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The nurse is using inspection to assess the breasts of a female client. Which finding should the nurse anticipate documenting?

A.

Symmetry

B.

Hard nodules

C.

Skin texture

D.

Tenderness

Answer and Explanation

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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View Related questions

Correct Answer is A

Explanation

A) Information sharing is limited to those directly involved in the client's care: This statement reflects the principle of confidentiality and the ethical obligation to protect the client's private health information. Only healthcare providers directly involved in the client’s care should have access to their information, ensuring that it remains secure and confidential.

B) All members of the unit's healthcare team may have access to the client's chart: While many healthcare team members need access to the client's information for care coordination, this statement is misleading. Access should be limited to those directly involved in the client’s care to protect their confidentiality.

C) The Health Insurance Portability and Accountability Act (HIPAA) determines who may communicate with the client: While HIPAA does set guidelines for the protection of health information and governs the sharing of health data, it does not specifically determine who may communicate with the client. Instead, it focuses on protecting their privacy.

D) The medical records are open to any hospital employee, including administration: This statement is incorrect as it violates confidentiality principles. Medical records are not accessible to all hospital employees; access is restricted to authorized personnel only, ensuring that patient information is kept confidential.

Correct Answer is B

Explanation

A) Muscle strength: While muscle strength can influence gait, it specifically refers to the ability of muscles to exert force against resistance. Assessing muscle strength involves different techniques, such as manual muscle testing, rather than observing arm and leg movements.

B) Gait: The observation that both arms swing freely in alternation with leg swings is a direct assessment of the patient's gait. A normal gait pattern includes coordinated movements of the arms and legs, indicating proper motor function and balance.

C) Alignment: This term refers to the positioning of the body and its parts in relation to one another. While alignment can impact gait, it is not specifically assessed by observing the movement of the arms and legs.

D) Joint function: Joint function assessment typically focuses on the range of motion, stability, and mobility of individual joints. Observing the swing of arms and legs provides insight into overall gait rather than specific joint function.

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