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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View Related questions
Correct Answer is A
Explanation
A) "Women should be familiar with their own breasts so that they can report any changes to their provider": This statement aligns with current recommendations emphasizing the importance of breast self-awareness. Women are encouraged to be familiar with their breast tissue so they can recognize any changes, such as lumps or alterations in size or shape, and report these changes to their healthcare provider. This proactive approach can lead to earlier detection of breast cancer.
B) "All women should have a breast screening with an MRI beginning at age 40": This statement is misleading, as the American Cancer Society does not recommend routine MRI screenings for all women. MRI is typically reserved for women at high risk for breast cancer. The standard guideline includes annual mammograms starting at age 40, but not MRI for all.
C) "Mammograms do not help with detecting breast cancer until after age 54": This statement is incorrect. Mammograms are effective in detecting breast cancer well before age 54, and the American Cancer Society recommends that women start getting annual mammograms at age 40. Early detection through regular screenings is critical for improving outcomes.
D) "Mammograms are only indicated if there is a strong family history": This statement is also inaccurate. While family history can increase the risk for breast cancer and may influence screening frequency, all women are encouraged to have regular mammograms starting at age 40, regardless of family history. This guideline aims to catch potential cancers early in all women.
Correct Answer is C
Explanation
A) Motor component of IV (Trochlear): The trochlear nerve primarily controls the superior oblique muscle of the eye, which is responsible for downward and lateral eye movements. The findings described do not relate to eye movement and therefore do not indicate dysfunction of this nerve.
B) Motor and sensory components of XI (Accessory): The accessory nerve innervates the sternocleidomastoid and trapezius muscles, primarily affecting head rotation and shoulder elevation. The symptoms noted in the assessment do not pertain to these muscle functions, so this option is not correct.
C) Motor component of VII (Facial): The signs of asymmetry in frowning, uneven eyebrow lifting, sagging eyelids, and air escaping when puffing the cheeks are characteristic of dysfunction in the facial nerve (cranial nerve VII). This nerve controls the muscles of facial expression, and impairment would lead to the described asymmetrical movements.
D) Motor component of X (Vagus) and sensory component of XII (Hypoglossal): The vagus nerve affects autonomic functions and some swallowing muscles, while the hypoglossal nerve controls tongue movements. Neither nerve is primarily responsible for the facial expressions described in the assessment findings, making this option incorrect.