You are performing a breast exam on an adult woman. You are inspecting the breasts for signs of retraction. What is the best position to observe for this?

Lying supine with arms at the sides.

Sitting with the hands pushing into the hips.

Lying supine with one arm elevated over her head.

Learning forward with hands outstretched.

Answer and Explanation

The Correct Answer is C

A.   This position is useful for inspecting the overall shape and size of the breasts, but it may not be the best for detecting retractions.
B.   This position can help identify changes in the breast tissue, but it may not be as effective as raising one arm overhead for detecting retractions.
C.   Raising one arm over the head tenses the muscles in the breast and chest, which can make any retractions more visible. Retraction is often characterized by dimpling or pulling of the skin, which may be more noticeable when the breast tissue is taut.
D.   This position can be helpful for examining the breasts for other abnormalities, but it may not be the best for detecting retractions.

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Correct Answer is C

Explanation

A. Atelectasis refers to the collapse or incomplete expansion of a lung or a portion of a lung. It can cause decreased breath sounds and dullness upon percussion, but it is less likely to present with a fever as high as 102.1°F. However, atelectasis can occur secondary to an obstructive pneumonia, making the distinction important in clinical settings.
B. Pulmonary obstruction, such as from an obstruction of the airway or bronchus, might cause symptoms like difficulty breathing and decreased oxygen saturation. However, it would less commonly present with fever and localized crackles.
C. Pneumonia often presents with symptoms such as fever (elevated temperature of 102.1°F), increased respiratory rate (30 breaths per minute), decreased oxygen saturation (90% on room air), and abnormal lung findings. The decreased expansion and dullness over the right lung, along with crackles (rales) heard in the right lower lobe, are indicative of fluid accumulation and inflammation in the lung, which are characteristic of pneumonia.
D. Acute bronchitis involves inflammation of the bronchi and is often associated with a cough, sputum production, and sometimes fever. However, it typically presents with a productive cough and wheezing rather than localized dullness and crackles confined to one lobe.

A. Bronchial breath sounds over a peripheral lung field B. Soft high-pitched expiratory wheezing with forced expiration. C. Absent breath sounds over one lung lobe D. Stridor

Correct Answer is D

Explanation

A. While abnormal bronchial breath sounds can indicate underlying pathology, they are not typically considered immediately life-threatening.
B. Wheezing is a common symptom of asthma and other conditions that cause airway narrowing. While it can be uncomfortable and distressing, it is not typically considered a life-threatening emergency.
C. Absent breath sounds can indicate a collapsed lung or other serious respiratory condition. However, it is not as immediately life-threatening as stridor, which indicates a severe airway obstruction.
D. Stridor is a high-pitched, wheezing sound caused by obstruction or narrowing of the upper airway (larynx or trachea). It is often associated with conditions like croup, epiglottitis, or an allergic reaction leading to airway swelling. Stridor indicates a significant obstruction in the upper airway that can rapidly lead to severe respiratory distress or compromise.

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You are performing a breast exam on an adult woman. You are inspecting the breasts for signs of retraction. What is the best position to observe for this?

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Naxlex Comprehensive Predictor Exams

Upon assessment, the nurse noted a temperature of 102.1, respirations of 30 breaths per minute, oxygen saturation of 90% on room air, decreased expansion and dullness over the right lung, and crackles heard on the right lower lobe. Which condition should the nurse suspect?

Correct Answer is C

Explanation

Which assessment finding is most likely to be immediately life-threatening?

Correct Answer is D

Explanation

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