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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A) Press the stethoscope's diaphragm firmly on the skin over each lung field: The diaphragm of the stethoscope is best for hearing high-pitched sounds, such as breath sounds, including adventitious lung sounds like crackles, wheezes, and rhonchi. Pressing the diaphragm firmly against the skin ensures optimal transmission of these sounds, allowing for accurate assessment of the client's lung condition.

B) Use the bell of the stethoscope to listen to the lung fields over lower lobes: The bell of the stethoscope is designed to pick up low-pitched sounds and is typically used for heart sounds and vascular sounds. It is not the best choice for auscultating breath sounds in the lungs, which are better heard with the diaphragm.

C) Shave all chest hair that may distort sounds heard through the diaphragm: While chest hair can sometimes cause distortion, it is generally not necessary to shave the chest. Instead, pressing the diaphragm firmly against the skin can help minimize interference from chest hair. If needed, the nurse can also moisten the chest hair to reduce the sound interference.

D) Have the client lay flat while listening to the anterior surface of the chest: Although certain positions can aid in auscultation, lying flat is not always necessary and can be uncomfortable for clients with respiratory issues. Sitting up or in a semi-recumbent position is generally more comfortable and effective for assessing lung sounds.

A. Inspection of head and neck is observed in a straight alignment without lateral curves. B. Evaluation of cranial nerve XI reveals flexion is maintained against full resistance. C. Observation of cervical range of motion reveals flexion and extension is 25 degrees. D. Palpation of the spinous processes and surrounding muscles are non-tender.

Correct Answer is C

Explanation

A) Inspection of head and neck is observed in a straight alignment without lateral curves:
This finding describes the normal alignment of the head and neck without lateral curves, indicating proper cervical spine alignment. While it provides information about cervical alignment, it does not directly suggest lifestyle habits that could contribute to neck stiffness and discomfort.

B) Evaluation of cranial nerve XI reveals flexion is maintained against full resistance:
Assessing cranial nerve XI (accessory nerve) involves testing the strength of the trapezius and sternocleidomastoid muscles. While weakness in these muscles may indicate pathology affecting the nerve, it does not specifically relate to lifestyle habits contributing to neck stiffness and discomfort.

C) Observation of cervical range of motion reveals flexion and extension is 25 degrees:
Limited cervical range of motion, such as the restricted flexion and extension described, may suggest musculoskeletal issues or lifestyle habits contributing to neck stiffness and discomfort. Further inquiry into the client's lifestyle habits, such as occupational activities, posture, and exercise habits, would be warranted to identify potential factors contributing to limited cervical range of motion.

D) Palpation of the spinous processes and surrounding muscles are non-tender:
Non-tender palpation of the spinous processes and surrounding muscles suggests the absence of acute musculoskeletal issues or inflammation in the cervical spine region. While it rules out tenderness on palpation, it does not provide specific information about lifestyle habits that could contribute to neck stiffness and discomfort.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A male client arrives at the clinic for follow-up health assessment after recent antibiotic treatment for pneumonia without hospitalization. Which technique should the nurse implement to assess for adventitious lung sounds?

Correct Answer is A

Explanation

The nurse assesses a client who comes to the clinic with neck stiffness and discomfort. Which finding of the cervical spine should the nurse inquire further about lifestyle habits?

Correct Answer is C

Explanation

The nurse should anticipate difficulty locating the point of maximal impulse (PMI) in which client? Reference Range: Body mass index (BMI) Normal or healthy weight (18.5 kg/m2 to 24.9 kg/m2)]

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

An adult client presents with gnawing epigastric pain. The pain is worse when the client is hungry and abates after eating something. Which problem do these symptoms suggest?

An older male client reports to the nurse that his feet are cold. Before covering the client's feet, which assessment(s) should the nurse complete? Select all that apply.

During the admission assessment, a client admitted with chest pain reports having no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

To objectively confirm the presence of fever, before taking the client's temperature, which action should the nurse take?

When systematically auscultating a client's anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation, but reports pain when the pressure is released. Which action should the nurse implement?