Health Assessment Chapters 16 & 17

"Sit up with the head tilted forward and pinch the nose."

A patient in the hospital experiences epistaxis. What should the nurse instruct the patient to do to stop the bleeding?

"The paranasal sinuses in the nasal cavity lighten the weight of the skull bones."

The nurse asks a nursing student to list the functions of the nose. Which statement by the student nurse needs correction?

There is redness and warmth around the scar.

The nurse is assessing a patient after a mastectomy on the right side. Which assessment finding is a cause for concern?

Nasal polyps

The nurse is assessing a patient who reports feeling like there is a valve that moves in the nose while breathing. What would the nurse expect to find during the examination of the nose?

Examine the features of the right breast followed by the left breast.

The nurse is assessing a patient who reports finding a lump in the left breast. Which intervention by the nurse is most appropriate?

Cranial nerve I

The nurse is assessing a patient who reports having lost the sense of smell. Which cranial nerve may be affected in this patient?

Stagnation of cellular debris in the ducts

The nurse is assessing a patient who reports purulent nipple discharge. What is the likely cause of this condition?

Instruct the patient to lean forward as the nurse supports the arms.

The nurse is assessing a patient with large, pendulous breasts for retraction. Which is the best intervention by the nurse?

The presence of localized redness with heat

The nurse is assessing a patient's breasts. Which finding does the nurse identify as abnormal?

Mastitis

The nurse is caring for a patient in the second month of lactation. The patient has an inflammatory mass forming outward from the areola and flu-like symptoms. What is the diagnosis for this patient?

Keep the area clean, dry, and exposed to the air.

The nurse is caring for a patient with cracked nipples due to breastfeeding. What instructions should the nurse provide to the patient?

Bleeding from the anterior nasal septum

The nurse is caring for a patient with epistaxis. Which symptom is most likely to be seen in this patient?

The nasal mucosa will become burned.

The nurse is caring for a young child who has inserted a tiny battery into the nostril. What is the impending risk for this patient?

Allow the patient to depress the tongue with the tongue blade. Ask the patient to lower the tongue without a tongue blade. Use the tongue blade to depress the tongue slightly off-center.

The nurse needs to assess the posterior pharyngeal wall of a patient whose gag reflex is easily triggered. What should the nurse do to prevent discomfort in the patient?

History of genetic mutations for BRCA1 or BRCA2

The nurse is evaluating the relative risk for breast cancer in a patient. Which factor contributes to a relative risk greater than 4.0?

Poor dental hygiene habits Poor ingestion of vitamin C Changes of hormone levels

The nurse is examining a patient with gingivitis. What are the causes that lead to this condition?

Paget's disease

The nurse is examining the breast of a patient. The nurse observes a small crust on the nipple apex that has spread to the areola. Which condition does the nurse suspect in the patient?

14

The nurse is examining the mouth of a 20-month-old infant. What is the expected number of deciduous teeth in this infant? Record your answer using a whole number.

Liver disease

The nurse is examining the mouth of a patient and notices a musty breath odor. What is the most likely cause of this finding?

The upper teeth rest directly on the lower teeth.

The nurse is examining the teeth of a patient. What is considered a normal finding?

A recent increase in size in one of the breasts

The nurse is performing a clinical breast examination (CBE) on a patient. Which assessment finding should the nurse refer for further investigation?

Speech difficulty

The nurse is preparing a young child with a cleft lip for surgery. What would be the consequence of delayed treatment?

"Do not put your baby in the crib with a bottle of milk."

The nurse is teaching a mother about preventing baby bottle tooth decay. Which statement by the nurse is appropriate?

Fruits Vegetables Sunflower Oil

The nurse is teaching a patient about the factors that can decrease the risk for breast cancer. Which foods does the nurse encourage the patient to consume?

"It is benign and may resolve spontaneously."

The nurse is teaching an adolescent who was diagnosed with fibroadenoma in the left breast. Which statement by the nurse would be appropriate?

Leukoplakia

Which assessment finding should the nurse refer for further investigation?

The anterior hard palate is muddy yellow.

The nurse shines a light on the roof of the patient's mouth to examine the palate. Which finding would need further investigation?

Palpate the nipple area and axillary lymph nodes. Combine with the examination of the anterior thorax. Inspect the chest wall and the skin surface for lumps.

What are the appropriate nursing interventions while examining the breast of a male patient?

Provide the patient with a pamphlet about BSE. Encourage a return demonstration of the teaching. Tell the patient to inspect the breasts in the shower. Instruct the patient to palpate in a supine position.

What interventions are appropriate for a nurse caring for a 22-year-old female patient who expresses the desire to learn the process of breast self-examination (BSE)?

Observe the newborn for any flaring nares. Suction both nares by using a bulb syringe. Insert a small lumen catheter into the nares.

What interventions should the nurse implement to determine the patency of the nares in a newborn?

It is freely moveable and feels firm and elastic.

What is a characteristic of fibroadenoma?

The presence of sucking tubercle

What is a normal finding in a 1-year-old infant?

Inability to metabolize estrogens

What is the cause of gynecomastia in a patient with Cushing syndrome?

Asking the patient to lean forward while the nurse supports the forearms

What is the proper method to examine large pendulous breasts?

Mastalgia

What is the term used by the nurse to describe pain in the breast?

Increased risk of nosebleeds Increased risk of gum bleeds Increased occurrence of nasal stuffiness

What should the nurse teach the patient about the changes in the nose and mouth during pregnancy?

The nose appears to feel more prominent.

When examining an elderly patient, what changes in the structure and function of the nose would the nurse expect to find?

Ipsilateral axillary nodes

Where does more than 75% of lymph from the breasts drain?

Save the mouth for the end of the examination. Put the infant supine on the examination table. Restrain the infant's arms during examination.

Which actions by the nurse would be indicated during the oral examination of a 2-week-old infant?

Pain increase before menses

Which assessment finding does the nurse associate with fibrocystic disease?

Presence of a unilateral, dense, irregular mass

Which assessment finding in a patient may indicate breast cancer?

Bifid uvula Ankyloglossia Macroglossia

Which conditions are likely to affect the speech of a patient?

Exposure to diethylstilbestrol (DES) Absence of full-term pregnancies Menopause after 55 years of age

Which factors are responsible for a 1.1 to 2.0 relative risk of breast cancer?

The patient has lacrimation and sneezing.

Which finding would the nurse associate with hay fever?

There is a slight enlargement and tenderness. The lobes feel prominent, with distinct margins. There is a transverse tissue in the lower quadrant.

Which findings are normal in the breast examination of a lactating 20-year-old patient?

Ensure complete emptying of the breast

Which information should the nurse provide to a lactating patient with a plugged duct?

The superior lateral corner

Which part of the breast is called the tail of Spence?

A perimenopausal woman who has lactated

Which patient is likely to have mammary duct ectasia?

Tonsillar tissue enlarges until puberty and then shrinks.

Which statement best describes a tonsillar tissue?

Tonsils touch the uvula

While assessing the throat of a child, the nurse documents the tonsils as 3+. What does this indicate?