Renee is a 43-year-old female who presents to her gynecology office to follow up on a breast lump she discovered while performing a self-exam two days ago. Renee explains she has a family history of breast cancer. Her mother was diagnosed with stage Ill breast cancer at 40 years and passed away 5 years later. Renee's sister tested BRACA and elected to undergo a prophylactic double mastectomy Renee underwent BRACA testing and was found to be but she elected not to undergo the surgery. Considering the strong family history, Renee presents annually for mammograms and performs self-breast exams once a month. Two days ago, while performing her monthly exam in the shower. Renee felt a firm, non-tender lump in the right breast located to the right of the nipple. She immediately called to schedule an appointment for consultation.

Renee denies any associated symptoms including fatigue, changes to the skin of the breast pain, discharge from the nipples, or sore lymph nodes She describes herself as healthy and has no.
The nurse prepares to perform a breast exam on Renee to evaluate the palpable mass. When documenting pertinent objective findings related to the breast mass characteristics, the nurse includes information on (Select all that apply)

Skin turgor Mobility

Location

Age of Menarche

Orientation

Consistency

Answer and Explanation

Correct Answer : A,B,F

A.   Skin turgor refers to the elasticity of the skin, which can be affected by various conditions, including malignancy. The nurse should assess for any skin changes near the lump to identify any unusual signs.
B.   The nurse should document the precise location of the mass, noting whether it is near the nipple or in another quadrant of the breast. This will help with future imaging and assessment.
C.   While the history is important, it does not fall under objective findings that the nurse would document during the physical exam.
D.   This is part of the patient’s history, not a direct observation during the physical exam, so it is not included in the documentation of objective findings of the breast mass.
E.   Orientation refers to the patient’s mental status and does not relate to the characteristics of the breast mass.
F.   The nurse should note the consistency of the mass (e.g., hard, firm, or soft). A firm, non-tender mass is often concerning for malignancy and should be documented.

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Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"}}

Explanation

Shortness of breath is a first-level priority because it is a potentially life-threatening issue. It requires immediate attention to ensure the patient is not experiencing an acute respiratory or cardiovascular event.

Headache with pain level 4/10 is a second-level priority because it is uncomfortable but not immediately life-threatening. The nurse should assess the cause of the headache, considering anxiety and other factors.

Generalized anxiety is a third-level priority as it does not pose an immediate threat to life, but should still be addressed to improve the patient’s comfort and well-being.

A. Extinction B. Tactile discrimination C. Stereognosis. D. Graphesthesia

Correct Answer is C

Explanation

A. This term refers to the inability to recognize stimuli presented to both sides of the body simultaneously, often seen in cases of neurologic damage.
B. This refers to the ability to differentiate between various sensations, but it is not the specific term for identifying objects by touch.
C. This is the correct term for the ability to recognize objects through touch alone. The nurse would describe the client's ability to identify the key as stereognosis.
D. This refers to the ability to recognize letters or numbers written on the skin, typically with a fingertip, not the identification of a physical object.

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Naxlex Comprehensive Predictor Exams

A newly admitted patient is having generalized anxiety, headache with pain level 4/10, and shortness of breath at rest. How should the nurse prioritize these problems?

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"A"}}

Explanation

During an assessment of the neurological system, a nurse places a key in the hand of a client, and he identifies it as a key. The nurse would describe this finding as

Correct Answer is C

Explanation

The nurse is assessing voice sounds during a respiratory assessment. Which of these findings indicates a normal assessment? (Select All that Apply)

The nurse is testing the function of CN XI. Which statement best describes the response the nurse should expect if this nerve is intact? The patient.

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve 11?

While assessing the client's gait during, which of the following would indicate a need for further evaluation?

A nurse is assessing a client's cardiovascular system. To palpate for unexpected pulsations in the pulmonic area, at which anatomical location should the nurse place her fingers?

A nurse is interviewing a male client who has a hearing impairment. What techniques would be most beneficial in communicating with this client?

The movement of the leg laterally then medially, with knee straight is referred to as:

During an assessment of the CNs, the nurse finds the following: asymmetry when the patient smiles or frowns, uneven lifting of the eyebrows, sagging of the lower eyelids, and escape of air when the nurse presses against the right puffed cheek. This would indicate dysfunction of which of these CNs?