The nurse is performing a breast exam on a client. The client asks the nurse why the left breast is slightly larger than the right breast. Which of the following should be the appropriate response by the nurse?

A slight asymmetry in breast size can be expected

Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about.

A sudden uneven increase in breast size is normal in adults

Breasts should always be symmetric.

Answer and Explanation

The Correct Answer is A

A. A slight asymmetry in breast size can be expected: This response is accurate. It acknowledges the natural variation in breast size that many women experience. It's common for one breast to be slightly larger or shaped differently than the other. It assures the client that this asymmetry is normal and not a cause for concern.

B. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about: While breastfeeding can cause temporary changes in breast size and shape, not all cases of breast asymmetry are related to breastfeeding. This statement might not cover all situations, making it less accurate.

C. A sudden uneven increase in breast size is normal in adults: This statement is not accurate. Sudden changes in breast size should always be investigated, as they can indicate underlying health issues and may not be considered normal.

D. Breasts should always be symmetric: This statement is not accurate. Perfect symmetry in breast size and shape is rare. Most women have some degree of asymmetry, which is entirely normal. It's important to reassure the client that slight differences are common and not a cause for concern.

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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. The pupils constrict when the examiner's index finger slowly moves toward the client's nose. B. The client involuntary blinks in the presence of bright light directed over the pupils during the eye exam. C. The client's peripheral vision becomes sharper when the examiner shines a light over the pupils. D. The pupils dilate when the examiner's index finger slowly moves toward the client's nose.

Correct Answer is A

Explanation

A. The pupils constrict when the examiner's index finger slowly moves toward the client's nose.

This statement is correct. Visual accommodation is the process by which the eye's lens changes shape to focus on objects at varying distances. When an object moves closer to the eyes, the pupils constrict to adjust and focus on the near object, preventing double vision.

B. The client involuntarily blinks in the presence of bright light directed over the pupils during the eye exam.

This statement describes the pupillary light reflex, not visual accommodation. The pupillary light reflex is the response of the pupils to light exposure.

C. The client's peripheral vision becomes sharper when the examiner shines a light over the pupils.

This statement is not accurate. Peripheral vision sharpness is not related to visual accommodation. Visual accommodation mainly involves adjusting focus for objects at varying distances.

D. The pupils dilate when the examiner's index finger slowly moves toward the client's nose.

This statement is incorrect. Pupils should constrict, not dilate, when focusing on a near object (as in visual accommodation). Dilation occurs in low-light conditions or in response to sympathetic stimulation.

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The nurse is performing a breast exam on a client. The client asks the nurse why the left breast is slightly larger than the right breast. Which of the following should be the appropriate response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to assess the visual acuity of an adult patient, which of the following assessment should the nurse use for visual acuity

Correct Answer is D

Explanation

The nurse is testing a client's visual accommodation. Which of the following should the nurse recognize as an assessment finding from visual accommodation?

Correct Answer is A

Explanation

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