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 B
Explanation
A) The patient's integumentary system is within normal limits for his age: While thinning skin and decreased turgor can be common in older adults, the specific combination of findings, including the patient feeling cold, suggests that further investigation is warranted rather than assuming they are normal.
B) The patient may have a metabolic condition causing him to feel cold: Thin skin and non-elastic turgor can be indicative of aging, but the sensation of always feeling cold may point to an underlying metabolic condition, such as hypothyroidism or poor circulation, which can affect thermoregulation.
C) The patient has abnormal thinning of skin: While skin thinning is common in older adults, it is not necessarily "abnormal" in the context of aging. However, in conjunction with other symptoms like non-elastic turgor and cold sensitivity, it may warrant further evaluation.
D) The patient should have elastic turgor: In older adults, it is common to see decreased elasticity and turgor of the skin. Therefore, expecting the patient to have elastic turgor may not be appropriate, as it reflects the natural aging process rather than a healthy standard.
Correct Answer is ["C","E"]
Explanation
A) "I have cut back on fat and switched to a vegetarian diet." This statement suggests a positive change in dietary habits, which can lower the risk of cardiovascular disease. A vegetarian diet, particularly if it includes plenty of fruits, vegetables, and whole grains, is associated with a reduced risk of heart disease. Therefore, this statement does not indicate an increased risk.
B) "I have cut back on my smoking." While reducing smoking is a positive step, smoking itself is a significant risk factor for cardiovascular disease. However, the statement indicates an attempt to decrease risk, which does not inherently suggest an increased risk. It may show improvement rather than risk.
C) "I have been stressed out since my divorce last year." Chronic stress is a recognized risk factor for cardiovascular disease, as it can lead to behaviors such as poor diet, inactivity, and increased blood pressure. This statement highlights a significant concern for the client’s cardiovascular health.
D) "I have an occasional glass of wine." Moderate alcohol consumption is sometimes associated with cardiovascular benefits. While excessive drinking can pose risks, this statement alone does not indicate an increased risk of cardiovascular disease. It reflects moderation rather than concern.
E) "I have gained 25 pounds over the past year." Weight gain, especially if it leads to obesity, is a significant risk factor for developing cardiovascular disease. This statement indicates a change in health status that could negatively impact the client’s cardiovascular risk profile.