Chapter 04 Assessment and Health Promotion

Chapter 04  Assessment and Health Promotion

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. Due to the effects of cyclic ovarian changes in the breast, when is the best time for breast self-examination (BSE)?
a.
Between 5 and 7 days after menses ceases
b.
Day 1 of the endometrial cycle
c.
Midmenstrual cycle
d.
Any time during a shower or bath

ANS: A
The physiologic alterations in breast size and activity reach their minimal level approximately 5 to 7 days after menstruation ceases. Therefore, BSE is best performed during this phase of the menstrual cycle. Day 1 of the endometrial cycle is too early to perform an accurate BSE. After the midmenstrual cycle, breasts are likely to become tender and increase in size, which is not the ideal time to perform BSE. Lying down after a shower or bath with a small towel under the shoulder of the side being examined is appropriate teaching for BSE. A secondary BSE may be performed while in the shower.

DIF: Cognitive Level: Understand REF: p. 63 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance

2. Individual irregularities in the ovarian (menstrual) cycle are most often caused by what?
a.
Variations in the follicular (preovulatory) phase
b.
Intact hypothalamic-pituitary feedback mechanism
c.
Functioning corpus luteum
d.
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 would be regular, not irregular. The luteal phase begins after ovulation. The corpus luteum is dependent 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.

DIF: Cognitive Level: Understand REF: pp. 66-67
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

3. How would the physiologic process of the sexual response best be characterized?
a.
Coitus, masturbation, and fantasy
b.
Myotonia and vasocongestion
c.
Erection and orgasm
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.

DIF: Cognitive Level: Knowledge REF: p. 68
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

4. Which action would be inappropriate for the nurse to perform before beginning the health history interview?
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.
d.
Tell the client her questions are irrelevant.

ANS: D
The woman should be assured that all of her questions are relevant and important. Beginning any client interaction with a smile is important and assists in putting the client at ease. If the nurse speaks in a relaxed manner, then the client will likely be more relaxed during the interview. The client’s comfort should always be ensured before beginning the interview.

DIF: Cognitive Level: Understand REF: pp. 78-79
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance

5. 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 replies, “I have special undergarments that I do not remove for religious reasons.” Which is the most appropriate response from the nurse?
a.
“You can’t have an examination without removing all your clothes.”
b.
“I’ll ask the physician to modify the examination.”
c.
“Tell me about your undergarments. I’ll explain the examination procedure, and then we can discuss how you can comfortably have your examination.”
d.
“I have no idea how we can accommodate your beliefs.”

ANS: C
Explaining the examination procedure reflects cultural competence by the nurse and shows respect for the woman’s religious practices. The nurse must respect the rich and unique qualities that cultural diversity brings to individuals. The examination can be modified to ensure that modesty is maintained. In recognizing the value of cultural differences, the nurse can modify the plan of care to meet the needs of each woman. Telling the client that her religious practices are different or strange is inappropriate and disrespectful to the client.

DIF: Cognitive Level: Apply REF: pp. 79-80 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity