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 A

Explanation

A. Wheezing is a high-pitched, musical sound produced by narrowed airways. It is a common and classic finding in asthma due to the bronchoconstriction that occurs during an asthma exacerbation. The presence of wheezing on auscultation is a strong indicator of asthma, as it reflects the turbulent airflow through constricted bronchi.
B. Normal breath sounds would generally not indicate asthma. In the absence of an asthma attack or during periods of remission, a person with asthma might have normal breath sounds. However, during an asthma exacerbation, the breath sounds are more likely to be abnormal, such as wheezing or decreased breath sounds if airflow is severely compromised.
C. Clear lung sounds on auscultation would typically indicate that there are no abnormal sounds such as wheezes, crackles, or rhonchi. In the context of asthma, clear lung sounds could be heard if the asthma is well-controlled or if the client is not currently experiencing an exacerbation.
D. A decreased respiratory rate (bradypnea) is not a typical finding in asthma. During an asthma exacerbation, clients often experience tachypnea (increased respiratory rate) due to difficulty breathing and the increased effort required to breathe.

A. Cyclic pain B. Noncyclic C. Fibrocystic breast D. Breast cancer

Correct Answer is B

Explanation

A. Cyclic breast pain is related to the menstrual cycle and typically follows a pattern in relation to hormonal changes. It often starts in the luteal phase of the cycle and resolves with the onset of menstruation. Since the described pain is not associated with the menstrual cycle, this term is not appropriate for the given scenario.
B. Noncyclic breast pain is pain that is not related to the menstrual cycle and does not have a specific, cyclical pattern. It is often described as occurring independently of hormonal changes and can be associated with a variety of other factors, including infections, injuries, or other conditions affecting the breast tissue.
C. Fibrocystic breast changes refer to a condition characterized by lumpy, tender breasts with pain often related to hormonal changes. The pain and lumps can vary with the menstrual cycle, so it does not fit the description of noncyclic pain that is independent of the menstrual cycle.
D. While breast cancer can present with pain, particularly in advanced stages or in the presence of a mass, the term "breast cancer" is not used to describe the nature of the pain itself. It is a diagnosis rather than a descriptive term for pain characteristics.

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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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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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