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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Have the client breathe quickly:
This choice is incorrect because having the client breathe quickly is not a technique for assessing tactile fremitus. Tactile fremitus is assessed by feeling vibrations on the chest wall while the patient speaks, not during normal breathing.
B. Palpate the chest symmetrically:
This choice is correct. To assess tactile fremitus, the nurse places the palms or ulnar aspects of both hands firmly against the patient's chest while the patient speaks a phrase. The nurse should palpate the chest symmetrically to detect vibrations equally on both sides, which can help identify abnormalities in the lungs.
C. Ask the client to cough:
This choice is incorrect. Asking the client to cough is not a technique for assessing tactile fremitus. Tactile fremitus is evaluated by feeling vibrations while the patient speaks, not while coughing.
D. Use the bell of the stethoscope:
This choice is incorrect. Tactile fremitus is assessed by palpation, not auscultation with a stethoscope. Using the bell of the stethoscope is a technique for listening to low-pitched sounds, not for assessing tactile fremitus.
Correct Answer is D
Explanation
A. The eyes converge to focus on the light.
This statement refers to the convergence reflex, where both eyes move medially (towards each other) to maintain single binocular vision when focusing on a near object. It is not related to the pupillary light reflex, which involves changes in pupil size in response to light.
B. The eye focuses the image in the center of the pupil.
This choice does not accurately describe the pupillary light reflex. The pupillary light reflex involves constriction of the pupil in response to light, not focusing an image in the center of the pupil.
C. Dilation of both pupils occurs in response to bright light.
This statement is incorrect. In response to bright light, the pupils should constrict, not dilate. Dilation of pupils in bright light could indicate an abnormal response, such as in cases of certain neurological conditions or drug use.
D. Constriction of both pupils occurs in response to bright light.
This choice is correct. In the pupillary light reflex, both pupils constrict when exposed to bright light. This response is a protective mechanism to prevent excessive light from entering the eyes, ensuring optimal visual acuity.
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