During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast.
Which of these statements is true about this finding?

Asymmetry of breast size and shape is very unusual and means she may have an inflammation or growth.

Asymmetry of the breasts is common, but the nurse should verify that this finding is not new.

Asymmetry of the breast is unusual, and the patient should be referred to a physician.

Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about.

Answer and Explanation

The Correct Answer is B

Choice A rationale

While a sudden and significant asymmetry in breast size or shape could indicate a new issue such as inflammation or a growth and warrants investigation, a slight, long-standing asymmetry is quite common among women. It does not automatically signify a pathological condition.

Choice B rationale

It is a well-established fact that many women have some degree of natural asymmetry in their breast size and shape. However, it is crucial for the nurse to ascertain if this finding is new for the patient. A recent change in asymmetry could be a sign of a developing condition that requires further evaluation.

Choice C rationale

While any new or significant asymmetry should be evaluated by a physician to rule out underlying issues, a long-standing, slight asymmetry is a common physiological variation and does not necessarily require immediate referral unless other concerning signs or symptoms are present.

Choice D rationale

Breastfeeding can sometimes cause temporary changes in breast size due to milk production and engorgement, and one breast might produce slightly more milk than the other. However, a noticeable and persistent asymmetry might predate breastfeeding or persist beyond it, and while it might be benign, attributing it solely to breastfeeding without further assessment of its history is not prudent. .

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Correct Answer is B

Explanation

Choice A rationale

Sublingual medications are designed to be absorbed directly into the bloodstream through the highly vascular mucous membranes under the tongue. Dissolving it in water and administering it through an NG tube would bypass this route, potentially altering the drug's absorption and effectiveness, as it would then be processed through the gastrointestinal system.

Choice B rationale

Administering the medication under the client's tongue ensures that it is absorbed sublingually, bypassing the gastrointestinal tract. This is the intended route for this medication, allowing for rapid absorption and avoiding potential interactions or degradation in the digestive system. The rich blood supply under the tongue facilitates quick entry into systemic circulation.

Choice C rationale

Requesting an oral formulation might be an option if the sublingual route is absolutely contraindicated, but it doesn't address the immediate situation. Oral medications have different absorption rates and may be unsuitable for a client with an NG tube if they have swallowing difficulties or other gastrointestinal issues.

Choice D rationale

Crushing a sublingual medication and administering it through an NG tube is inappropriate. This alters the intended drug delivery mechanism and could lead to unpredictable absorption, potential blockage of the NG tube, and loss of the medication's intended effect. Sublingual formulations are not designed for enteral administration.

A. Medications need to be documented in the record for the physician's review. B. The nurse needs to assess the patient for allergic reactions. C. Certain drugs can affect the metabolism of nutrients. D. Medications can affect one's memory and ability to identify food eaten in the last 24 hours.

Correct Answer is C

Explanation

Choice A rationale

While documenting medications is important for the physician's review, this is not the primary nutritional assessment reason for asking about medications. The focus here is on how medications interact with nutritional status.

Choice B rationale

Assessing for allergic reactions to medications is crucial for patient safety, but it is a separate aspect of medication history and not directly related to the metabolism of nutrients during a nutritional assessment.

Choice C rationale

Certain medications can significantly interfere with the absorption, metabolism, and excretion of various nutrients. For example, some drugs can increase nutrient excretion, decrease appetite, or alter the body's ability to utilize vitamins and minerals, directly impacting nutritional status.

Choice D rationale

While some medications can affect memory and thus the accuracy of a 24-hour food recall, the more direct and critical reason for asking about medications during a nutritional assessment is to identify potential drug-nutrient interactions that affect metabolism.

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During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast.Which of these statements is true about this finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast.
Which of these statements is true about this finding?