The nurse is teaching the patient about different stages of sleep. The nurse knows that REM sleep includes which one of the following?

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.

A. Dilated pupils in response to dimmed lights are a normal response and not an indication of a

vision problem.

B. Pupils that remain dilated during an accommodation test indicate that the client may have an

issue with their autonomic nervous system and is not able to adjust their pupil size appropriately.

C. Far vision acuity of 20/20 bilaterally indicates normal vision.

D. A symmetrical pupillary light reflex response is a normal finding and not an indication of a vision

problem.

E. Frowning and squinting while reading the Snellen chart may indicate that the client is having difficulty seeing the letters clearly and may have a vision problem.