SITUATIONAL 2

The nurse is caring for a healthy adult client with no history of vision problems. The nurse should tell the client that a thorough eye examination is recommended every

2 years

Fibrocystic breast

A female client tells the nurse that her breast become lumpy and sore before menstruation but get better at the end of the menstrual cycle. The nurse should explain to the client that these symptoms are associated with

An adult client visits the outpatient clinic and tells the nurse that he has a throbbing arching pain in his right eye. The nurse should assess the client for

A foreign body in the eye

While assessing an adult client's skull, the nurse observes that the client's skulls and facial bones are larger and thicker than usual. The nurse should assess the client for

Acromegaly

An adult client tells the nurse that she frequently experiences burning and itching of both eyes. The nurse should assess the client for

Allergies

4. While assessing an adult client, the nurse observes decreased chest expansion at the bases of the client's lungs. The nurse should refer the client to a physician for possible

Ans: Chronic obstructive pulmonary disease

1. While assessing an adult client, the client tells the nurse that she "has had difficulty catching her breath since yesterday." The nurse should assess the client further for signs and symptoms of

Ans: Infection

9. While assessing an adult client's lungs during the postoperative period, the nurse detects coarse crackles. The nurse should refer the client to a physician for possible

Ans: Pneumonia

7. While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice sounds. To assess bronchophony, the nurse should ask the client to

Ans: Repeat the phrase "ninety-nine"

3. The nurse is planning a presentation to a group of high school students on the topic of lung cancer. Which of the following should the nurse plan to include in the presentation?

Ans: Studies have indicated that there is a genetic component in the development of lung cancer

2. An adult client visits the clinic and tells the nurse that he has been "spitting up rust-colored sputum." The nurse should refer the client to the physician for possible

Ans: Tuberculosis

An adult client visits the clinic complaining of recurrent ulcers in the mouth. The nurse assesses the client's mouth and observes a painful ulcer. The nurse should document the presence of

Aphthous stomatitis

The nurse is planning to assess an adult client's thyroid gland. The nurse should plan to

Approach the client posteriorly

The nurse is assessing an adult client's oral cavity for possible oral cancer. The nurse should explain to the client that the most common site of oral cancer is the

Area underneath the tongue

The nurse is assessing the mouth of an older adult and observes that the client appears to have poorly fitting dentures. The nurse should instruct the client that she may be at greater risk for

Aspiration

An adult client tells the nurse that he has been experiencing gradual vision loss. The nurse should

Check the client's blood pressure

The nurse is planning to inspect an adult client's mouth, using a tongue depressor. The nurse should plan to

Depress the tongue blade slightly off center

The nurse is planning a presentation to a group of high school students about the risk factors for oral cancer. Which of the following should be included in the nurse's plan?

Diets low in fruits and vegetables are a possible risk for oral cancer

Before examining the mouth of an adult client, the nurse should first

Don clean gloves for the procedure

African American women may not engage in breast cancer screening

During breast assessment, the nurse should consider the client culture because

While assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. The nurse should document the client's

Esotropia

An adult client visits the clinic and tells the nurse that she has had a sudden change in her vision. The nurse should explain to the client that sudden changes in vision are often associated with

Head trauma

A female client visits the clinic and tells the nurse that she wants to "stay healthy." The nurse observes that the client has diffuse neck enlargement, is perspiring, and is quite fidgety. The client tells the nurse that she is "hungry all the time, but I have lost weight." A priority nursing diagnosis for the client is

Health-seeking behaviors related to verbalization of wanting to stay healthy and concerns over weight loss

An adult client visits the clinic and tells the nurse that he has been experiencing double vision for the past few days. The nurse refers the client to a physician for evaluation of possible

Increased intracranial pressure

While assessing the ears of an adult client, the nurse observes that the tympanic membrane is completely immobile. The nurse should further assess the client for signs and symptoms of

Infection

An adult client visits the clinic and tells the nurse that he has had excessive tearing in his left eye. The nurse should assess the client's eye for

Lacrimal obstruction

The nurse is preparing to examine the sinuses of an adult client. After examining the frontal sinuses, the nurse should proceed to examine the

Maxillary sinuses

A client visit the outpatient center with a complaint of sudden head and neck pain and stiffness. The client's oral temperature is 37.7 C (100 F). The nurse suspects the client is experiencing symptoms of

Meningeal irritation

A female client visits the clinic and tells the nurse that she frequently experiences severe recurring headache that sometimes last for several days and are accompanied by nausea and vomiting. The nurse determines that the type of headache the client is describing is a

Migraine headache

The nurse is planning to perform an ear examination on an adult client. After explaining the procedures to the client, the nurse should

Observe the client's response to the explanations

Set a day of the month for BSE

Older clients and others who no longer menstruate and who decide to continue with BSE may find it helpful to do what?

The nurse assesses an adult client's head and neck. While examining the carotid arteries, the nurse assesses each artery individually to prevent a

Reduction of the blood supply to the brain

An adult client visits the clinic and tells the nurse that she has been experiencing frequent nosebleeds for the past month. The nurse should

Refer the client for further evaluation

The nurse is preparing to assess the lymph nodes of an adult client. The nurse should instruct the client to

Sit in an upright position

The nurse is preparing to assess the neck of an adult client. To inspect movements of the client's thyroid gland, the nurse should ask the client to

Swallow a small sip of water

A client visits the clinic and tells the nurse that he is depressed because of a recent job loss. He complains of dull, aching, tight, and diffuse headaches that have lasted for several days. The nurse should recognize that these are symptoms of

Tension headaches

Lateral lymph nodes

The lymph nodes that are responsible for drainage from the arms are the

Having a baby before the ago of 20 years

The nurse has discussed the risks for breast cancer with a group of high school seniors. The nurse determines that one of the students need further instructions when the student says that one risk factor is

Refer the client for a cytology examination

The nurse is assessing a 50-year-old clients breast and observer a spontaneous discharge of fluid from the left nipple. The nurse should

Grapefruit juice

The nurse is caring for a female client who has received a diagnosis of fibrocystic breast disease. The nurse has instructed the client about the disease. The nurse determines that the client needs further instructions when the client says she should avoid drinking

Contraceptives

The nurse is caring for an adult female client when the client tells the nurse that she has had a clear discharge from her nipples for the past month. The nurse should ask the client if she had been taking

An infectious drainage

The nurse is preparing to examine the breasts of a female client who had a left radical mastectomy 3 years ago. When examining the client, the nurse observe redness at the scar area. The nurse should explain to the client that this may be indicative of

Tumor

The nurse observers dimpling in an adult female client's breast. The nurse should explain to the client that dimpling of the breast may indicate a

Women who have never given birth Women who had their first child after age 30

The risk of breast cancer is greater to whom?

Liver disorder

Then nurse is assessing an adult male client when the nurse observes gynecomastia in the client. The nurse should ask the client if he is taking any medications for

Breast cancer

This is the most common cancer amount women

An adult client tells the nurse that his father had cataracts. He asks the nurse about risk factors for cataracts. The nurse should instruct the client that a potential risk factor is

UV light exposure

Inspection Palpation

What two physical assessment techniques you use when assessing the Breast?

An adult client tells the nurse that his 80 year old father is almost completely deaf. After an explanation to the client about risk factors for hearing loss, the nurse determines that the client needs further instruction when the client says

"It is difficult to prevent hearing loss or worsening of hearing"

Disturbed body image related to mastectomy

A client has had a recent mastectomy and visit the clinic for postoperative evaluation. The client tells the nurse that she has been depressed and feels as if she is less of a woman. The most appropriate nursing diagnosis fo this client is

After examining the client's tympanic membranes, the nurse documents "Right tympanic membrane, red and bulging with no light reflex." The nurse recognizes that these are signs of

Acute otitis media

Upper outer quadrant

After assessing the breast of a female client, the nurse should explain to the client that most breast tumors occur in the

The nurse has assessed the nose of an adult client and has explained to the client about her thick yellowish nasal discharge. The nurse determines that the client understands the instructions when the client says that the yellowish discharge is most likely due to

An upper respiratory infection

6. The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should

Ans: Ask the client to breathe deeply through her mouth

5. The nurse is planning to percuss the chest of an adult male client for diaphramagtic excursion. The nurse should begin the assessment by

Ans: Asking the client exhale forcefully and hold his breath

10. The nurse assesses an adult client breath sounds and hears sonorous wheezes, primarily during the client's expiration. The nurse should refer the client to a physician for a possible

Ans: Bronchitis

8. The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible

Ans: Chronic bronchitis

The nurse is preparing to perform a head and neck assessment of an adult client who has immigrated to the US from Cambodia. The nurse should first

Ask the client if touching the head is permissible

The nurse is assessing a client who has been taking antibiotics for an infection for 10 days. The nurse observes whitish curd-like patches in the client's mouth. The nurse should explain to the client that these spots are most likely

Candida albicans infection

An adult client visits the clinic and tells the nurse that she has had headache recently that are intense and stabbing and often occur in the late evening. The nurse should suspect the presence of

Cluster headache

The transmission of sound waves through the external ear and the middle ear is known as

Conductive hearing

The nurse has performed the Rinne test on an older adult client. After the trst, the client reports that her bone conduction sound was heard longer than the air conduction sound. The nurse determines that the client is most likely experiencing

Conductive hearing loss

An adult client tells the nurse that his eyes are painful because he left his contact lenses in too lon the day before yesterday. The nurse should instruct the client that prolonged wearing of contact lenses can lead to

Corneal damage

While assessing the eyes of an adult client, the nurse uses a wisp of cotton to stimulate the client's

Corneal reflexes

The nurse has tested the near visual acuity of a 45 year old client. The nurse explains to the client that the client has impaired near vision and discusses a possible reason for the condition. The nurse determines that the client has understood the instructions when the client says that presbyopia is

Decreased accommodation

The nurse has tested an adult client's visual fields and determined that the temporal field is 90 degrees in both eyes. The nurse should

Document the findings in the client's records

An adult client tells the nurse that her peripheral vision is not what it used to be and she has a blind spots in her left eye. The nurse should refer the client for evaluation of possible

Glaucoma

While assessing an adult client's head and neck, the nurse observes asymmetry in front of the client's ear lobes. The nurse refers the client to the physician because the nurse suspects the client is most likely experiencing an

Parotid gland enlargement

The nurse is preparing to examine an adult client's eyes, using a Snellen chart. The nurse should

Position the client 609.6 cm (20ft) away from the chart

The nurse is preparing to inspect the nose of an adult client with an otoscope. The nurse plans to

Position the handle of the otoscope to one side

A nurse assesses the mouth of an adult male client and observes a rough, crusty, eroded area. The nurse should

Refer the client for further evaluation

While assessing the ears of an adult client, the nurse observes bloody drainage in the client's ear. The nurse should

Refer the client to a physician

While assessing an older adult's neck, the nurse observes that the client's trachea is pulled to the left side. The nurse should

Refer the client to a physician for further evaluation

A client visits the local clinic after experiencing head trauma. The client tells the nurse that he has a consistent blind spot in his right eye. The nurse should

Refer the client to an ophthalmologist

A client has tested 20/40 on the distant visual acuity test using a Snellen chart. The nurse should

Refer the client to an optometrist

The nurse is examining an adult client's eyes. The nurse has explained the positions test to the client. The nurse determines the client needs further instructions when the client says that the positions test

Requires the covering of each eye separately

A client visits the clinic and tells the nurse that she has painful cracking in the corners of her lips. The nurse should assess the client's diet for a deficiency of

Riboflavin

An adolescent client tells the nurse that her mother says she grinds her teeth when she sleeps. The nurse should explain to the client that grinding the teeth may be a sign of

Stress and anxiety

The nurse is planning to conduct the Weber test on an adult male client. To perform this test, the nurse should plan to

Strike a tuning fork and place it on the center of the client's head or forehead

An adult client visits the clinic and complains of tinnitus. The nurse should ask the client if she has been

Taking antibiotics

A 45 year old client tells the nurse that he occasionally sees spots in front of his eyes. The nurse should

Tell the client that these often occur with aging

Breast cancer patients of the same race

The nurse is working with a community group to set up teaching programs to increase awareness among African American women about preventive screening techniques for breast cancer. In the teaching program, the nurse should plan to include

Blocked lymphatic drainage

The nurse observes an orange peel appearance, or pear d'orange, of the areolae of a clients breast. The nurse should explain to the client that this is most likely due to

Right after menstruation

The nurse plan to instruct an adult female client with regular menstural cycles, who is not taking oral contraceptives, about breast self- examination. The nurse should plan to instruct the client to perform breast self-examination.

An adult client visits the clinic complaining of a sore throat. After assessing the throat, the nurse documents the client's tonsils as 4+. The nurse should explain to the client that 4+ tonsils are present when the nurse observes tonsils that are

Touching each other

While assessing the head and neck of an adult client, the client tells the nurse that she has been experiencing sharp shooting facial pains that last from 10 to 20 seconds but are occuring more frequently. The nurse should refer the client for possible

Trigeminal neuralgia

An older client visits the clinic accompanied by his daughter. The daughter tells the nurse that her father has been experiencing severe headache that usually begin in the morning and become worse when he coughs. The client tells the nurse that he feels dizzy when he has the headaches. The nurse refers the client for further evaluation because these symptoms are characteristic of a

Tumor-related headache

A client tells the nurse that she has difficulty seeing while driving at night. The nurse should explain to the client that night blindness is often associated with

Vitamin A deficiency

Decrease size, firmness, and glandular tissue

What are expected changes in aging female breast?

Having no children or living birth to first child after age of 30 Recent oral contraceptive use Use of menopausal combined hormone replacement therapy No history of breast-feeding Alcohol consumption Excess weight or obesity Weight gain as adult female Limited physical activity Even dim light at night while sleeping

What are the risk assessment that are modifiable for Breast Cancer?

Gender Age Genetics Race/Ethnicity Family history Personal history Breast consistency Early menstruation Previous chest radiation Diethylstilbestrol

What are the risk assessment that are non modifiable for Breast Cancer?

Breast

What examination is this for? 1. Lie down and place your right arm behind you head 2. Use finger pads of the three-middle fingers on your left hand to feel for lumps in the right breast 3. Use three different levels of pressure to feel all the breast tissue 4. Use each pressure level to feel the breast tissue before moving on the next spot 5. It is normal to feel a firm ridge in the lower curve of each breast 6. Move around the breast in an up and down pattern 7. Be sure to check entire breast area

The nurse is preparing to examine the ears of an adult client with an otoscope. The nurse should plan to

firmly pull the auricle out, up and back