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 C

Explanation

A. Nystagmus in extreme superior gaze: Nystagmus is an involuntary eye movement and is not a normal finding, especially in extreme superior gaze. Nystagmus can be indicative of neurological issues and requires further evaluation.

B. Slight amount of lid lag when moving the eyes from a superior to an inferior position: Lid lag refers to a delay in the downward movement of the upper eyelid during eye movement. This can be a sign of hyperthyroidism and is not a normal finding.

C. Parallel movement of both eyes: This is the correct answer. During the diagnostic positions test, the nurse should observe parallel movement of both eyes in all directions, indicating normal extraocular muscle function and coordination.

D. Convergence of the eyes: Convergence refers to the inward movement of both eyes when focusing on a close object. While convergence is a normal phenomenon, it is not specifically assessed during the diagnostic positions test, which primarily evaluates the range of motion and coordination of the extraocular muscles.

A. Friction rub B. Tactile fremitus C. Crepitus D. Adventitious sounds

Correct Answer is C

Explanation

A. Friction rub:

A friction rub is a grating or rubbing sound or sensation heard or felt during auscultation or palpation. It occurs when inflamed pleural or pericardial surfaces rub against each other during breathing or heartbeats, respectively.

B. Tactile fremitus:

Tactile fremitus refers to the palpable vibrations transmitted through the bronchopulmonary tree to the chest wall as the patient speaks. It is assessed by placing hands on the patient's back while the patient speaks certain words. Increased tactile fremitus can occur in conditions with lung consolidation, such as pneumonia.

C. Crepitus:

Crepitus is a crackling or grating sensation felt under the skin or heard when the ends of a broken bone rub against each other. It can also occur when air leaks into subcutaneous tissue, leading to a crackling sensation upon palpation.

D. Adventitious sounds:

Adventitious sounds refer to abnormal lung sounds heard during auscultation. These sounds include crackles (rales), wheezes, rhonchi, and pleural friction rubs. Adventitious sounds can indicate various respiratory conditions, such as pneumonia, bronchitis, or asthma.

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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 performing the diagnostic positions test. The nurse recognizes that normal findings from the diagnostic positions test should be which of these results?

Correct Answer is C

Explanation

The nurse is palpating a client's anterior chest wall and notices a course, crackling sensation over the skin surface. Which of the following should the nurse suspect from her findings?

Correct Answer is C

Explanation

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