The nurse is using inspection to assess the breasts of a female client. Which finding should the nurse document?

palpable lymph nodes

Symmetry.

breast sensitivity

Tenderness

Answer and Explanation

The Correct Answer is B

A. Palpable lymph nodes are assessed through palpation, not inspection. The nurse would use their hands to feel for lymph nodes in areas such as the axilla (armpit) and supraclavicular regions. This is a tactile examination and therefore not documented as part of the inspection.
B. Symmetry refers to the visual observation of whether the breasts are equal in size and shape. During the inspection phase, the nurse notes whether the breasts appear symmetrical or if there are any visible asymmetries.
C. Breast sensitivity is typically assessed through palpation or the client’s report of symptoms rather than through inspection alone. Sensitivity involves asking the client about their experience of pain or discomfort in the breasts, which cannot be observed visually.
D. Tenderness is assessed through palpation, where the nurse would gently press on the breast tissue to determine if the client experiences pain. Tenderness is not a visual finding and therefore is not documented during the inspection phase.

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Correct Answer is B

Explanation

A. Wheezes are high-pitched, continuous sounds that occur during expiration (and sometimes inspiration) due to narrowed airways, commonly seen in conditions like asthma or chronic bronchitis. They are not typically associated with pleural inflammation.
B. This description matches a pleural friction rub. A pleural friction rub is a low-pitched, grating or rubbing sound that occurs when inflamed pleural surfaces rub against each other. It is characteristic of pleural inflammation and is best heard during both inspiration and expiration. This sound results from the roughened pleural surfaces due to inflammation and is the expected finding in a patient with pleuritis.
C. Crackles (or rales) are discontinuous, high-pitched sounds heard typically during inspiration, caused by the opening of collapsed or fluid-filled alveoli. They are commonly associated with conditions like pneumonia, congestive heart failure, or pulmonary fibrosis, rather than pleural inflammation.
D. Gurgling is not a standard term for describing lung sounds. It may refer to rhonchi, which are low- pitched, continuous sounds heard due to mucus or fluid in the larger airways. Rhonchi can be heard in conditions like bronchitis or pneumonia but are not specifically associated with pleural inflammation.

A. Tuberculin skin test B. Low socioeconomic status. C. Complete blood count (CBC) D. Male gender E. Aral blood gases (ABG) F. Chest x-ray

Correct Answer is ["A","C","E","F"]

Explanation

A. This is a diagnostic test used to determine if a client has been exposed to tuberculosis (TB). It is a secondary data source because it provides information about potential TB infection which can affect respiratory health.
B. While low socioeconomic status can impact health and access to healthcare, it is not a direct diagnostic tool or test for assessing the respiratory system. Instead, it is a social determinant that may influence health outcomes but does not provide direct data about the respiratory system itself.
C. A CBC is a laboratory test that provides information on various components of the blood, including red blood cells, white blood cells, and platelets. It can give insights into conditions that might affect the respiratory system, such as anemia or infections.
D. Male gender is a demographic characteristic rather than a diagnostic or data-gathering tool. While gender may influence the prevalence of certain respiratory conditions, it does not itself provide direct information or data about respiratory health.
E. ABG tests measure the levels of oxygen and carbon dioxide in the blood, as well as the blood’s pH balance. This test provides crucial information about a client’s respiratory function and is considered a secondary data source because it results from a specific diagnostic test rather than direct observation or physical assessment.
F. A chest x-ray is a diagnostic imaging test that provides detailed pictures of the lungs and chest cavity. It can reveal abnormalities such as infections, tumors, or fluid in the lungs. Since it is a test conducted outside of direct physical examination, it is classified as a secondary data source.

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The nurse is using inspection to assess the breasts of a female client. Which finding should the nurse document?

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