An adolescent female client comes to the clinic troubled by breast tenderness before her menstrual periods. On examination, the nurse notes generalized lumpiness of both breasts with no discrete masses and no nipple discharge. Which action should the nurse take?

Suggest that the client schedule a mammogram after her next menstrual period.

Explain to the client that an ultrasound of the breast will likely be necessary.

Assure the client that her breasts are normal, and advise annual evaluations.

Request a return visit after her menstrual period for a breast exam re-check.

Answer and Explanation

The Correct Answer is C

Answer: C. Assure the client that her breasts are normal, and advise annual evaluations.

Rationale:

A. Suggest that the client schedule a mammogram after her next menstrual period:
A mammogram is generally not indicated for adolescents unless there are specific concerns such as a family history of breast cancer or the presence of abnormal findings. Given the client's age and the findings of generalized lumpiness without discrete masses, a mammogram would not be the most appropriate action at this stage.

B. Explain to the client that an ultrasound of the breast will likely be necessary:
An ultrasound is typically used for further evaluation if discrete masses are found or if there are unusual characteristics in the breast tissue. In this case, the generalized lumpiness is likely related to normal physiological changes, making an ultrasound unnecessary at this time.

C. Assure the client that her breasts are normal, and advise annual evaluations:
The findings of generalized lumpiness and tenderness before menstruation are consistent with normal physiological changes associated with the menstrual cycle, often due to hormonal fluctuations. Providing reassurance and advising annual evaluations is appropriate, as it addresses the client's concerns and promotes confidence in her breast health without unnecessary interventions.

D. Request a return visit after her menstrual period for a breast exam re-check:
While a follow-up can be beneficial, it may not be necessary in this case since the findings are typical of normal breast tissue changes associated with the menstrual cycle. Reassuring the client and encouraging annual evaluations is a more effective approach than suggesting an unnecessary follow-up visit.

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Correct Answer is D

Explanation

A) Face is flushed and diaphoretic:
While flushing and diaphoresis can indicate fever, anxiety, or other conditions, they do not typically require immediate intervention unless associated with other severe symptoms.

B) Eyelids are matted and crusted:
Matted and crusted eyelids may indicate an eye infection, such as conjunctivitis, which requires treatment but not immediate emergency intervention.

C) Cornea are jaundiced:
Jaundiced corneas (scleral icterus) suggest elevated bilirubin levels and possible liver dysfunction. This finding requires prompt evaluation but is not typically an emergency requiring immediate intervention.

D) Oral mucosa is cyanotic:
Cyanosis of the oral mucosa indicates a lack of oxygen in the blood and is a sign of hypoxemia or respiratory distress. This is a critical finding that requires immediate intervention to address potential life-threatening respiratory or cardiovascular issues.

A. Neurological status intact. B. Glasgow Coma Scale (GCS) of 15. C. Pupils equal, round, reacts to light, and accommodation (PERLA). D. Pupils equal, round, reacts to light (PERRL).

Correct Answer is D

Explanation

A) Neurological status intact: While the findings suggest that the client's neurological status is intact, this description does not specifically address the pupillary assessment.

B) Glasgow Coma Scale (GCS) of 15: The Glasgow Coma Scale evaluates a client's level of consciousness based on eye, verbal, and motor responses. While the findings may contribute to an overall assessment of neurological function, they specifically pertain to pupillary assessment.

C) Pupils equal, round, reacts to light, and accommodation (PERLA): This description includes accommodation, which is the ability of the pupils to constrict when focusing on a near object. The assessment provided in the scenario does not mention accommodation testing, so including it in the documentation would be inaccurate.

D) Pupils equal, round, reacts to light (PERRL): This notation accurately summarizes the findings of the pupillary assessment. It indicates that both pupils are equal in size, round in shape, and react briskly to light, which is a normal finding. This documentation is concise and specific to the pupillary examination without including additional findings not assessed in the scenario.

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An adolescent female client comes to the clinic troubled by breast tenderness before her menstrual periods. On examination, the nurse notes generalized lumpiness of both breasts with no discrete masses and no nipple discharge. Which action should the nurse take?

Rationale:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While observing a client's face, which assessment finding requires immediate intervention by the nurse?

Correct Answer is D

Explanation

When performing a neurologic assessment on an alert client, the nurse observes that the client's pupils are both round, 3 mm in size, and respond briskly to light. Which notation should the nurse use when documenting the assessment?

Correct Answer is D

Explanation

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