Which of the following statements concerning breast examination is true?
The examiner uses bimanual palpitation to evaluate the tail of spence.
The axillae are not palpitated if the breast tissue is normal.
Nipple discharge in pregnant women is considered abnormal.
The breasts are inspected as the client changes positions to detect abnormal symmetry.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A.This option is appropriate for children under the age of 3. Pulling the pinna down and back straightens the ear canal in young children, but it does not align the canal correctly in adults.
B.For an adult, the correct method to straighten the ear canal during examination is to pull the pinna (outer part of the ear) up and back. This maneuver aligns the ear canal for better visualization of the tympanic membrane (eardrum) and inner structures.
C.Pulling the pinna down and forward is incorrect for both adults and children. This action would not provide a clear view of the ear canal and could make examination difficult.
D.Pulling the pinna straight back does not fully straighten the ear canal in adults and may make the examination less effective. The correct technique is up and back for adults to fully straighten the canal and enhance visualization.
Correct Answer is C
Explanation
"Pain is whatever the person experiencing it says it is," to include in the orientation. This definition reflects the concept of pain as a subjective experience that cannot be directly observed or measured, but only reported by the individual experiencing it. It emphasizes the importance of believing and acknowledging the patient's report of pain, and not relying solely on objective indicators or assumptions about the cause or intensity of pain. This definition also aligns with current standards of pain assessment and management, which prioritize patient-centered care and the use of self-report measures to guide treatment decisions.
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