is incorrect because heat increases swelling in already congested tissue and extra fluids do nothing for a mechanical constriction. Cool compression to shrink the glans, not warmth, precedes attempts at reduction. Option d is incorrect because removing the catheter leaves the underlying entrapment untouched. The foreskin must always be returned to its normal position after any procedure, and here it needs urgent help to get there.

Correct Answer: Three semilunar folds crossing half the rectal circumference.

The valves of Houston are three semilunar transverse folds, each crossing about half the circumference of the rectal lumen. They are shelves of mucosa that must be negotiated during sigmoidoscopy, and a lesion can hide behind one. Option a is incorrect because there are three valves, not four, and each crosses only about half the lumen rather than encircling it completely. They obstruct nothing; they are simply transverse shelves of mucosa. Option b is incorrect because the folds are semilunar and transverse rather than longitudinal, and there are three of them. Longitudinal folds of mucosa running down from the rectum are the anal columns of Morgagni. Option c is incorrect because vertical mucosal columns describe the anal columns, which end at the anorectal junction rather than at the anus. Houston valves lie higher, crossing the rectal lumen as transverse shelves.

Correct Answer: Continue the examination as an expected finding

The normal testis is oval, firm, rubbery, smooth, freely movable, and slightly sensitive to moderate compression. Mild tenderness is expected rather than abnormal, so the nurse simply proceeds with the remainder of the examination. Option a is incorrect because summoning a second examiner to repeat a normal finding subjects the client to an unnecessary intimate examination and signals alarm where none exists. Expected tenderness never justifies duplicating the assessment. Option b is incorrect because ultrasound is reserved for a palpable nodule, a mass that cannot be characterized, or swelling that hides the testis. Nothing described here meets any of those imaging criteria. Option d is incorrect because no mass was found. The testes are smooth and uniformly firm with no nodule or hardened section, and charting a suspicious finding would place inaccurate information in the record.

Correct Answer: Warming the specula and adjusting the examination light

Warming instruments and setting up equipment and lighting are standard, non-assessment tasks within the assistant's scope. Explaining the procedure, eliciting a history of painful examinations, obtaining consent and documenting remain nursing responsibilities that require judgment. Option a is incorrect because teaching is a nursing function, and the explanation belongs earlier, while the client is still dressed and seated at eye level rather than draped and supine. Option c is incorrect because asking about prior traumatic or painful examinations is history taking, which changes how the examination proceeds. Data collection that guides clinical decisions cannot be handed to unlicensed personnel. Option d is incorrect because consent must be obtained by the clinician performing the procedure, and charting is a licensed responsibility tied to accountability for the record. An assistant may be present but does not document it.