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. Although this client has an arm sling, which could potentially limit movement and cause some localized pressure, they are generally at a lower risk for widespread skin breakdown compared to older adults. Their younger age and lack of other risk factors make them less susceptible overall.
B. Older adults have thinner skin and decreased elasticity, making them more susceptible to pressure ulcers and skin breakdown. Frequent exposure to moisture from urine or feces can lead to skin irritation and breakdown, especially in areas where skin is already compromised.
C. While an elderly individual with an ankle fracture is at risk for skin breakdown, especially if immobilized and in a cast, this risk is somewhat less immediate compared to someone with incontinence.
D. This client is recovering from surgery, which could include temporary changes in mobility or activity levels. However, they are younger and do not have the additional complicating factors like incontinence or dementia. While there is some risk of skin issues post-surgery, it is not as high as the risk posed by incontinence and cognitive impairment in an elderly client.

A. High pitch continuous sounds on inspiration and expiration. B. High pitched short crackling C. Low pitch continuous rattling on inspiration and expiration. D. Low pitched grating and rubbing on inhalation and exhalation.

Correct Answer is A

Explanation

A. This option describes wheezes, which are high-pitched continuous sounds often heard on both inspiration and expiration. Wheezes are commonly associated with asthma because they result from the narrowing of the airways, causing turbulent airflow.
B. This description refers to crackles (or rales), which are short, high-pitched sounds often heard on inspiration. Crackles are typically associated with conditions such as pneumonia, congestive heart failure, or other forms of pulmonary edema. They are not as specific to asthma as wheezes are.
C. This option describes rhonchi, which are low-pitched, continuous rattling sounds that may occur on both inspiration and expiration. Rhonchi are often associated with airway obstruction due to secretions or mucus and can be heard in conditions such as chronic bronchitis.
D. This option describes pleural friction rubs, which are low-pitched, grating sounds heard during both inhalation and exhalation. Pleural friction rubs occur when the pleural layers become inflamed and rub against each other.

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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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