Health Assessment Quiz 2 (ch.18- ch.26)

A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a lump in her right breast for years. Recently, it has begun to change in consistency and is becoming harder. She reports that 5 years ago her physician evaluated the lump and determined that it was "nothing to worry about." The nurse's examination validates the presence of a mass in the right upper outer quadrant at 1 o'clock, approximately 5 cm from the nipple. It is firm, mobile, and nontender, with borders that are not well defined. What is the best response by the nurse? a. "Because of the change in consistency of the lump, it should be further evaluated by a physician." b. "The changes could be r/t your menstrual cycles. Keep track of the changes in the mass each month." c. "The lump is probably nothing to worry about because it has been present for years and was determined to be noncancerous 5 years ago." d. "Because you are experiencing no pain and the size has not changed, you should continue to monitor the lump and return to the clinic in 3 months."

A

A 54-year-old man comes to the clinic with a "horrible problem." He tells the nurse that he has just discovered a lump on his breast and is fearful of cancer. The nurse knows which statement about breast cancer in men is true? a. Breast cancer in men rarely spreads to the lymph nodes. b. Less than one percent of all breast cancers occurs in men. c. Most breast masses in men are diagnosed as gynecomastia. d. Breast masses in men are difficult to detect because of minimal breast tissue.

A

A new mother calls the clinic to report that part of her left breast is red, swollen, tender, very hot, and hard. She has a fever of 38.3° C. She also has had symptoms of influenza, such as chills, sweating, and feeling tired. The nurse notices that she has been breastfeeding for 1 month. From her description, what condition does the nurse suspect? a. Mastitis b. Paget disease c. Plugged milk duct d. Mammary duct ectasia

A

A patient is newly diagnosed with benign breast disease. The nurse recognizes which statement about benign breast disease to be true? a. It makes it more difficult to examine the breasts. b. It is easily reduced with hormone replacement therapy. c. It frequently turns into cancer in a woman's later years. d. It is usually diagnosed before a woman reaches childbearing age.

A

A woman has just learned that she is pregnant. What should the nurse teach this patient about changes in her breasts? a. She can expect her areolae to become larger and darker in color. b. Breasts may begin secreting milk after the fourth month of pregnancy. c. She should inspect her breasts for visible veins and immediately report these. d. During pregnancy, breast changes are fairly uncommon; most of the changes occur after the birth.

A

An adult patient with a history of allergies comes to the clinic complaining of wheezing and difficulty in breathing when working in his yard. The assessment findings include tachypnea, the use of accessory neck muscles, prolonged expiration, intercostal retractions, decreased breath sounds, and expiratory wheezes. What do these findings suggest? a. Asthma b. Atelectasis c. Lobar pneumonia d. Heart failure

A

During a breast examination on a female patient, the nurse notices that the nipple is flat, broad, and fixed. The patient states it "started doing that a few months ago." What does this finding suggest? a. Dimpling b. Retracted nipple c. Nipple inversion d. Deviation in nipple pointing

A

During an annual physical examination, a 43-year-old patient states that she does not perform monthly breast self-examinations (BSEs). She tells the nurse that she believes that mammograms "do a much better job than I ever could to find a lump." What should the nurse include in his or her response to this patient? a. BSEs may detect lumps that appear between mammograms. b. She is correct—mammography is a good replacement for BSE. c. The American Cancer Society recommends women over 40 years old perform a monthly BSE. d. She does not need to perform BSEs as long as a physician checks her breasts annually.

A

During an examination, the nurse notes a supernumerary nipple just under the patient's left breast. The patient tells the nurse that she always thought it was a mole. Which statement about this finding is correct? a. This variation is normal and not a significant finding. b. This finding is significant and needs further investigation. c. A supernumerary nipple also contains glandular tissue and may leak milk during pregnancy and lactation. d. The patient is correct—a supernumerary nipple is actually a mole that happens to be located under the breast.

A

The nurse has palpated a lump in a female patient's right breast. The nurse documents this as a small, round, firm, distinct, lump located at 2 o'clock, 2 cm from the nipple. It is nontender and fixed. No associated retraction of the skin or nipple, no erythema, and no axillary lymphadenopathy are observed. What information is missing from the documentation? a. Size of the lump b. Shape of the lump c. Consistency of the lump d. Whether the lump is solitary or multiple

A

The nurse is assisting with a BSE clinic. Which of these women reflects abnormal findings during the inspection phase of breast examination? a. Woman whose nipples are in different planes (deviated) b. Woman whose left breast is slightly larger than her right c. Nonpregnant woman whose skin is marked with linear striae d. Pregnant woman whose breasts have a fine blue network of veins visible under the skin

A

The nurse is listening to the breath sounds of a patient with severe asthma. Air passing through narrowed bronchioles would produce which of these adventitious sounds? a. Wheezes b. Bronchophony c. Bronchial sounds d. Whispered pectoriloquy

A

The nurse is observing the auscultation technique of a student nurse. What is the correct method to use when progressing from one auscultatory site on the thorax to another? a. Side-to-side comparison b. Top-to-bottom comparison c. Posterior-to-anterior comparison d. Interspace-by-interspace comparison

A

The nurse is palpating a female patient's breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation? a. Supine with the arms raised over her head b. Sitting with the arms relaxed at her sides c. Supine with the arms relaxed at her sides d. Sitting with the arms flexed and fingertips touching her shoulders

A

What are the primary muscles of respiration? a. Diaphragm and intercostals b. Sternomastoids and scaleni c. Trapezii and rectus abdominis d.External obliques and pectoralis major

A

When assessing a patient's lungs, what should the nurse recall about the left lung? a. Consists of two lobes. b. Is divided by the horizontal fissure. c. Primarily consists of an upper lobe on the posterior chest. d. Is shorter than the right lung because of the underlying stomach.

A

When assessing tactile fremitus, the nurse recalls that it is normal to feel tactile fremitus most intensely over which location? a. Between the scapulae b. Third intercostal space, MCL c. Over the lower lobes, posterior side d. Fifth intercostal space, midaxillary line (MAL)

A

Which of the following statements is true regarding the internal structures of the breast? a. Fibrous, glandular, and adipose tissues b. Primarily muscle with very little fibrous tissue c. Primarily milk ducts, known as lactiferous ducts d. Glandular tissue, which supports the breast by attaching to the chest wall

A

Which of these statements is true regarding the vertebra prominens? a. It is the spinous process of C7. b. It is nonpalpable in most individuals. c. It is opposite the interior border of the scapula. d. It is located next to the manubrium of the sternum.

A

The nurse is assessing the breasts of a 68-year-old woman and discovers a mass in the upper outer quadrant of the left breast. When assessing this mass, the nurse is aware that characteristics of a cancerous mass include which of the following? (Select all that apply.) a. Nontender mass b. Regular border c. Hard, dense, and immobile d. Rubbery texture and mobile e. Dull, heavy pain on palpation f. Irregular, poorly delineated border

A, F

The nurse is percussing over the lungs of a patient with pneumonia. If the patient has atelectasis, what sound will the nurse hear? a. Tympany b. Dullness c. Resonance d. Hyperresonance

B

The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique? a. The best time to perform BSE is in the middle of the menstrual cycle. b. A woman should perform BSEs bimonthly unless she has fibrocystic breast tissue. c. The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. d. If she suspects that she is pregnant, then the woman should not perform a BSE

C

A 55-year-old postmenopausal woman is being seen in the clinic for her annual examination. She is concerned about changes in her breasts that she has noticed over the past 5 years. She states that her breasts have decreased in size and that the elasticity has changed so that her breasts seem "flat and flabby." Which is the best reply by the nurse? a. "This change occurs most often because of long-term use of bras that do not provide enough support to the breast tissues." b. "Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast and is a normal process of aging." c. "This is a normal change that occurs as women get older and is due to the increased levels of progesterone during the aging process." d. "Postural changes in the spine make it appear that your breasts have changed in shape. Exercises to strengthen the muscles of the upper back and chest wall will help prevent the changes in elasticity and size."

B

A patient states during the interview that she noticed a new lump in the shower a few days ago. It was on her left breast near her axilla. How should the nurse proceed? a. Palpate the lump first. b. Palpate the unaffected breast first. c. Avoid palpating the lump because it could be a cyst, which might rupture. d. Palpate the breast with the lump first but plan to palpate the axilla last.

B

A teenage patient comes to the emergency department with complaints of an inability to breathe and a sharp pain in the left side of his chest. The assessment findings include cyanosis, tachypnea, tracheal deviation to the right, decreased tactile fremitus on the left, hyperresonance on the left, and decreased breath sounds on the left. What do these findings suggest? a. Bronchitis b. Pneumothorax c. Acute pneumonia d. Asthmatic attack

B

During a breast health interview, a patient states that she has noticed pain in her left breast. Which statement by the nurse is most appropriate? a. "Don't worry about the pain; breast cancer is not painful." b. "I would like some more information about the pain in your left breast." c. "Oh, I had pain like that after my son was born; it turned out to be a blocked milk duct." d. "Breast pain is almost always the result of benign breast disease."

B

During an assessment of an adult, the nurse has noted unequal chest expansion and recognizes that this occurs in which situation? a. In an obese patient b. When part of the lung is obstructed or collapsed c. When bulging of the intercostal spaces is present d. When accessory muscles are used to augment respiratory effort

B

During an assessment, the nurse knows that expected assessment findings in the normal adult lung include which findings? a. Adventitious sounds and limited chest expansion b. Muffled voice sounds and symmetric tactile fremitus c. Increased tactile fremitus and dull percussion tones d. Absent voice sounds and hyperresonant percussion tones

B

During an examination of a woman, the nurse notices that her left breast is slightly larger than her right breast. Which of these statements is true about this finding? a. Asymmetry of the breasts is unusual and the patient should be referred to physician b. Asymmetry of the breasts is common, but the nurse should verify that this finding is not new. c. Asymmetry of breast size and shape is very unusual and means she may have an inflammation or growth. d. Asymmetry of breast size and shape is probably due to breastfeeding and is nothing to worry about.

B

During auscultation of the lungs, the nurse expects decreased breath sounds to be heard in which situation? a. When adventitious sounds are present b. When the bronchial tree is obstructed c. In conjunction with whispered pectoriloquy d. In conditions of consolidation, such as pneumonia

B

If a patient reports a recent breast infection, then the nurse should expect to find what type of node enlargement? a. Nonspecific b.Ipsilateral axillary c.Inguinal and cervical d.Contralateral axillary

B

In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. What is the reason for this? a. It is the largest quadrant of the breast. b. It is the most common location of breast tumors. c. It is where the majority of suspensory ligaments attach. d. It is more prone to injury and calcifications than other locations in the breast.

B

The nurse is preparing for a class on breast cancer. Which statement is true with regard to cultural differences in breast cancer in the United States? a. Black women have a lower incidence of aggressive, triple negative breast cancer. b. The relative 5-year survival rate for black women is lower than that for Caucasian women. c. For every stage of breast cancer, Asian/Pacific Islander women have the lowest rate of survival. d. Ashkenazi Jewish women have a significantly lower prevalence of BRCA1 and BRCA2 gene mutations.

B

The nurse is reviewing the characteristics of breath sounds. Which statement about bronchovesicular breath sounds is true? a. Musical in quality b. Expected near the major airways c. Usually caused by a pathologic disease d. Similar to bronchial sounds except shorter in duration

B

The nurse is reviewing the technique of palpating for tactile fremitus with a new graduate. Which statement by the graduate nurse reflects a correct understanding of tactile fremitus? a. "Is caused by moisture in the alveoli." b. "Is caused by sounds generated from the larynx." c. "Reflects the blood flow through the pulmonary arteries." d. "Indicates that air is present in the subcutaneous tissues."

B

When assessing the respiratory system of a 4-year-old child, which of these findings would the nurse expect? a. Crepitus palpated at the costochondral junctions b. Presence of bronchovesicular breath sounds in the peripheral lung fields c. No diaphragmatic excursion as a result of a child's decreased inspiratory volume d. Irregular respiratory pattern and a respiratory rate of 40 breaths per minute at rest

B

Where does the trachea bifurcate on the anterior chest? a. Costal angle b. Sternal angle c. Xiphoid process d. Suprasternal notch

B

Which is a normal finding when assessing the respiratory system of an older adult? a. Increased thoracic expansion b. Decreased mobility of the thorax c. Decreased anteroposterior diameter d. Bronchovesicular breath sounds throughout the lungs

B

Which statement about the apices of the lungs is true? a. Are at the level of the second rib anteriorly. b. Extend 3 to 4 cm above the inner third of the clavicles. c. Are located at the sixth rib anteriorly and the eighth rib laterally. d. Rest on the diaphragm at the fifth intercostal space in the midclavicular line (MCL).

B

While inspecting a patient's breasts, the nurse finds that the left breast is slightly larger than the right with the bilateral presence of Montgomery glands. How should the nurse proceed? a. Palpate over the Montgomery glands, checking for drainage. b. Consider these findings as normal, and proceed with the examination. c. Ask extensive health history questions regarding the woman's breast asymmetry. d. Continue with the examination, and then refer the patient for further evaluation of the Montgomery glands.

B

The nurse is examining a 62-year-old man and notes that he has bilateral gynecomastia. The nurse should explore his health history for which related conditions? (Select all that apply.) a. Malnutrition b. Liver disease c. Hyperthyroidism d. Type 2 diabetes mellitus e. History of alcohol abuse

B, C, E

. A patient contacts the office and tells the nurse that she is worried about her 10-year-old daughter having breast cancer. She describes a unilateral enlargement of the right breast with associated tenderness. She is worried because the left breast is not enlarged. Which response by the nurse to the mother is best? a. "Breast development is usually fairly symmetric your daughter should be examined right away." b. "You should bring in your daughter right away because breast cancer is fairly common in preadolescent girls." c. "Although an examination of your daughter would rule out a problem, her breast development is most likely normal." d. "It is unusual for breasts that are first developing to feel tender because they haven't developed much fibrous tissue."

C

A 65-year-old patient with a history of heart failure comes to the clinic stating "I keep waking up from sleep with shortness of breath." Which action by the nurse is most appropriate? a. Obtain a detailed health history of the patient's allergies and a history of asthma. b. Tell the patient to sleep on his or her right side to facilitate ease of respirations. c. Assess for other signs and symptoms of paroxysmal nocturnal dyspnea. d. Assure the patient that paroxysmal nocturnal dyspnea is normal and will probably resolve within the next week.

C

A mother brings her 3-month-old infant to the clinic for evaluation of a cold. She tells the nurse that he has had "a runny nose for a week." When performing the physical assessment, the nurse notes that the child has nasal flaring and sternal and intercostal retractions. What should the nurse do next? a. Ask the mother if the infant has had trouble with feedings. b. Assure the mother that these signs are normal symptoms of a cold. c. Recognize that these are serious signs, and contact the physician. d. Perform a complete cardiac assessment because these signs are probably indicative of early heart failure.

C

A woman is in the family planning clinic seeking birth control information. She states that her breasts "change all month long" and that she is worried that this is unusual. What is the best response by the nurse? a. "Continual changes in your breasts are unusual. The breasts of nonpregnant women usually stay pretty much the same all month long." b. "Breast changes in response to stress are very common and you should assess your life for stressful events." c. "Because of the changing hormones during the monthly menstrual cycle, cyclic breast changes are common." d. "Breast changes normally occur only during pregnancy. You should get a pregnancy test done as soon as possible."

C

During a physical examination, a 45-year-old woman states that she has had a crusty, itchy rash on her breast for approximately 2 weeks. In trying to find the cause of the rash, which question would be important for the nurse to ask? a. "Is the rash raised and red?" b. "Does it appear to be cyclic?" c. "Where did the rash first appear—on the nipple, the areola, or the surrounding skin?" d. "What was she doing when she first noticed the rash, and do her actions make it worse?"

C

During an examination of a 7-year-old girl, the nurse notices that the girl is showing breast budding. What should the nurse do next? a. Nothing; breast budding is a normal finding. b. Ask the young girl if her periods have started. c. Assess the girl's weight and body mass index (BMI). d. Ask the girl's mother at what age she started to develop breasts.

C

During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate? a. Normal nipple inversion is usually bilateral. b. Unilateral inversion of a nipple is always a serious sign. c. Whether the inversion is a recent change should be determined. d. Nipple inversion is not significant unless accompanied by an underlying palpable mass.

C

In examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurse's best course of action? a. Recommend that he make an appointment with his physician for a mammogram. b. Acknowledge it as benign breast enlargement which is not unusual in men. c. Explain that this condition may be the result of hormonal changes, and recommend that he see his physician. d. Explain that gynecomastia in men is usually associated with prostate enlargement and recommend that he be thoroughly screened.

C

In performing an assessment of a woman's axillary lymph system, the nurse should assess which of these nodes? a. Central, axillary, lateral, and sternal b. Pectoral, lateral, anterior, and sternal c. Central, lateral, pectoral, and subscapular d. Lateral, pectoral, axillary, and suprascapular

C

The nurse is auscultating the chest in an adult. Which technique is correct? a. Instructing the patient to take deep, rapid breaths b. Instructing the patient to breathe in and out through his or her nose c. Firmly holding the diaphragm of the stethoscope against the skin of the chest d. Lightly holding the bell of the stethoscope against the skin on the chest to avoid friction

C

The nurse would most likely hear fine crackles in which patient or situation? a. A pregnant woman b. A healthy 5-year-old child c. The immediate newborn period d. A patient with a pneumothorax

C

When auscultating the lungs of an adult patient, the nurse notes that low-pitched, soft breath sounds are heard over the posterior lower lobes, with inspiration being longer than expiration. How should the nurse interpret these findings? a. Normal sounds auscultated over the trachea. b. Bronchial breath sounds that are normal in that location. c. Vesicular breath sounds that are normal in that location. d. Bronchovesicular breath sounds that are normal in that location.

C

When performing a respiratory assessment on a patient, the nurse notices a costal angle of approximately 90 degrees. What should the nurse recognize about this finding? a. Observed in patients with kyphosis. b. Indicative of pectus excavatum. c. A normal finding in a healthy adult. d. An expected finding in a patient with a barrel chest.

C

While examining a 75-year-old woman, the nurse notices that the skin over her right breast is thickened and the hair follicles are exaggerated. What is this condition called? a. Dimpling b. Retraction c. Peau d'orange d. Benign breast disease

C

29.)The nurse is assessing the lungs of an older adult. Which of these changes are normal in the respiratory system of the older adult? a. Decrease in small airway closure occurs, leading to problems with atelectasis. b. Severe dyspnea is experienced on exertion, resulting from changes in the lungs. c. Respiratory muscle strength increases to compensate for a decreased vital capacity. d. Lungs are less elastic and distensible, which decreases their ability to collapse and recoil.

D

A 14-year-old girl is anxious about not having reached menarche. When taking the health history, the nurse should ascertain which of the following? a. The age her mother developed breasts b. The age she began to develop pubic hair c. The age she began developing axillary hair d. The age the girl began to develop breasts

D

A 65-year-old patient remarks that she just cannot believe that her breasts "sag so much." She states it must be from a lack of exercise. What explanation should the nurse offer her? a. After menopause, only women with large breasts experience sagging. b. After menopause, sagging is usually due to decreased muscle mass within the breast. c. After menopause, a diet that is high in protein will help maintain muscle mass, which keeps the breasts from sagging. d. After menopause, the glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag.

D

A 9-year-old girl is in the clinic for a sport physical examination. After some initial shyness she finally asks, "Am I normal? I don't seem to need a bra yet, but I have some friends who do. What if I never get breasts?" Which response by the nurse is best? a. "Don't worry, you still have plenty of time to develop." b. "I know just how you feel, I was a late bloomer myself. Just be patient, and they will grow." c. "You will probably get your periods before you notice any significant growth in your breasts." d. "I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age."

D

A patient has a long history of chronic obstructive pulmonary disease (COPD). During the assessment, the nurse will most likely observe which of these? a. Unequal chest expansion b. Increased tactile fremitus c. Atrophied neck and trapezius muscles d. Anteroposterior-to-transverse diameter ratio of 1:1

D

During a health history interview, a female patient states that she has noticed a few drops of clear discharge from her right nipple. What should the nurse do next? a. Ask her if she is possibly pregnant. b. Immediately contact the physician to report the discharge. c. Immediately obtain a sample for culture and sensitivity testing. d. Ask the patient some additional questions about the medications she is taking.

D

During an interview, a patient reveals that she is pregnant. She states that she is not sure whether she will breastfeed her baby and asks for some information about this. Which of these statements by the nurse is accurate? a. "Breastfed babies tend to be more colicky." b. "Breastfed babies eat more often than infants on formula." c. "Breastfeeding is second nature, and every woman can do it." d. "Breastfeeding provides the perfect food and antibodies for your baby."

D

During auscultation of the lungs of an adult patient, the nurse notices the presence of bronchophony. The nurse should assess for signs of which condition? a. Asthma b. Emphysema c. Airway obstruction d. Pulmonary consolidation

D

During percussion, the nurse hears a dull percussion note elicited over a lung lobe. What is the most likely cause of this finding? a. Shallow breathing b. Normal lung tissue c. Decreased adipose tissue d. Increased density of lung tissue

D

The nurse is performing a breast examination. Which of these statements best describes the correct procedure to use when screening for nipple and skin retraction during a breast examination? a. Have the patient bend over and touch her toes. b. Have the patient lie down on her left side and observe for any retraction. c. Have the patient shift from a supine position to a standing position, and note any lag or retraction. d. Have the patient slowly lift her arms above her head, and note any retraction or lag in movement.

D

The nurse is reviewing risk factors for breast cancer. Which of these women have risk factors that place them at a higher risk for breast cancer? a. 37-year-old who is slightly overweight b. 42-year-old who has had ovarian cancer c. 45-year-old who has never been pregnant d. 66-year-old whose mother had breast cancer

D

The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct? a. "Your breast milk is immediately present after the delivery of your baby." b. "Breast milk is rich in protein and sugars (lactose) but has very little fat." c. "The colostrum, which is present right after birth, does not contain the same nutrients as breast milk." d. "You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy."

D

When inspecting the anterior chest of an adult, the nurse should include which assessment? a. Diaphragmatic excursion b. Symmetric chest expansion c. Presence of breath sounds d. Shape and configuration of the chest wall

D

Which of these clinical situations would the nurse consider to be outside normal limits? a. A patient has had one pregnancy and states that she believes she may be entering menopause. Her breast examination reveals breasts that are soft and slightly sagging. b. A patient has never been pregnant. Her breast examination reveals large pendulous breasts that have a firm, transverse ridge along the lower quadrant in both breasts. c. A patient has never been pregnant and reports that she should begin her period tomorrow. Her breast examination reveals breast tissue that is nodular and somewhat engorged. She states that the examination was slightly painful. d. A patient has had two pregnancies, and she breastfed both of her children. Her youngest child is now 10 years old. Her breast examination reveals breast tissue that is somewhat soft, and she has a small amount of thick yellow discharge from both nipples.

D