Some of the factors that negatively aﬀect nutrition in the older adult include which of the following? (Select all that apply)

Low economic status

Self-care deficits may hurt their ability to eat, prepare food, or secure food.

Healthy diet.

Dental problems.

Answer and Explanation

Correct Answer : A,B,D

A. Low economic status: This can limit their access to healthy and nutritious foods.

B. Self-care deficits that may hurt their ability to eat, prepare food, or secure food: This can include physical or cognitive impairments that make it difficult for them to shop, cook or feed themselves.

D. Dental problems: These can aﬀect their ability to chew and digest food properly.

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Correct Answer is A

Explanation

When assessing the abdomen, the nurse would expect to auscultate bowel sounds, which are the sounds made by the movement of gas and ﬂuid through the intestines. The normal bowel sounds are characterized as high-pitched, gurgling, and occurring at a rate of 5-30 sounds per minute.

Bruits are abnormal sounds indicating turbulent blood ﬂow and are usually assessed in other areas of the body, such as the epigastric and renal arteries, as well as in the aorta.

Friction rubs are also abnormal sounds, but they are typically heard during auscultation of the heart and lungs.

Low-pitched sonorous sounds are not typical sounds that are expected to be heard during an abdominal assessment

A. The examiner uses bimanual palpitation to evaluate the tail of spence. B. The axillae are not palpitated if the breast tissue is normal. C. Nipple discharge in pregnant women is considered abnormal. D. The breasts are inspected as the client changes positions to detect abnormal symmetry.

Correct Answer is A

Explanation

A. The examiner uses bimanual palpitation to evaluate the tail of spence.

This statement is true. The tail of Spence is the extension of breast tissue into the axilla, and it is important to evaluate this area during a breast examination. Bimanual palpation, which involves using both hands to examine the breast tissue, is commonly used to assess the tail of Spence.

B. The axillae are not palpated if the breast tissue is normal.

This statement is false. The axillae should be palpated during a breast examination, even if the breast tissue is normal. Lymph nodes in the axilla can sometimes be the first site of metastasis for breast cancer, so it is important to check for any abnormalities in this area.

C. Nipple discharge in pregnant women is considered abnormal.

This statement is false. Nipple discharge is a common occurrence during pregnancy and is usually considered normal, especially in the later stages of pregnancy. However, any sudden or persistent discharge should be evaluated by a healthcare provider.

D. The breasts are inspected as the client changes positions to detect abnormal symmetry.

This statement is false. The breasts should be inspected in a consistent position, such as with the patient sitting or lying down. Changing positions can alter the appearance of the breasts and make it difficult to detect any changes or abnormalities. However, it is important to inspect both breasts and compare them for any signs of asymmetry or abnormalities.

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Some of the factors that negatively aﬀect nutrition in the older adult include which of the following? (Select all that apply)

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Naxlex Comprehensive Predictor Exams

When assessing the abdomen, the nurse would expect to auscultate which sounds?

Correct Answer is A

Explanation

Which of the following statements concerning breast examination is true?

Correct Answer is A

Explanation

Which of the following would be considered an abnormal finding and require prompt follow up when auscultating breath sounds?

A 58-year-old patient is going home today. The nurse does her final assessment of the patient. Which of the following would be considered a normal finding?

The role of a registered nurse in a genitalia examination is mainly:

The nurse would use which of the following skills first when examining the cardiovascular system of a patient?

The nurse auscultates the client’s abdomen for 1 minute and does not hear any bowel sounds. What should the nurse do next?

When assessing the breast, the nurse would teach the patient to palpate which of the following areas?

Child maltreatment, sibling violence, bullying, elder abuse, hate crimes and war/combat violence are types of?

The nurse is mapping the client’s abdomen into four quadrants. Which landmarks should the nurse use to perform this assessment? (Select all that apply)