The nurse is performing a breast examination on a client. The nurse understands that examining the upper outer quadrant of the breast is especially important because this part is:

The location of most breast tumors.

More prone to Injury and calcifications than other locations in the breast

The largest quadrant of the breast

Where most of the suspensory ligaments attach

Answer and Explanation

The Correct Answer is A

A. The location of most breast tumors: This choice is correct. The upper outer quadrant of the breast is the most common site for breast tumors. This area has a higher concentration of glandular tissue, making it more susceptible to the development of tumors. Therefore, thorough examination of this area is crucial during breast examinations.

B. More prone to Injury and calcifications than other locations in the breast: While injuries can occur in any part of the breast, the statement about calcifications is not accurate. Calcifications in breast tissue can occur in various areas and are not specific to the upper outer quadrant.

C. The largest quadrant of the breast: This statement is not accurate. The breast quadrants are not distinguished by size; they are anatomical divisions used for reference during breast examinations. Each quadrant has its significance for examination purposes, but none is considered the largest.

D. Where most of the suspensory ligaments attach: The suspensory ligaments, also known as Cooper's ligaments, provide structural support to the breast tissue. While they are essential for breast anatomy, they are not concentrated in the upper outer quadrant exclusively. These ligaments are distributed throughout the breast tissue.

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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.

A. Checks the instrument gauge to ensure the reading starts at zero B. Centers the cuff bladder over the client's brachial artery C. Places the client's arm above the level of the client's heart D. Wraps the blood pressure cuff around the client's arm using firm pressure

Correct Answer is C

Explanation

A. Checks the instrument gauge to ensure the reading starts at zero:

This action is correct. Before taking a blood pressure reading, it's essential to ensure that the instrument's gauge starts at zero. This ensures accurate measurement as the reading reflects the pressure above zero.

B. Centers the cuff bladder over the client's brachial artery:

This action is correct. Proper placement of the blood pressure cuff over the brachial artery is crucial for accurate readings. Centering the cuff ensures that the artery is correctly compressed for measurement.

C. Places the client's arm above the level of the client's heart:

This action is incorrect. Placing the arm above heart level can result in a falsely low blood pressure reading. The arm should be at the same level as the heart to obtain an accurate measurement.

D. Wraps the blood pressure cuff around the client's arm using firm pressure:

This action is correct, but it's important to note that while the cuff should be snug, it should not be too tight or too loose. Wrapping the cuff with firm, even pressure ensures proper compression of the artery for an accurate measurement.

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The nurse is performing a breast examination on a client. The nurse understands that examining the upper outer quadrant of the breast is especially important because this part is:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is examining a client for tactile fremitus. The nurse recognizes that when examining for tactile fremitus it is important to:

Correct Answer is B

Explanation

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner indicates a need for further instruction?

Correct Answer is C

Explanation

The nurse is assessing the heart sounds of a client. The nurse understands that to listen to the pulmonic valve, the stethoscope should be placed where?

The nurse is preparing to auscultate for heart sounds on a client. Which of the following technique should be used by the nurse?

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The nurse is performing a breast examination on a client. The nurse understands that examining the upper outer quadrant of the breast is especially important because this part is:

The nurse is discussing the blood flow pattern of the heart. The nurse should recognize which of the following as the accurate blood flow pattern of the heart?

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?

A nurse documents that the client has a normal pupillary light reflex. The nurse should recognize that this reflex indicates which of the following?

The nurse examines a client's auditory canal and tympanic membrane with an otoscope. The nurse recognizes that which of the following is considered an abnormal finding?