Which of the following statements concerning breast examination is true?
The examiner uses bimanual palpitation to evaluate the tail of spence.
The axillae are not palpitated if the breast tissue is normal.
Nipple discharge in pregnant women is considered abnormal.
The breasts are inspected as the client changes positions to detect abnormal symmetry.
The Correct Answer is A
A. The examiner uses bimanual palpitation to evaluate the tail of spence.
This statement is true. The tail of Spence is the extension of breast tissue into the axilla, and it is important to evaluate this area during a breast examination. Bimanual palpation, which involves using both hands to examine the breast tissue, is commonly used to assess the tail of Spence.
B. The axillae are not palpated if the breast tissue is normal.
This statement is false. The axillae should be palpated during a breast examination, even if the breast tissue is normal. Lymph nodes in the axilla can sometimes be the first site of metastasis for breast cancer, so it is important to check for any abnormalities in this area.
C. Nipple discharge in pregnant women is considered abnormal.
This statement is false. Nipple discharge is a common occurrence during pregnancy and is usually considered normal, especially in the later stages of pregnancy. However, any sudden or persistent discharge should be evaluated by a healthcare provider.
D. The breasts are inspected as the client changes positions to detect abnormal symmetry.
This statement is false. The breasts should be inspected in a consistent position, such as with the patient sitting or lying down. Changing positions can alter the appearance of the breasts and make it difficult to detect any changes or abnormalities. However, it is important to inspect both breasts and compare them for any signs of asymmetry or abnormalities.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The nurse is assessing the 6 stages of the cardinal gaze to evaluate the function of the cranial nerves III, IV, and VI for ocular motor movements, which control eye movement and positioning.
Cranial nerve III controls the superior rectus, inferior rectus, and medial rectus muscles, which move the eye up, down, and inward, respectively. Cranial nerve IV controls the superior oblique muscle, which moves the eye downward and laterally. Cranial nerve VI controls the lateral rectus muscle, which moves the eye outward.
Therefore, the nurse will observe the patient's ability to move their eyes smoothly in each of the six cardinal positions of gaze and note any abnormalities that may indicate dysfunction of these cranial nerves. This test is used to diagnose conditions such as strabismus, nystagmus, and palsy of the ocular motor nerves.
Cranial nerve II, on the other hand, is responsible for visual acuity, not eye movement, and is tested separately using a visual acuity chart or other vision tests.
Correct Answer is B
Explanation
Pupillary response is one of the important indicators of a patient's level of consciousness (LOC). The nurse can observe the size, shape, and reaction of the patient's pupils to light. The pupils should be equal in size, round, and reactive to light. Any abnormalities in the pupils, such as unequal size or lack of reaction to light, may indicate an altered LOC and require further evaluation by a healthcare provider.
Checking turgor, observing for awake and alertness, and auscultating the temporal artery are not specific assessments for evaluating a patient's LOC. Turgor is used to assess for dehydration, observing for awake and alertness is a general assessment of the patient's mental status, and auscultating temporal artery is used to assess for temporal artery pulse.
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