The nurse is inspecting the anterior chest of an adult client. The nurse recognizes that which of the following should be included in the assessments?

Presence of breath sounds

Diaphragmatic excursion

Symmetric chest expansion

Shape and configuration of the chest wall

Answer and Explanation

The Correct Answer is D

. Presence of breath sounds: While assessing the anterior chest, the nurse should listen for breath sounds over various areas of the lungs. However, this is related to auscultation, not inspection.

B. Diaphragmatic excursion: Diaphragmatic excursion involves assessing the movement of the diaphragm during breathing. This is typically done by percussing the level where dullness changes to resonance during inhalation and exhalation. It is more related to percussion, not inspection.

C. Symmetric chest expansion: Symmetric chest expansion refers to the equal expansion of both sides of the chest during inhalation. The nurse can observe and palpate the chest to assess if it expands symmetrically on both sides. This is a crucial aspect of the inspection of the anterior chest.

D. Shape and configuration of the chest wall: The shape and configuration of the chest wall, including abnormalities or deformities, should be assessed during inspection. This includes observing for any asymmetry, deformities, masses, or scars on the anterior chest.

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Correct Answer is C

Explanation

A. Xerostomia: Xerostomia refers to dry mouth, which is caused by reduced saliva production. While it can be a symptom of various conditions, it is not directly associated with facial drooping after a stroke.

B. Epistaxis: Epistaxis is a medical term for a nosebleed. It occurs due to the rupture of small, delicate blood vessels within the nose. While it can happen independently of a stroke, it is not directly related to facial drooping caused by a stroke.

C. Dysphagia: Dysphagia refers to difficulty in swallowing, which can occur after a stroke due to muscle weakness, including the facial muscles. Facial drooping on one side can be indicative of stroke-related muscle weakness and can contribute to difficulties in swallowing.

D. Rhinorrhea: Rhinorrhea is the medical term for a runny nose, where the nasal cavity is filled with a significant amount of mucus. It is usually caused by various factors such as allergies, infections, or irritants. Rhinorrhea is not directly associated with facial drooping after a stroke.

A. Inform the client that his breast enlargement is benign, and normal for a man of his age B. Explain that this condition may be the result of hormonal changes, and recommend that he see his physician. C. Recommend that he alter his diet to include fewer fats and more lean proteins D. Explain that gynecomastia in men is usually associated with prostate enlargement and recommend that he be thoroughly screened.

Correct Answer is B

Explanation

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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The nurse is inspecting the anterior chest of an adult client. The nurse recognizes that which of the following should be included in the assessments?

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