The nurse is using inspection to assess the breasts of a female client. Which finding should the nurse anticipate documenting?
Symmetry
Hard nodules
Skin texture
Tenderness
The Correct Answer is A
A) Symmetry: During a breast inspection, the nurse should assess for symmetry between the two breasts. It is normal for there to be some slight differences, but significant asymmetry can indicate underlying issues that may need further evaluation.
B) Hard nodules: While the presence of hard nodules would be a significant finding, this would typically be assessed through palpation rather than inspection. The initial visual assessment focuses on appearance, shape, and symmetry.
C) Skin texture: Skin texture may be observed during inspection, but it is not a primary finding that stands out as a key assessment element. It can be noted as part of a comprehensive evaluation but is not the main focus.
D) Tenderness: Tenderness is a subjective assessment that is evaluated through palpation and client reporting, rather than through inspection. The nurse cannot document tenderness solely based on visual assessment.
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Correct Answer is D
Explanation
A) Changes in peripheral vision in response to light: While peripheral vision is important in a comprehensive eye assessment, it is not specifically evaluated through the PERRLA acronym. PERRLA focuses on how the pupils respond to light and accommodation, not on peripheral vision changes.
B) Involuntary blinking in the presence of bright light: Involuntary blinking is part of a reflex action known as the blink reflex, which helps protect the eyes from bright lights and foreign objects. However, this response is not what the "A" in PERRLA refers to, which is more specifically about pupillary reactions to focus.
C) Pupillary dilation when looking at a near object: When focusing on a near object, the pupils actually constrict rather than dilate. This process, known as accommodation, is important for clear vision at close distances but does not pertain to the dilation of pupils.
D) Pupillary constriction when looking at a near object: The "A" in PERRLA stands for accommodation, which specifically refers to the pupils constricting when a person looks at a nearby object. This reaction helps the eyes focus properly and is a normal finding in a healthy neurological assessment. Thus, option D accurately describes the "A" in the PERRLA assessment.
Correct Answer is A
Explanation
A) Obtain a height and weight and calculate a body mass index (BMI): Calculating BMI provides a valuable assessment of a patient’s body composition and overall health related to dietary habits. BMI is a widely used indicator that helps categorize individuals into underweight, normal weight, overweight, and obese categories. Understanding where a patient falls within these categories can highlight the potential impact of dietary habits on health and guide further dietary interventions or education.
B) Review all medications the patient is taking: While reviewing medications is important, it primarily focuses on pharmacological management rather than directly assessing dietary habits. Some medications may have dietary restrictions or require specific nutrient intake, but this does not provide a comprehensive view of the patient's overall dietary habits and their effects on health.
C) Ask about how much food is eaten at an average meal: While inquiring about portion sizes is relevant, it does not give a full picture of dietary habits, including food variety, nutrient quality, and frequency of meals or snacks. A single question about average meal size may overlook other critical aspects of the patient’s eating patterns and nutritional intake.
D) Assess for the presence of any chronic disease processes: Evaluating chronic diseases is crucial for understanding health implications, but it does not directly assess dietary habits. Chronic conditions can be influenced by diet, but the assessment of dietary habits requires a more direct inquiry into nutritional intake and lifestyle choices rather than focusing solely on disease presence.