The nurse is assessing the symmetry of the client's chest. The nurse recognizes that a client's symmetric expansion of the chest is best confirmed by:

Percussion of the posterior chest

Inspection of the shape and configuration of the chest wall

Placing the palmar surface of the fingers of one hand against the chest and having the client repeat "ninety nine"

Placing hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10

Answer and Explanation

The Correct Answer is D

A. Percussion of the posterior chest: Percussion helps assess the underlying structures of the chest but does not directly confirm symmetric chest expansion.

B. Inspection of the shape and configuration of the chest wall: Inspection is a crucial part of assessing chest symmetry. Any deformities, asymmetry, or abnormalities in the shape and configuration of the chest wall can be visually identified.

C. Placing the palmar surface of the fingers of one hand against the chest and having the client repeat "ninety-nine": This technique, known as tactile fremitus, involves feeling for vibrations or tremors while the client repeats a phrase. While it can provide information about underlying lung conditions, it's not primarily used to confirm symmetric chest expansion.

D. Placing hands sideways on the posterolateral chest wall with thumbs pointing together at the level of T9 or T10: This technique, known as chest expansion measurement, is used to assess symmetric chest expansion. Placing hands in this manner allows the nurse to feel for bilateral chest expansion during inspiration, ensuring that both sides of the chest expand symmetrically.

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Correct Answer is D

Explanation

A. A shiny, pearly white color tympanic membrane: This is a normal finding. A healthy tympanic membrane often appears shiny and pearly white.

B. The presence of cerumen: This is a normal finding. Cerumen, or earwax, is a natural substance that helps protect the ear canal.

C. The presence of a cone of light: This is a normal finding. The cone of light is a reflection of the otoscope light on the tympanic membrane and is a normal variation.

D. A yellow or amber color to the tympanic membrane: This is considered an abnormal finding. A yellow or amber coloration of the tympanic membrane can indicate the presence of fluid or infection behind the eardrum, which may be a sign of otitis media or other ear conditions.

A. The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. B. If she suspects that she is pregnant, then the woman should not perform a BSE until her baby is born. C. The best time to perform BSE is in the middle of the menstrual cycle. D. The woman needs to perform BSE only bimonthly unless she has fibrocystic breast tissue.

Correct Answer is A

Explanation

A. The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period:

This statement is correct. Performing BSE a few days after the menstrual period ensures that the breasts are less likely to be swollen or tender, which can make it easier to detect any unusual changes.

B. If she suspects that she is pregnant, then the woman should not perform a BSE until her baby is born:

This statement is incorrect. Pregnant women can still perform breast self-examinations. In fact, it's important for pregnant women to be aware of any changes in their breasts.

C. The best time to perform BSE is in the middle of the menstrual cycle:

This statement is not as accurate as the first choice. While it's true that performing BSE a few days after the menstrual period can be easier due to reduced breast tenderness, it doesn't necessarily mean the middle of the menstrual cycle for every woman. The timing can vary based on an individual's menstrual cycle.

D. The woman needs to perform BSE only bimonthly unless she has fibrocystic breast tissue:

This statement is incorrect. Regular monthly breast self-examinations are recommended for all women, regardless of whether they have fibrocystic breast tissue or not. Detecting changes early is crucial for breast health.

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The nurse is assessing the symmetry of the client's chest. The nurse recognizes that a client's symmetric expansion of the chest is best confirmed by:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse examines a client's auditory canal and tympanic membrane with an otoscope. The nurse recognizes that which of the following is considered an abnormal finding?

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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