The nurse is examining an adult client within normal weight limit. The nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse's best course of action?

Inform the client that his breast enlargement is benign, and normal for a man of his age

Explain that this condition may be the result of hormonal changes, and recommend that he see his physician.

Recommend that he alter his diet to include fewer fats and more lean proteins

Explain that gynecomastia in men is usually associated with prostate enlargement and recommend that he be thoroughly screened.

Answer and Explanation

The Correct Answer is B

A. Inform the client that his breast enlargement is benign, and normal for a man of his age:

This choice is not appropriate because while gynecomastia can be benign, it should not be assumed without a proper medical evaluation. Gynecomastia can have various causes, including hormonal imbalances or underlying medical conditions. It's crucial to identify the cause through a medical assessment.

B. Explain that this condition may be the result of hormonal changes, and recommend that he see his physician:

This is the correct choice. Gynecomastia can indeed be caused by hormonal changes, but it can also be due to medications, certain health conditions, or hormonal imbalances. Therefore, the nurse should recommend a medical evaluation to determine the underlying cause and appropriate management.

C. Recommend that he alter his diet to include fewer fats and more lean proteins:

This choice is not relevant to gynecomastia. Gynecomastia is not typically caused by dietary factors, so altering the diet would not be a suitable response to this situation.

D. Explain that gynecomastia in men is usually associated with prostate enlargement and recommend that he be thoroughly screened:

This choice is incorrect. Gynecomastia is not directly associated with prostate enlargement. While both conditions can occur in older men, they are distinct medical issues. Screening for prostate enlargement is not indicated based solely on the presence of gynecomastia. Proper evaluation and assessment of each condition are necessary.

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Correct Answer is D

Explanation

A. Perform the confrontation test:

The confrontation test is a basic visual field screening test. It assesses the peripheral vision by having the patient cover one eye and the examiner covers the opposite eye. The patient and the examiner then bring their fingers into the visual field from the periphery, and the patient indicates when they see the fingers.

B. Ask the patient to read the print on a handheld Jaeger card:

Jaeger cards are used for near vision testing. The patient reads progressively smaller print to assess their near vision acuity.

C. Determine the patient's ability to read newsprint at a distance of 12 to 14 inches:

This method assesses near vision. It is often used informally in clinical settings, where the patient is asked to read a newspaper or similar print at a comfortable reading distance.

D. Use the Snellen chart positioned 20 feet away from the patient:

The Snellen chart is a standardized chart used for visual acuity testing. It is placed 20 feet away from the patient, and the patient is asked to read the letters or symbols on the chart with one eye covered at a time.

A. Increased temperature B. Increase hematocrit C. Blood pressure 180/100 D. Respiratory rate 32 E. Heart rate 120bpm

Correct Answer is ["C","D"]

Explanation

A. Increased temperature: Fluid overload typically doesn't cause an increased temperature. Infections or other inflammatory processes are more likely causes of elevated body temperature.

B. Increased hematocrit: Fluid overload usually results in dilution of blood components, leading to a decreased hematocrit (lower concentration of red blood cells in the blood). An increased hematocrit is not a typical finding in fluid overload.

C. Blood pressure 180/100: Elevated blood pressure can be associated with fluid overload, especially if the overload is chronic. This is a correct assessment finding that requires intervention and monitoring.

D. Respiratory rate 32: An increased respiratory rate can be a sign of respiratory distress, which may occur in severe cases of fluid overload, especially if it leads to pulmonary edema. This is a correct assessment finding that requires intervention and further evaluation.

E. Heart rate 120 bpm: An increased heart rate can be a compensatory mechanism in response to fluid overload, especially if the heart is trying to maintain cardiac output. However, this heart rate alone is not specific enough to confirm fluid overload. Other signs and symptoms, such as edema, increased blood pressure, and respiratory distress, are more indicative of fluid overload.

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The nurse is examining an adult client within normal weight limit. The nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse's best course of action?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to assess the visual acuity of an adult client. Which of the following assessment should the nurse use for visual acuity?

Correct Answer is D

Explanation

The nurse is assessing a client diagnosed with fluid overload. The nurse should implement priority interventions for which of the following assessment findings? (Select all that apply.)

Correct Answer is ["C","D"]

Explanation

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