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 C

Explanation

Choice A rationale

Placing the client in a prone position is contraindicated during nasogastric tube insertion. This position does not facilitate the passage of the tube into the esophagus and can increase the risk of aspiration if the client were to vomit. The optimal position is high Fowler's, which utilizes gravity to aid tube advancement.

Choice B rationale

Measuring the nasogastric tube from the tip of the nose to the earlobe to the xiphoid process is the correct technique to estimate the length of the tube needed to reach the stomach. This method accounts for the distance from the nasal passage, down the pharynx and esophagus, to the stomach.

Choice C rationale

Instructing the client to place their chin to their chest and swallow helps to close the epiglottis, thereby preventing the nasogastric tube from entering the trachea and directing it towards the esophagus. Swallowing facilitates the downward movement of the tube with esophageal peristalsis.

Choice D rationale

Advancing the nasogastric tube quickly increases the client's discomfort and anxiety and elevates the risk of trauma to the nasal passages, pharynx, and esophagus. The tube should be advanced slowly and gently, allowing the client to swallow and cooperate during the procedure.

A. Energy. B. Electrolytes. C. Minerals. D. Vitamins.

Correct Answer is A

Explanation

Choice A rationale

Carbohydrates are the body's primary source of energy. They are broken down into glucose, which cells use for fuel to perform various functions, including muscle contraction, nerve impulse transmission, and maintaining body temperature.

Choice B rationale

Electrolytes, such as sodium, potassium, and chloride, are minerals that carry an electrical charge and are crucial for fluid balance, nerve function, and muscle contraction. While some foods containing carbohydrates may also contain electrolytes, providing energy is not their primary function. Normal ranges for serum sodium are 135-145 mEq/L, potassium is 3.5-5.0 mEq/L, and chloride is 95-105 mEq/L.

Choice C rationale

Minerals are inorganic substances that the body needs for various functions, including building strong bones, transmitting nerve impulses, and maintaining fluid balance. Examples include calcium, iron, and zinc. While essential, they are not primarily known for providing direct energy. Normal ranges for serum calcium are 8.5-10.5 mg/dL, iron varies by gender (males: 65-175 mcg/dL, females: 50-170 mcg/dL), and zinc is 70-120 mcg/dL.

Choice D rationale

Vitamins are organic compounds that the body needs in small amounts for various metabolic processes. They do not directly provide energy but help the body utilize energy from carbohydrates, fats, and proteins. Examples include vitamin C, vitamin D, and B vitamins. Normal ranges vary widely depending on the specific vitamin.

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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?

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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?