NCM 102: ASSESSMENT EXAM

REPRODUCTIVE SYSTEM – (STD Review)

1. The thick, dense connective tissue capsule that covers each testis is called the:
A. Tunica albuguinea
B. Tunica vaginalis
C. Tunica vasculosa
D. Seminiferous tubule

2. Which of the following involves rhythmic contractions that create peristaltic waves to help move
spermatozoa through the seminiferous tubules?
A. Sertoli (sustentacular) cells
B. Leydig (interstitial) cells
C. Myoid cells (tunica propria)
D. Spermatogenic cells

3. Which of the following is NOT true?

A. The seminal vesicles secrete viscous material containing fructose, which can be used to
identify specimens as ejaculate
B. The peripheral zone is the most common site of prostatic carcinomas
C. The transitional zone is the side of benign prostatic hyperplasia in older men
D. The central zone of the prostate is easily palpable by digital rectal exam

4. A 16-year-old female comes to the physician because of an increased vaginal discharge. She
developed this symptom 2 days ago. She also complains of dysuria. She is sexually active with
one partner and uses condoms intermittently. Examination reveals some erythema of the cervix
but is otherwise unremarkable. A urine culture is sent which comes back negative. Sexually
transmitted disease testing is performed and the patient is found to have gonorrhea. While
treating this patient's gonorrhea infection, treatment must also be given for which of the
following?

A. Bacterial vaginosis

B. Chlamydia

C. Herpes

D. Syphilis

Rationale: This patient has a gonorrhea infection. Gonorrhea is one of the most prevalent sexually
transmitted diseases (STDs) in the United States. It is more common in patients of lower socioeconomic
status, patients with multiple sexual partners, and in urban settings. The causative organism is N.
gonorrhoeae, a gram-negative aerobic diplococcus. Up to 80% of women that are infected with the
organism will have no symptoms at all or only vague symptoms. Symptoms that are frequently noted are
vaginal discharge, postcoital spotting, and urinary symptoms if the urethra is involved. Examination may
reveal a cervicitis, although this is not always present. A patient found to have gonorrhea should be
treated with intramuscular ceftriaxone or oral cefixime, ofloxacin, or ciprofloxacin. These medications
will effectively eradicate the gonococcus. However, because Chlamydia trachomatis can be isolated in

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NCM 102: ASSESSMENT EXAM

up to 50% of women with gonorrhea and because women treated for gonorrhea only may soon go on to
develop Chlamydia or pelvic inflammatory disease (PID), any woman receiving treatment for gonorrhea
should also be treated for Chlamydia. Treatment of Chlamydia is with azithromycin or doxycycline. It is
also essential that this patient's partner be treated as well. When treating a patient for gonorrhea, there
is no need to treat the patient with metronidazole to treat bacterial vaginosis (choice A) as well, unless
there is evidence of a bacterial vaginosis . Herpes (choice C) often presents as painful vesicles and ulcers.
Patients with gonorrhea do not need to be treated for herpes as well, unless there is evidence for
herpes infection. Patients with gonorrhea are at increased risk of having other sexually transmitted
diseases, including syphilis (choice D). It would be prudent to check this patient for syphilis with a blood
test. However, in the absence of a positive syphilis test, patients with gonorrhea do not need to be
treated for syphilis.

5. A 31-year-old woman comes to the physician for follow-up after an abnormal Pap test and
cervical biopsy. The patient's Pap test showed a high-grade squamous intraepithelial lesion
(HGSIL). This was followed by colposcopy and biopsy of the cervix. The biopsy specimen also
demonstrated HGSIL. The patient was counseled to undergo a loop electrosurgical excision
procedure (LEEP). Which of the following represents the potential long-term complications from
this procedure?

A. Abscess and chronic pelvic inflammatory disease

B. Cervical incompetence and cervical stenosis

C. Constipation and fecal incontinence

D. Hernia and intraperitoneal adhesions

Rationale: The loop electrosurgical excision procedure (LEEP) is relatively simple and can be performed
in the outpatient setting with local anesthesia. The procedure involves using a wire loop to excise lesions
of the transformation zone. A benefit of LEEP, along with its ease of performance, is that it provides
tissue that can be examined histologically. The most appropriate candidates for LEEP are women with
high-grade squamous intraepithelial lesions (HGSIL). The immediate risks of LEEP are bleeding and
infection. The possible long-term risks include cervical incompetence and cervical stenosis. These may
seem like exact opposites, but LEEP can lead to both of them because, to a certain extent, it injures the
cervix. If the body's response to this injury is with "too much" scarring, then cervical stenosis can result.
If too much of the cervix is injured, the cervix may be too weakened to carry a pregnancy to term, and
cervical incompetence may result. Abscess and chronic pelvic inflammatory disease (choice A) are not
known to be long-term complications of the procedure. Constipation and fecal incontinence (choice C)
should not be caused by LEEP. LEEP involves the distal portion of the cervix and should not involve the
intestines or rectum at all. Hernia and intraperitoneal adhesions (choice D) should not result from LEEP.
The procedure does not involve entry into the peritoneal cavity; therefore, there should be no risk of
hernia or intraperitoneal adhesions.

6. A 12-year-old female comes to the physician because of a vaginal discharge. The discharge
started about 2 months ago and is whitish in color. There is no odor. The patient has no
complaints of itching, burning, or pain. The patient started breast development at 9 years of age
and her pubertal development has proceeded normally to this point. She has not had her first

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NCM 102: ASSESSMENT EXAM

menses and she is not sexually active. She has no medical problems. Examination is normal for a
12-year-old female. Microscopic examination of the discharge shows no evidence of
pseudohyphae, clue cells, or trichomonads. Which of the following is the most likely diagnosis?
A. Bacterial vaginosis
B. Candida vulvovaginitis
C. Physiologic leukorrhea
D. Syphilis

Rationale: Physiologic leukorrhea can be seen during 2 different periods of childhood. Some female
neonates develop a physiologic leukorrhea shortly after birth as maternal circulating estrogens stimulate
the newborn's endocervical glands and vaginal epithelium. The discharge in these neonates is often gray
and gelatinous. Physiologic leukorrhea can also be seen during the months preceding menarche. During
this time, rising estrogen levels lead to a whitish discharge not associated with any symptoms of
irritation. This patient has a whitish discharge, no other symptoms, and she has had normal pubertal
development up to this point. The discharge itself has no characteristics of infection. Therefore,
physiologic leukorrhea is the most likely diagnosis. Bacterial vaginosis (choice A) is not the most likely
diagnosis in this patient because the discharge is not malodorous and there are no clue cells seen on
microscopic examination of the discharge. Candida vulvovaginitis (choice B) is not the most likely
diagnosis because the discharge is not thick and white (or "cottage-cheese"-like) and the patient has no
irritative symptomatology. Syphilis (choice D) most often presents with a painless ulcer (called a
chancre) or is found with serologic testing. A nonmalodorous, whitish vaginal discharge in a 12-year-old
female who is not sexually active is almost certainly not evidence of syphilis.

7. A 29-year-old woman comes to the physician for follow-up of a right breast lump. The patient
first noticed the lump 4 months ago. It was aspirated at that time, and cytology was negative,
but the cyst recurred about 1 month later. The cyst was re-aspirated 2 months ago and, again,
the cytology was negative. The lump has recurred. Examination reveals a mass at 10 o'clock,
approximately 4 cm from the areola. Ultrasound demonstrates a cystic lesion. Which of the
following is the most appropriate next step in management?
A. Mammography in 1 year
B. Ultrasound in 1 year
C. Tamoxifen therapy
D. Open biopsy

Rationale: Breast lumps are a common complaint in women. Many of these masses are benign
processes. Benign conditions of the breast include fibrocystic disease, fibroadenomas, galactoceles,
abscesses, and necrosis. It is appropriate to aspirate a palpable macrocyst in the breast; the fluid should
be placed on a slide and sent for cytologic evaluation. If the cytology is negative, no further treatment is
needed. Some would argue that if the cyst recurs, it may be aspirated again. However, when a lesion
recurs twice, as has occurred in this patient, open biopsy is warranted. To wait to perform
mammography in 1 year (choice A) or ultrasound in 1 year (choice B) would be incorrect management.
First, if a malignancy is present, waiting another year will allow progression of the cancer. Second, the
mammogram is not definitive. Imaging can contribute information to the workup of a breast mass, but

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NCM 102: ASSESSMENT EXAM

the definitive diagnosis rests on histologic evaluation. Tamoxifen therapy (choice C) is used to both
prevent and treat breast cancer. However, this patient does not yet have a diagnosis. She has a cystic
mass that has been aspirated twice and has recurred twice. She therefore requires a biopsy to establish
a diagnosis prior to the institution of any treatment.

8. A 43-year-old African American woman comes to the physician because of her concern
regarding breast cancer. She has no complaints at present. In past years, she had noted bilateral
breast tenderness prior to her menses, but this has since abated. She has no medical problems.
She had two cesarean deliveries, but no other surgeries. She takes a low-dose oral contraceptive
pill and has no known drug allergies. She does not smoke, and her family history is negative.
Physical examination is normal. All mammograms (yearly since age 40) have been negative to
date. She wants to know whether BRCA1 and BRCA2 screening would be appropriate for her.
Which of the following is the correct response?
A. BRCA1 and 2 screening is not recommended
B. BRCA1 and 2 screening should be performed after age 50
C. BRCA1 and 2 screening should be performed if breast pain recurs
D. BRCA1 screening is recommended

Rationale: Of the cases of breast cancer that are heritable, approximately 80% are due to mutations in
BRCA1 and BRCA2. BRCA1 is associated with high risk for breast and ovarian cancer. BRCA2 is associated
with a high risk of female and male breast cancer. On the basis of our current understanding, however,
less than 10% of all breast cancer cases can be considered to be heritable. Therefore, the total number
of breast cancer cases associated with BRCA1 and BRCA2 mutations is a small percentage of the total
number of breast cancer cases. Furthermore, there are numerous mutations that can occur in the
BRCA1 and BRCA2 genes and can be related to an increased cancer risk. Some patients who have a
mutation associated with cancer will not go on to develop cancer. Other patients may have a strong
family history of breast cancer but no identifiable mutation. At present, therefore, screening of the
general population is not recommended. This patient has no family history and is not in a high-risk
group. Her prior breast tenderness was likely mastalgia related to the premenstrual phase. Therefore,
BRCA1 and 2 screening would not be recommended for this patient. To state that BRCA1 and 2
screening should be performed after age 50 (choice B) is incorrect. As noted above, given the limitations
of the testing for BRCA1 and 2 mutations, screening of the general population is not recommended. To
state that BRCA1 and 2 screening should be performed if breast pain recurs (choice C) is incorrect. This
patient does not need screening, not because her breast pain has resolved, but rather because BRCA1
and 2 screening is not appropriate for the general population at this time. As noted above, her breast
pain was likely cyclic mastalgia secondary to hormonal changes prior to menses.

9. A 40-year-old woman comes to the physician for an annual examination. She has no complaints.
She has menses every 28-30 days that last for 3 days. She has no intermenstrual bleeding. She
has asthma, for which she uses an occasional inhaler. She had a tubal ligation 10 years ago. She
has no known drug allergies. Examination is unremarkable, including a normal pelvic
examination. One of her friends was recently diagnosed with endometrial cancer, and the

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NCM 102: ASSESSMENT EXAM

patient wants to know when and if she needs to be screened for this. Which of the following is
the most appropriate response?

A. Screening for endometrial cancer is not cost effective or warranted

B. Screening is with endometrial biopsy and starts at age 40

C. Screening is with endometrial biopsy and starts at age 50

D. Screening is with ultrasound and starts at age 40

Rationale: Endometrial cancer is the most common gynecologic cancer in women older than 45. There
are tens of thousands of new cases every year in the U.S., and thousands of deaths from it yearly.
However, there is no effective screening test for endometrial cancer at this point. It is not cost-effective
to screen asymptomatic women for endometrial cancer. Occasionally, a Pap test will detect abnormal
endometrial cells, but it is not a proper screening tool for endometrial cancer. Patients with endometrial
hyperplasia or cancer often present with irregular uterine bleeding. Therefore, patients with irregular
uterine bleeding should be considered for endometrial biopsy or ultrasonic evaluation of the
endometrial cavity. This strategy may be modified for young patients, in whom the risk of endometrial
hyperplasia or cancer is limited. To state that screening is with endometrial biopsy and starts at age 40
(choice B) or age 50 (choice C) is incorrect. Endometrial biopsy can and should be used in certain
circumstances. For example, a woman with postmenopausal bleeding should undergo the procedure.
However, endometrial biopsy should not be used as a screening tool. To perform endometrial biopsies
on women with no indication other than screening would place these women at risk for bleeding,
infection, and uterine perforation, and would not be cost-effective. To state that screening is with
ultrasound and starts at age 40 (choice D) is incorrect. Pelvic ultrasound can be used to help diagnose
endometrial hyperplasia and endometrial cancer. For example, studies have shown that in
postmenopausal women, measurement of the endometrial stripe can be useful in helping to rule out
these conditions. However, pelvic ultrasound has not been shown to be cost-effective or warranted for
screening for endometrial cancer.

10. A 19-year-old female comes to the physician because she has not had a menstrual period. She
experienced normal breast development through puberty but has yet to have a period. She has
no other complaints. She has no medical problems. Examination shows the patient to be tall
with long arms and big hands. The breasts are normal-appearing except that the nipples are
immature and the areolae are pale. Pelvic examination shows scant pubic hair with a blind-
ended vaginal pouch. Which of the following is the most likely diagnosis?
A. Asherman syndrome
B. Kallmann syndrome
C. Polycystic ovarian syndrome
D. Testicular feminization syndrome

Rationale: This patient has a presentation and findings that are most consistent with androgen
insensitivity syndrome (also called testicular feminization syndrome). These patients are genotypically
male (46, XY) but phenotypically female because they have a defect that prevents normal androgen
receptor function. The androgen receptor gene is located on the X chromosome and various defects in

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NCM 102: ASSESSMENT EXAM

the gene (e.g., absence of the gene or abnormalities in the androgen binding domain of the receptor)
can lead to this syndrome. Patients with androgen insensitivity are amenorrheic and have no internal
female structures. Testes rather than ovaries are present. These patients also have minimal axillary and
pubic hair. They do experience abundant breast development at puberty, as testosterone is unable to
suppress the formation of breast tissues. These patients also tend to be very tall with big hands and feet
and long arms. Testes should be removed after pubertal development is completed, as many of these
patients will develop gonadal malignancies after puberty. Asherman syndrome (choice A) is amenorrhea
caused by intrauterine adhesions. These adhesions typically develop after curettage and infection of the
uterus. Kallmann syndrome (choice B) is amenorrhea caused by hypogonadotropic hypogonadism. It is
associated with anosmia, color blindness, and facial deformities. Patients have normal female
structures. Patients with polycystic ovarian syndrome (choice C) usually have the characteristics of
oligomenorrhea, hirsutism, infertility, and obesity. This patient has none of these characteristics.

11. A 53-year-old woman comes to the physician because of concerns regarding menopause. She
has a period almost every month, but her cycle is lengthening. She is worried because her
mother, her two older sisters, and practically all her aunts have osteoporosis. She does not want
to be on estrogen because she is concerned about cancer and thrombosis. Physical examination
is within normal limits. The patient is started on raloxifene. On this medication, which of the
following is this patient most likely to develop?
A. Breast cancer
B. Elevated cholesterol
C. Endometrial hyperplasia
D. Hot flashes

Rationale: Raloxifene is a medication that belongs to the class of drugs called selective estrogen receptor
modulators (SERMs). These drugs, of which the most widely known are raloxifene and tamoxifen, have
pro-estrogenic effects in some tissues and anti-estrogenic effects in other tissues. Raloxifene has been
approved by the U.S. Food and Drug Administration for the prevention of osteoporosis. This patient,
with her strong family history of osteoporosis, is a good candidate for prevention. However, although
raloxifene acts as an estrogen agonist in the bone, it appears to have no effect on hot flashes or to
actually cause hot flashes. Therefore, this perimenopausal patient is most likely to develop hot flashes
while on raloxifene. Although definitive proof is not available, it appears that raloxifene acts as an
estrogen antagonist in the breast. Therefore, this patient would not be most likely to develop breast
cancer (choice A) while on raloxifene. She would be more likely to develop hot flashes. Raloxifene
appears to lower cholesterol, especially LDL cholesterol, in patients. Therefore, elevated cholesterol
(choice B) would be less likely while on this medication. Raloxifene appears to act as an estrogen
antagonist at the level of the endometrium; therefore, endometrial hyperplasia (choice C) would be less
likely than hot flashes.

12. A 47-year-old woman comes to the physician for an annual examination. One year ago, she was
diagnosed with endometrial carcinoma and underwent a total abdominal hysterectomy and
bilateral salpingo-oophorectomy. She was found to have grade I, stage I, disease at that time.
Over the past year, she has developed severe hot flashes that occur throughout the day and

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NCM 102: ASSESSMENT EXAM

night and are worsening. She is also concerned because her mother and several of her aunts
have severe osteoporosis. She wonders whether she can take estrogen replacement therapy.
Which of the following is the most appropriate response?
A. Estrogen replacement therapy is absolutely contraindicated
B. Estrogen replacement therapy may be used, and there are no risks
C. Estrogen replacement therapy may be used, but there are risks
D. Estrogen replacement therapy will lead to breast cancer

Rationale: The issue of whether a patient who had endometrial carcinoma can be placed on estrogen
replacement therapy (ERT) is somewhat controversial. If the patient is completely free of tumor,
estrogen replacement therapy should not result in recurrence. And, in this patient's case, it would be
helpful for her hot flashes and osteoporosis. However, if an estrogen-dependent neoplasm is still
present somewhere in her body, ERT may result in an earlier recurrence. Stage I, grade I, endometrial
cancer is the lowest grade and lowest stage endometrial cancer. The risk of persistent disease is less
than 5%. Many gynecologic oncologists would feel comfortable giving ERT to this patient. However, the
patient must be fully informed regarding the benefits and risks of ERT. These risks include not only
earlier recurrence, but also the standard risks such as venous thrombosis. To state that estrogen
replacement therapy is absolutely contraindicated (choice A) is incorrect. As explained above, ERT may
be given to certain patients with a history of grade I, stage I, endometrial carcinoma. To state that
estrogen replacement therapy may be used and there are no risks (choice B) is not appropriate. Even in
women with no history of endometrial carcinoma, there are risks to ERT. The history of endometrial
carcinoma adds a further risk for this patient. To state that estrogen replacement therapy will lead to
breast cancer (choice D) is incorrect. There are a number of studies that show that ERT leads to
increased rates of breast cancer. There are also a number of studies that show no increased risk.
Therefore, to make the definitive statement that ERT will lead to breast cancer is incorrect.

13. A 14-year-old girl is referred to the physician for primary amenorrhea. She has never had a
menses but does note some cyclic abdominal pain that seems to occur each month. She has no
other medical problems and has never had surgery. She takes a multivitamin every day and has
no known drug allergies. A thorough evaluation of the patient, including imaging studies, reveals
that the patient has Mayer-Rokitansky-Kuster-Hauser syndrome. Which of the following is this
patient likely to require, given her condition?
A. Creation of a neovagina
B. Creation of breasts
C. Hormone replacement therapy
D. Intrauterine device

Rationale: Mayer-Rokitansky-Kuster-Hauser syndrome is the condition in which patients have müllerian

agenesis with congenital absence of the uterus and vagina. Müllerian agenesis occurs when there is
embryologic failure of the müllerian duct, with resulting anomalies in the female organs. Patients with
müllerian agenesis most often have a normal 46,XX karyotype and a normal female phenotype, and they
develop normal secondary sexual characteristics. Consequently, patients with this condition often
present in adolescence with [Link] medical issues arise for these patients, including
increased rates of skeletal and urinary tract abnormalities, infertility, and psychological issues. One of
the major issues that these patients face is the need to create a neovagina in order for the patient to

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NCM 102: ASSESSMENT EXAM

have a normal sex life. There are nonsurgical and surgical methods available to create neovaginas for
these patients. Patients with müllerian agenesis should be reassured that they will be able to have
normal sex lives with the creation of a neovagina

14. When assessing the adequacy of sperm for conception to occur, which of the following is the
most useful criterion?
A. Sperm count
B. Sperm motility
C. Sperm maturity
D. Semen volume

Rationale: Although all of the factors listed are important, sperm motility is the most significant criterion
when assessing male infertility. Sperm count, sperm maturity, and semen volume are all significant, but
they are not as significant sperm motility.
15. A couple who wants to conceive but has been unsuccessful during the last 2 years has
undergone many diagnostic procedures. When discussing the situation with the nurse, one
partner states, “We know several friends in our age group and all of them have their own child
already, Why can’t we have one?” Which of the following would be the most pertinent nursing
diagnosis for this couple?
A. Fear related to the unknown
B. Pain related to numerous procedures.
C. Ineffective family coping related to infertility.
D. Self-esteem disturbance related to infertility.
Rationale: Based on the partner’s statement, the couple is verbalizing feelings of inadequacy and
negative feelings about themselves and their capabilities. Thus, the nursing diagnosis of self-esteem
disturbance is most appropriate. Fear, pain, and ineffective family coping also may be present but as
secondary nursing diagnoses.

16. The nurse is teaching a group of college students about breast self-examination. A woman asks
for the best time to perform the monthly exam. What is the best reply by the nurse?
A. "The first of every month, because it is easiest to remember"
B. "Right after the period, when your breasts are less tender"
C. "Do the exam at the same time every month"
D. "Ovulation, or mid-cycle is the best time to detect changes"
Rationale: The best time for a breast self exam (BSE) is a week after a menstrual cycle, when the breasts
are no longer swollen and tender due to hormone elevation.

17. Which of the following is true of the endometrial proliferative phase?

A. Estrogen is increased and progesterone is increased
B. Estrogen is decreased and progesterone is decreased
C. Estrogen is increased and progesterone is decreased
D. Estrogen is decreased and progesterone is increased

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NCM 102: ASSESSMENT EXAM

PREPARED BY: TJM