The nurse is performing a breast exam on a client. The client asks the nurse why the left breast is slightly larger than the right breast. Which of the following should be the appropriate response by the nurse?
A slight asymmetry in breast size can be expected
Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about.
A sudden uneven increase in breast size is normal in adults
Breasts should always be symmetric.
The Correct Answer is A
A. A slight asymmetry in breast size can be expected: This response is accurate. It acknowledges the natural variation in breast size that many women experience. It's common for one breast to be slightly larger or shaped differently than the other. It assures the client that this asymmetry is normal and not a cause for concern.
B. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about: While breastfeeding can cause temporary changes in breast size and shape, not all cases of breast asymmetry are related to breastfeeding. This statement might not cover all situations, making it less accurate.
C. A sudden uneven increase in breast size is normal in adults: This statement is not accurate. Sudden changes in breast size should always be investigated, as they can indicate underlying health issues and may not be considered normal.
D. Breasts should always be symmetric: This statement is not accurate. Perfect symmetry in breast size and shape is rare. Most women have some degree of asymmetry, which is entirely normal. It's important to reassure the client that slight differences are common and not a cause for concern.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Atelectatic crackles that do not have a pathologic cause:
Atelectatic crackles are short, popping, crackling sounds heard during auscultation. They occur in individuals who are in a supine position and disappear after a few breaths. These crackles are not indicative of any pathological condition; they are common when the lungs are not fully aerated, especially when a person is lying down.
B. Vesicular breath sounds:
Vesicular breath sounds are normal lung sounds heard over the peripheral lung areas. They are soft, low-pitched, and continuous throughout inspiration and part of expiration. Vesicular breath sounds are the typical sounds heard during routine breathing and are not associated with crackling or popping noises.
C. Fine wheezes:
Wheezes are high-pitched whistling sounds heard during expiration. They occur due to narrowed airways and are commonly associated with conditions like asthma or bronchoconstriction. Fine wheezes suggest a partial obstruction in the smaller airways, causing turbulent airflow, leading to the characteristic sound.
D. Fine crackles and may be a sign of pneumonia:
Fine crackles are high-pitched, discontinuous, crackling sounds heard during inspiration. They can occur due to the sudden opening of small airways, and their presence may indicate fluid in the lungs or lung inflammation. Fine crackles are often associated with conditions such as pneumonia, heart failure, or interstitial lung diseases.
Correct Answer is B
Explanation
A. Wheezing: Wheezing is a continuous, high-pitched whistling sound usually heard during expiration. It is often associated with narrowed airways, such as in asthma or chronic obstructive pulmonary disease (COPD). Wheezing occurs due to the turbulent airflow through narrowed bronchi or bronchioles and is not typically associated with pleuritis.
B. Friction rub: Pleuritis, or inflammation of the pleura, can cause a friction rub. This sound occurs when the inflamed pleural layers rub against each other during breathing. It's a grating or rubbing sound heard on auscultation and is a hallmark sign of pleuritis.
C. Stridor: Stridor is a high-pitched, harsh sound heard during inspiration and sometimes expiration. It is often a sign of upper airway obstruction, such as in croup or anaphylaxis. Stridor results from turbulent airflow through a partially obstructed or narrowed larynx or trachea.
D. Crackles: Crackles, also known as rales, are brief, discontinuous, popping sounds heard on inspiration. They can be fine or coarse and are often associated with conditions that cause fluid or secretions in the alveoli or small airways, such as pneumonia or heart failure. Crackles are not typically associated with pleuritis.
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