A nurse is assessing the anterior chest of a client. The nurse recognizes that which of the following should be included in the assessment? (Select all that apply.)

Kyphosis

Gastrointestinal sounds

Heart sounds

Breath sounds

Symmetric expansion

Answer and Explanation

Correct Answer : C,D,E

A) Kyphosis: While kyphosis is an important physical finding that could impact a client's respiratory and musculoskeletal health, it is typically assessed during the general physical examination and postural assessment rather than as part of the anterior chest assessment. Therefore, kyphosis is not directly part of the anterior chest examination, though it could be a factor influencing respiratory mechanics.

B) Gastrointestinal sounds: Gastrointestinal sounds are assessed during the abdominal examination, not the chest examination. The anterior chest exam focuses on respiratory and cardiac assessments, which do not involve auscultating bowel sounds. Hence, gastrointestinal sounds are not part of the chest examination.

C) Heart sounds: Auscultation of heart sounds is a crucial part of assessing the anterior chest, as it helps the nurse evaluate cardiac function. The nurse listens to heart sounds at specific areas on the chest (e.g., aortic, pulmonic, tricuspid, and mitral areas) to identify any abnormalities such as murmurs, arrhythmias, or other issues.

D) Breath sounds: Breath sounds are an essential component of the chest assessment. By auscultating the lungs, the nurse can identify normal or abnormal breath sounds, such as wheezes, crackles, or decreased breath sounds, which may indicate respiratory issues like pneumonia, asthma, or emphysema.

E) Symmetric expansion: Symmetric expansion refers to the even movement of both sides of the chest during inhalation and exhalation. Assessing symmetric chest expansion helps the nurse identify any respiratory abnormalities, such as atelectasis, pneumonia, or other lung pathologies that may cause uneven chest expansion, signaling a potential underlying issue.

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Correct Answer is C

Explanation

A) The best time to perform BSE is immediately prior to the menstrual cycle:
Performing a breast self-examination (BSE) immediately prior to the menstrual cycle is not ideal because hormonal changes leading up to menstruation can cause the breasts to become swollen, tender, and lumpy. These changes could make it difficult to detect subtle lumps or changes in the breast tissue. For the most accurate assessment, it's recommended that women avoid performing BSE during the premenstrual phase when the breast tissue is most likely to be affected by hormonal fluctuations.

B) If pregnancy is suspected, BSE should not be performed until post-delivery:
This statement is incorrect. There is no contraindication to performing a breast self-examination during pregnancy, and it is important for pregnant women to continue self-monitoring for any changes in breast tissue. In fact, BSE should be performed regularly during pregnancy, as the breast tissue can undergo changes due to hormonal shifts, and early detection of any abnormalities is key to successful management.

C) The best time to perform BSE is 4 to 7 days after the first day of the menstrual period:
This is the correct recommendation. The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period because the breasts are least likely to be swollen or tender during this time. Hormonal levels are more stable at this point in the menstrual cycle, and any lumps or changes in the tissue are more likely to be noticeable. Performing BSE during this time increases the likelihood of detecting potential abnormalities.

D) The woman with diagnosed fibrocystic breast tissue should not rely on BSE:
While it is true that women with fibrocystic breast changes may experience lumpy, tender tissue, they should still perform BSE regularly. Fibrocystic tissue can sometimes make it more difficult to distinguish between normal and abnormal changes, but BSE remains an important tool for detecting significant changes, such as new lumps or changes in size, shape, or consistency. Women with fibrocystic breast tissue should be taught to perform BSE regularly and to report any unusual changes to their healthcare provider. Relying solely on BSE for breast cancer detection is not recommended, but it is an essential part of breast health awareness.

A. Daily, during the shower or bath B. One week after the menstrual period C. On the same day every month D. Weekly, at the client's convenience

Correct Answer is C

Explanation

A) Daily, during the shower or bath:
This is incorrect. Performing a breast self-examination (BSE) daily is not necessary. The goal of BSE is to check for any changes over time, not to examine the breasts every day. It's more effective to perform the exam regularly at a consistent time each month.

B) One week after the menstrual period:
This is incorrect. This instruction is relevant for pre-menopausal women, where the hormonal changes associated with the menstrual cycle can cause breast tissue to feel lumpy or swollen. The best time for them to perform a BSE is one week after the menstrual period ends when the breasts are least likely to be swollen or tender. However, for postmenopausal women, this is not necessary, as their hormonal levels are stable throughout the month.

C) On the same day every month:
This is the correct answer. For postmenopausal women, who no longer have menstrual cycles, the best time to perform a breast self-exam is on the same day every month. This ensures consistency and makes it easier for the client to notice any changes in the breast tissue over time. The day chosen should be one that is convenient and easy to remember, and it does not matter whether it is during the shower or bath, as long as the examination is done regularly.

D) Weekly, at the client's convenience:
This is incorrect. While performing a BSE weekly is not necessary, the key is consistency rather than frequency. Performing the exam monthly is sufficient, and it should be on a specific day each month, rather than at the client’s convenience on an irregular basis.

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A nurse is assessing the anterior chest of a client. The nurse recognizes that which of the following should be included in the assessment? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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