A nurse is teaching a patient to perform self-breast examination and tells the patient to pay particular attention to examining the upper outer quadrant of the breast. When asked why, “why,” how should the nurse respond to the patient?
“It is where most infections occur in the breast tissue.”
“It is the largest quadrant of the breast.”
cc) “It is where most of the suspensory ligaments attach.”
dd) “It is the location of most breast tumors.”
The Correct Answer is D
Choice A reason: Infections like mastitis are not specific to the upper outer quadrant; they can occur anywhere in the breast tissue. Most tumors occur in this area, so this is incorrect for the focus of breast examination.
Choice B reason: The upper outer quadrant is not necessarily the largest; breast size varies. It’s emphasized because it contains the highest concentration of breast tissue where tumors form tumors, so this is incorrect. for the reason.
Choice C reason: Suspensory ligaments ( ligaments) are distributed throughout the breast, not primarily in the upper quadrant. Tumor prevalence drives the focus on this area, so this is incorrect for the nurse’s response.
Choice D reason: The upper outer quadrant is where most common site for breast tumors due to greater glandular tissue density. This is the primary reason for thorough examination, making it the correct response for patient education.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: There is no standard “grade 5” in tonsil size grading. The scale typically ranges from 0 to 4+, with 4+ indicating tonsils touching or overlapping, making this an incorrect and non-standard documentation term.
Choice B reason: Grade 3 tonsils are enlarged, occupying about 75% of the pharyngeal space, but not touching. The described tonsils are touching, which corresponds to a higher grade, making grade 3 incorrect for this finding.
Choice C reason: Grade 2+ tonsils are moderately enlarged, taking up about 50% of the pharyngeal space. The tonsils touching indicate a more severe enlargement, aligning with a higher grade, making this an incorrect documentation choice.
Choice D reason: Grade 4+ tonsils are severely enlarged, touching or overlapping in the midline, as described. This matches the standard tonsil grading scale, where 4+ indicates maximal swelling, making this the correct documentation.
Correct Answer is D
Explanation
Choice A reason: Convergence and pupil constriction are accommodation reflexes, not corneal light reflex, which tests alignment. Light reflection symmetry indicates eye alignment, so this incorrect for the reflex’s purpose.
Choice B reason: Pupil constriction is a pupillary reflex, not corneal light reflex. The corneal reflex involves light reflection on corneas, assessing alignment, not pupil response, so this is incorrect.
Choice C reason: Macular focus is related to visual acuity, not corneal reflex, light reflex, which checks eye alignment via light reflection. Symmetric reflection is key, so this incorrect for the reflex’s indication.
Choice D reason: A normal corneal reflex shows light reflecting in the same spot on both corneas, indicating proper eye alignment. This is the definition of the reflex, making it the correct choice for eye assessment.
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