245 review exam 3

which of the following statements is true regarding the internal structures of the breast?
Click the card to flip 👆
1 / 197
Terms in this set (197)
"I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years of age."

Adolescent breast development usually begins between 8 and 10 years of age. The nurse should not belittle the girls feelings by using statements like dont worry or by sharing personal experiences. The beginning of breast development precedes menarche by approximately 2 years
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. What would be the nurses best response? Tell the mother that:
Because of the changing hormones during the monthly menstrual cycle, cycic breast changes are common.

Breasts of the nonpregnant woman change with the ebb and flow of hormones during the monthly menstrual cycle. During the 3 to 4 days before menstruation, the breasts feel full, tight, heavy, and occasionally sore. The breast volume is smallest on days 4 to 7 of the menstrual cycle
You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy.

After the fourth month, colostrum may be expressed. This thick yellow fluid is the precursor of milk, and it contains the same amount of protein and lactose byt practically no fat. The breasts produce colostrum for the first few days after delivery. It is rich with antibodies that protect the newborn against infection; therefore, breastfeeding is important.
A 65-year-old patient remarks that she just cannot believe that her breasts sag so much. She states that it must be from a lack of exercise. What explanation should the nurse offer her? After menopause:The glandular and fat tissue atrophies, causing breast size and elasticity to diminish, resulting in breasts that sag. After menopause, the glandular tissue atrophies and is replaced with connective tissue. The fat envelope also atrophies, beginning in the middle years and becoming significant in the eighth and ninth decades of life. These changes decrease breast size and elasticity; consequently, the breasts droop and sag, looking flattened and flabbyIn examining a 70-year-old male patient, the nurse notices that he has bilateral gynecomastia. Which of the following describes the nurses best course of action?Explain that this condition may be the result of hormonal changes, and recommend that he see his physician. Gynecomastia may reappear in the aging man and may be attributable to a testosterone deficiencyDuring an examination of a 7-year-old girl, the nurse notices that the girls is showing breast budding. What should the nurse do next?Assess the girls weight and body mass index (BMI) Research has shown that girls with overweight or obese BMI levels have a higher occurrence of early onset of breast budding (before 8 years for black girls and age 10 for white girls) and early menarche.The nurse is reviewing statistics regarding breast cancer. Which woman, aged 40 years in the United States has the highest risk for developing breast cancer?Black The incidence of breast cancer varies within different cultural groups. White women have a higher incidence of breast cancer thatn black women starting at age 45 years; but black women have a higher incidence before age 45 years. Asian, Hispanic, and American Indian women have a lower risk for development of breast cancer.The nurse is preparing for a class in early detection of breast cancer. Which statement is true with regard to breast cancer in black women in the United States?Black women are more likely to die of breast cancer at any age. Black women have a higher incidence of breast cancer before age 45 years that white women and are more likely to die of their disease. In addition, black women are significantly more likely to be diagnosed with regional or distant breast cancer than are white women. These racial differences in mortalitly rates may be related to an insufficient use of screeing measures and a lack of access to health careDuring a breast health interview, a patient states that she has notices pain in her left breast. The nurses most appropriate response to this would beI would like some more information about the pain in your left breast. Breast pain occurs with trauma, inflammation, infection, or benign breast disease. The nurse will need to gather more information about the patients pain rather than make statements that ignore the patients concernsDuring 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?Ask the patient some additional questions about the medications she is taking. The use of some medications, such as oral contraceptives, phenothiazines, diuretics, digitalis, steroids, methyldopa, and calcium channel blockers, may cause clear nipple discharge. Bloody or blood-tinged discharge from the nipple, not clear, is significant, especially if a lump is also present.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?Where did the rash first appear, on the nipple, the areola, or the surrounding skin? The location where the rash first appeared is important for the nurse to determine. Paget disease starts with a small crust on the nipple apex and then spreads to the areola. Eczema or other dermatitis rarely starts at the nipple unless it is a result of breastfeeding. It usually starts on the areola or surrounding skin and then spreads to the nipple.A patient is newly diagnosed with benign breast disease. The nurse recognizes which statement about benign breast disease to be true? The presence of benign breast disease:Makes it hard to examine the breasts. The presence of benign breast disease makes it hard to examine the breasts; the general lumpiness of the breast conceals a new lumpDuring 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. The nurse should explain to her that:BSEs may detect lumps that appear between mammograms. A monthly practice of BSE, along with clinical breast examination and mammograms, are complementary screening measures. Mammography can reveal cancers too small to be detected by the woman or by the most experience examiner. However, interval lumps may become palpable between mammograms.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?Breastfeeding provides the perfect food and antibodies for your baby. Exclusively breastfeeding for 6 months provides the perfect food and antibodies for the baby, decreases the risk of ear infections, promotes bonding, and provides relaxationThe 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?65 year old whose mother had breast cancer Risk factors for breast cancer include having a first-degree relative with breast cancer and being olderthan 50 years of age.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?Asymmetry is not unusual, but the nurse should verify that this change is not new. The nurse should notice symmetry of size and shape. It is common to have a slight asymmetry in size; often the left breast is slightly larger than the right. A sudden increase in the size of one breast signifies inflammation or new growthThe nurse is assisting with a BSE clinic. Which of these women reflect abnormal findings during the inspection phase of breast examination?Woman whose nipples are in different planes (deviated). The nipples should be symmetrically placed on the same plane on the two breasts. With deviation in pointing, an underlying cancer may cause fibrosis in the mammary ducts, which pulls the nipple angle toward it.During the physical examination, the nurse notices that a female patient has an inverted left nipple. Which statement regarding this is most accurate?Whether the inversion is a recent change should be determined. The nurse should distinguish between a recently retracted nipple from one that has been inverted for many years or since puberty. Normal nipple inversion may be unilateral or bilateral and usually can be pulled out; that is, if it is not fixed. Recent nipple retraction signifies acquired diseaseThe 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. Have the woman:Slowly lift her arms above her head, and note any retraction or lag in movement. The woman should be directed to change position while checking the breasts for signs of skin retraction. Initially, she should be asked to lift her arms slowly over her head. Both breasts should move up symmetrically. Retraction signs are due to fibrosis in the breast tissue, usually caused by growing neoplasms. The nurse should notice whether movement of one breast is lagging.The nurse is palpating a female patients breasts during an examination. Which of these positions is most likely to make significant lumps more distinct during breast palpation?Supine with the arms over the head The nurse should help the woman to a supine position, tuck a small pad under the side to be palpated, and help the woman raise her arm over her head. These maneuvers will flatten the breast tissue and medially displace it. Any significant lumps will then feel more distinctWhich of these clnical situations would the nurse consider to be outside normal limits?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. If any discharge appears, the nurse should note its color and consistency. Except in pregnancy and lactation, any discharge is abnormal. In nulliparous women, normal breast tissue feels firm, smooth, and elastic; after pregnancy, the tissue feels soft and loose. Premenstrual engorgement is normal, and consists of a slight enlargement, tenderness to palpation, and a generalized nodularity. A firm, transverse ridge of compressed tissue in the lower quadrants, known as the inframammary ridge, is especially noticeable in large breastsA 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. The nurse should plan to:Palpate the unaffected breast first. If the woman mentions a breast lump she has discovered herself, then the nurse should examine the unaffected breast first to learn a baseline of normal consistency for this individual.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?Size of the lump. If the nurse feels a lump or mass, then he or she should note these characteristics: 1. location, 2. size; judge in cm in three dimensions (width, length, thickness), 3. shape, 4. consistency, 5. motility, 6. distinctness, 7. nipple, 8. the skin over the lump, 9. tenderness, and 10. lymphadenopathyThe nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique?The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. The nurse should help each woman establish a regular schedule of self-care. The best time to conduct a BSE is right after the menstrual period, or the fourth through seventh day of the menstrual cycle, when the breasts are the smallest and least congested. The pregnant of menopausal woman who is not having menstrual periods should be advised to select a familiar date to examine her breasts each month.The nurse is preparing to teach a woman about BSE. Which statement by the nurse is correct?BSE on a monthly basis will help you become familiar with your own breasts and feel their normal variations. The nurse should stress that a regular monthly BSE will familiarize the woman with her own breasts and their normal variations. BSE is a positive step that will reassure her of her healthy state. While teaching, the nurse should focus on the positive aspects of BSE and avoid citing firghtening mortality statistive about breast cancer, which may generate excessive fear and denial that can obstruct a womans self-care actionsA 55-year-old postmenopausal woman is being seen in the clinic for her annual examination. Se 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. The nurses best reply would be:Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast and is a normal process of aging.A 43-year-old woman is at the clinic for a routine examination. She reports that she has had a breast 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 examination validates the presence of a mass in the right upper outer quadrant at 1 oclock, spproximately 5 cm from the nipple. It is firm, mobile, and nontender, with borders that are not well defined. .The nurse replies:Because of the change in consistency of the lump, it should be further evaluated by a physician. A lump that has been present for years and is not exhibiting changes may not be serious but should still be explored. Any recent change or a new lump should be evaluated.During a discussion about BSEs with a 30-year-old woman, which of these statements by the nurse is most appropriate?Examine your breasts shortly after your menstrual period each month. The best time to conduct a BSE is shortly after the menstrual period when the breasts are the smallest and least congested.The nurse is discussing BSEs with a postmenopausal woman. The best time for postmenopausal women to perform BSEs is:On the same day every month. Postmenopausal women are no longer experiencing regular menstrual cycles but need to continue to perform BSEs on a monthly basis. Choosing the same day of the month is a helpful reminder to perform the examination.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. The nurse should:Consider these findings as normal, and proceed with the examination Normal findings of the breast include on breast (most often the left) slightly larger than the other and the presence of Montgomery glands across the areolaDuring an examination, the nurse notes a supranumerary nipple just under the patients left breast. The patient tells the nurse that she always thought it was a mole. Which statement about this finding is correct?This variation is normal and not a significant finding. A supernumerary nipple looks like a mole, but close examination reveals a tiny nipple and areola; it is not a significant finding.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. This condition is known as:Peau dorange. This condition is known as peau dorange. Lymphatic obstruction produces edema, which thickens the skin and exaggerates the hair follicles. The skin has a pig-skin or orange-peel appearance, and this condition suggests cancerWhen a breastfeeding mother is diagnosed with a breast abscess, which of these instructions from the nurse is correct? The mother needs to:Temporaily discontinue nursing on the affected breast, and manually express milk and discard it. With a breast abcess, the patient must temporarily discontinue nursing on the affected breast, manually express the milk, and then discard it. Nursing can continue on the unaffected side.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 101 F. She has also had symptoms of the flu, 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?Mastitis The symptoms describe mastitis, which stems from an infection or stasis caused by a plugged duct. A plugged duct does not have an infection present.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." This finding suggests:Retracted nipple. The retracted nipple looks flatter and broader, similar to an underlying crater. A recent retraction suggests cancer, which causes fibrosis of the whole duct system and pulls in the nipple. It also ay occur with benign lesions such as ectasia of the ducts. The nurse should not confuse retraction with the normal long-standing type of nipple inversion, which has no broadening and is not fixedA 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?One percent of all breast cancers occurs in menThe 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?- Nontender mass - Hard, dense, and immobile - Irregular, poorly delineated border Cancerous breast masses are solitary, unilateral, and nontender. They are solid, hard, dense, and fixed to underlying tissues or skin as cancer becomes invasive. Their borders are irregular and poorly delineated. They are often painless, although the person may experience pain. They are most common in the upper outer quadrant.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?- Hyperthyroidism - Liver disease - History of alcohol abuse Gynecomastia occurs with Cushing syndrome, liver cirrhosis, adrenal disease, hyperthyroidism, and numerous drugs, such as alcohol and marijuana use, estrogen for prostate cancer, antibiotics, digoxin, ACE inhibitors, diazepam, and tricyclic antidepressants.Which statement is true regarding the arterial system?The arterial system is a high-pressure system The pumping heart makes the arterial system a high-pressure systemThe nurse is reviewing the blood supply to the arm. The major artery supplying the arm is the ______ artery.Brachial. The major artery supplying the arm is the brachial artery. The brachial artery bifurcates into the ulnar and radial arteries immediately below the elbow. In the hand, the ulnar and radial arteries form two arches known as the superficial and deep palmar archesThe nurse is preparing to assess the dorsalis pedis artery. Where is the correct location for palpation?Lateral to the extensor tendon of the great toe. The dorsalis pedis artery is located on the dorsum of the foot. The nurse should palpate just lateral to and parallel with the extensor tendon of the big toe. The popliteal artery is palpated behind the knee. The posterior tibial pulse is palpated in the groove between the malleolus and the Achilles tendon. No pulse is palpated at the lateral malleolus.A 65-year-old patient is experiencing pain in his left calf when he exercises that disappears after resting for a few minutes. The nurse recognizes that this description is most consistent with ______ the left leg.Ischemia caused by a partial blockage of an artery supplying Ischemia is a deficient supply of oxygenated arterial blood to a tissue. A partial blockage creates an insufficient supply, and the ischemia may be apparent only during exercise when oxygen needs increaseThe nurse is reviewing venous blood flow patterns. Which of these statements best describes the mechanisms by which venous blood returns to the heart?Intraluminal valves ensure unidirectional flow toward the heart Blood moves through the veins by (1) contracting skeletal muscles that proximally milk the blood; (2) pressure gradients caused by breathing, during which inspiration makes the thoracic pressure decrease and the abdominal pressure increase; and (3) the intraluminal valves, which ensure unidirectional flow toward the heartWhich vein(s) is(are) responsible for most of the venous return in the arm?Superficial The superficial veins of the arms are int he subcutaneous tissue and are responsible for most of the venous returnA 70-year-old patient is scheduled for open-heart surgery. The surgeon plans to use the great saphenous vein for the coronary bypass grafts. The patient asks, What happens to my circulation when this vein is removed? The nurse should reply:This vein can be removed without harming your circulation because the deeper veins in your leg are in good condition. As long as the femoral and popliteal veins remain intact, the superficial veins can be excised without harming circulation.The nurse is reviewing the risk factors for venous disease. Which of these situations best describes a person at highest risk for the development of venous disease?Person who has been on bed rest for 4 days. People who undergo prolonged standing, sitting, or bed rest are at risk for venous disease.The nurse is teaching a review class on the lymphatic system. A participant shows correct understanding of the material with which statement?The flow of lymph is slow, compared with that of the blood Lymph flow is not propelled by the heart but rather by contracting skeletal muscles, pressure changes secondary to breathing, and contraction of the vessel wallsWhen performing an assessment of a patient, the nurse notices the presence of an enlarged right epitrochlear lymph node. What should the nurse do next?Examine the patients lower arm and hand, and check for the presence of infection or lesions. The epitrochlear nodes are located in the antecubital fossa and drain the hand and lower arm.A 35-year-old man is seen in the clinic for an infection in his left foot. Which of these findings should the nurse expect to see during an assessment of this patient?Enlarged and tender inguinal nodes. The inguinal nodes in the groin drain most of the lymph of the lower extremities. With local inflammation, the nodes in that area become swollen and tender.The nurse is examining the lymphatic system of a healthy 3-year-old child. Which finding should the nurse expect?Presence of palpable lymph nodes. Lymph nodes are relatively large in children, and the superficial ones are often palpable even when the child is healthy.During an assessment of an older adult, the nurse should expect to notice which finding as a normal physiologic change associated with the aging process?Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressureA 67-year-old patient states that he recently began to have pain in hisleft calf when climbing the 10 stairs to his apartment. This pain is relieved by sitting for approximately 2 minutes; then he is able to resume his activities. The nurse interprets that this patient is most likely experiencing:Claudication Intermittent claudication feels like a cramp and is usually relieved by rest within 2 minutes.A patient complains of leg pain that wakes him up at night. He states that he has been having problems with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed a sore on the inner aspect of the right ankle. On the basis of this health history information, the nurse interprets that the patient is most likely experiencing:Problems related to arterial insufficiency Night leg pain is common in aging adults and may indicate the ischemic rest pain of peripheral vascular disease. Alterations in arterial circulation cause pain that becomes worse with leg elevation and is eased when the extremity is dangledDuring an assessment, the nurse uses the profile sign to detectEarly clubbingThe nurse is performing an assessment on an adult. The adult vital signs are normal, and capillary refill time is 5 seconds. What should the nurse do next?Consider this a delayed capillary refill time, and investigate further Normal capillary refill time is less than 1 to 2 seconds. The following conditions can skew the findings: a cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemiaWhen assessing a patient, the nurse notes that the left femoral pulse as diminished, 1+/4+. What should the nurse do next?Auscultate the site for a bruit. If a pulse is weak or diminished at the femoral site, then the nurse should auscultate for a bruit. The presence of a bruit, or turbulent blood flow, indicates partial occlusionWhen performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patients skin is warm and capillary refill time is normal. Next, the nurse should:Consider this finding as normal, and proceed with the peripheral vascular evaluation. Palpating the ulnar pulses is not usually necessary. The ulnar pulses are not often palpable in the normal personThe nurse is assessing the pulses of a patient who has been admitted for untreated hyperthyroidism. The nurse should expect to find a(n) _______ pulse.Bounding A full, bounding pulse occurs with hyperkinetic states, anemia, and hyperthyroidism.The nurse is preparing to perform a modified Allen test. Which is an appropriate reason for this test?To evaluate the adequacy of collateral circulation before cannulating the radial artery A modified Allen test is used to evaluate the adequacy of collateral circulation before the radial artery is cannulatedA patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe?Brownish discoloration to the skin of the lower leg A brown discoloration occurs with chronic venous stasis as a result of hemosiderin depositsThe nurse is attempting to assess the femoral pulse in an obese patient. Which of these actions would be most appropriate?The patient is asked to bend his or her knees to the side in a froglike position To help expose the femoral area, particularly in obese people, the nurse should ask the person to bend his or her knees to the side in a froglike positionWhen auscultating over a patients femoral arteries, the nurse notices the presence of a bruit on the left side. The nurse knows that bruits:Occur with turbulent blood flow, indicating partial occlusion of the artery.How should the nurse document mild, slight pitting edema the ankles of a pregnant patient?1+/0-4+ If pitting edema is present, then the nurse should grade it on a scale of 1+ (mild) to 4+ (severe).A patient has hard, nonpitting edema of the left lower leg and ankle. The right leg has no edema. Based on these findings, the nurse recalls that:Nonpitting, hard edema occurs with lymphatic obstruction Unilateral edema occurs with occlusion of a deep vein and with unilateral lymphatic obstruction. With these factors, the edema is nonpitting and feels hard to the touchWhen assessing a patients pulse, the nurse notes that the amplitude is weaker during inspiration and stronger during expiration. When the nurse measures the blood pressure, the reading decreases 20 mm Hg during inspiration and increases with expiration. This patient is experiencing pulsus:Paradoxus In pulsus paradoxus, beats have weaker amplitude with inspiration and stronger amplitude with expiroation and is best determined during blood pressure measurement; reading decreases (> 10 mmHg) during inspiration and increases with expirationDuring an assessment, the nurse has elevated a patients legs 12 inches off the table and has had him wag his feet to drain off venous blood. After helping him sit up and dangle his legs over the side of the table, the nurse should expect that a normal finding at this point would be:Venous filling within 15 seconds In this test, it normally takes 10 seconds or less for the color to return to the feet and 15 seconds for the veins of the feet to fill.During a visit to the clinic, a woman in her seventh month of pregnancy complains that her legs feel "heavy in the calf" and that she often has foot cramps at night. The nurse notices that the patient has dilated, tortuous veins apparent in her lower legs. Which condition is reflected by these findings?Varicose veins Superficial varicose veins are caused by incompetent distant valves in the veins, which results in the reflux of blood, producing dilated, tortuous veins. Varicose veins are more common in women, and pregnancy can also be a cause. Symptoms include aching, heaviness in the calf, easy fatigability, and night leg or foot cramps. Dilated, tortuous veins are observed on assessment.During an assessment, the nurse notices that a patients left arm is swollen from the shoulder down to the fingers, with nonpitting brawny edema. The right arm is normal. The patient had a left-sided mastectomy 1 year ago. The nurse suspects which problem?Lymphedema Lymphedema after breast cancer causes unilateral swelling and nonpitting brawny edema, with overlying skin indurated. It is caused by the removal of lymph nodes with breast surgery or damage to lymph nodes and channels with radiation therapy for breast cancer, and lymphedema can impede drainage of lymphThe nurse is preparing to assess the ankle-brachial index (ABI) of a patient. Which statement about the ABI is true?An ABI of 0.9 to 0.7 indicates the presence of peripheral vascular disease and mild claudication. Use of the doppler stethoscope is a noninvasive way to determine the extent of peripheral vascular disease. The normal ankle pressure is slightly greater than or equal to the brachial pressure. An ABI of 0.9 to 0.7 indicates the presence of PVD and mild claudication. The ABI is less reliable in patients with diabetes mellitus because of claudication, which makes the arteries noncompressible and may give a false high-ankle pressureThe nurse is performing a well-child checkup on a 5-year-old boy. He has no current condition that would lead the nurse to suspect an illness. His health history is unremarkable, and he recieved immunizations 1 week ago. Which of these findings should be considered normal in this patient?Palpable firm, small, shotty, mobile, and nontender lymph nodes. Palpable lymph nodes are often normal in children and infants. They are small, firm, shotty, mobile, and nontender.When using a Doppler ultrasonic stethoscope, the nurse recognizes venous flow when which sound is heard?Swishing, whooshing soundThe nurse is describing a weak, thready pulse on the documentation flow sheet. Which statement is correct?Is hard to palpate, but force varies with alternating beats of large and small amplitude A weak, thready pulse is hard to palpate, may fade in and out, and is easily obliterated by pressure. It is associated with decreased cardiac output and peripheral artery diseaseDuring an assessment, a patient tells the nurse that her fingers often change color when she goes out in cold weather. She describes these episodes as her fingers first turning white, then blue, then red with a burning, throbbing pain. The nurse suspects that she is experiencing:Raynaud diseaseDuring a routine office visit, a patient takes off his shoes and shows the nurse this awful sore that wont heal. On inspection, the nurse notes a 3-cm round ulcer on the left great toe, with a pale ischemic base, well-defined edges, and no drainage. The nurse should assess for other signs and symptoms of:Arterial ischemic ulcerThe nurse is reviewing an assessment of a patients peripheral pulses and notices that the documentation states that the radial pulses are 2+. The nurse recognizes that this reading indicates what type of pulse?NormalA patient is recovering from several hours of orthopedic surgery. During an assessment of the patient's lower legs, the nurse will monitor for signs of acute venous symptoms. Signs of acute venous symptoms include which of the following? Select all that apply.- Intense, sharp pain with the deep muscle tender to the touch - Sudden onset - Warm, red, and swollen calfA patient has been admitted with chronic arterial symptoms. During the assessment, the nurse should expect which findings?- Patient has a history of diabetes and cigarette smoking - Skin of the patient is pale and cool - He states that the pain gets worse when walkingThe sac that surrounds and protects the heart is called the:Pericardium The pericardium is a tough, fibrous double-walled sac that surrounds and protects the heart. It has two layers that contain a few milliliters of serous pericardial fluidDirection of blood flow through the heartRight atrium --> right ventricle --> pulmonary artery --> lungs --> pulmonary veins --> left atrium --> left ventricleThe nurse is reviewing the anatomy and physiologic functioning of the heart. Which statement best describes what is meant by atrial kick?The atria contract toward the end of diastole and push the remaining blood into the ventriclesWhen listening to heart sounds, the nurse knows the valve closures that can be heard best at the base of the heart areAortic and pulmonic The second heart sound (S2) occurs with the closure of the semilunar (aortic and pulmonic) valves and signals the end of systole. Although it is heard over all the precordium, the S2 is loudest at the base of the heartWhich of these statements describes the closure of the valves in a normal cardiac cycle?The tricuspid valve closes slightly later than the mitral valve Events occur just slightly later in the right side of the heart because of the route of myocardial depolarization. As a result, two distinct components to each of the heart sounds exist, and sometimes they can be heard seperately. In the first heart sound, the mitral component closes just before the tricuspid componentThe component of the conduction system referred to as the pacemaker of the heart is thesinoatrial (SA) node Specialized cells in the SA node near the superior vena cava initiate an electrical impulse. Because the SA node has an intrinsic rhythm, it is called the pacemaker of the heartThe electrical stimulus of the cardiac cycle follows which sequence?AV node --> SA node --> bundle of His --> bundle branchesThe findings from an assessment of a 70-year-old patient with swelling in his ankles include jugular venous pulsations 5 cm above the sternal angle when the head of his bed is elevated 45 degrees. The nurse knows that this finding indicates:Elevated pressure related to heart failure Because no cardiac valve exists to separate the superior vena cava from the right atrium, the jugular veins give information about the activity on the right side of the heart. They reflect filling pressures and volume changes. Normal jugular venous pulsation is 2 cm or less above the sternal angle. Elevated pressure is more than 3 cm above the sternal angle at 45 degrees and occurs with heart failureWhen assessing a newborn infant who is 5 minutes old, the nurse knows which of these statements to be true?Blood can flow into the left side of the heart through an opening in the atrial septum First, approximately two thirds of the blood is shunted through an opening in the atrial septum, the foramen ovale, into the left side of the heart, where it is pumped out through the aorta. The foramen ovale closes within the first hour after birth because the pressure in the right side of the heart is now lower than in the left side.A 25-year-old woman in her fifth month of pregnancy has a blood pressure of 100/70 mm Hg. In reviewing her previous examination, the nurse notes that her blood pressure in her second month was 124/80 mmHg. In evaluating this change, what does the nurse know to be true?This decline in blood pressure is the result of peripheral vasodilation and is an expected change Despite the increased cardiac output, arterial blood pressure decreases in pregnancy because of peripheral vasodilation. The blood pressure drops to its lowest point during the second trimester and then rises after thatIn assessing a 70-year-old man, the nurse finds the following: blood pressure 140/100 mm Hg; heart rate 104 and slightly irregular; split S2. Which of these findings can be explained by expected hemodynamic changes related to age?Increase in systolic blood pressure With aging, an increase in systolic blood pressure occurs. No significant change in diastolic pressure and no change in the resting heart rate occur with aging.A 45-year-old man is in the clinic for a routine physical examination. During the recording of his health history, the patient states that he has been having difficulty sleeping. Ill be sleeping great, and then I wake up and feel like I cant catch my breath. The nurses best response to this would be:Do you have any history of problems with your heart? Paroxysmal nocturnal dyspnea (SOB generally occurring at night) occurs with heart failure. Lying down increases the volume of intrathoracic blood, and the weakened heart cannot accommodate the increased load. Classically, the person awakens after 2 hours of sleep, arises, and flings open a window with the perception of needing fresh airIn assessing a patient's major risk factors for heart disease, which would the nurse want to include when taking a history?Smoking, hypertension, obesity, diabetes, and high cholesterol To assess for major risk factors of coronary artery disease, the nurse should collect data regarding elevated serum cholesterol, elevated blood pressure, blood glucose levels above 100 mg/dL or known diabetes mellitus, obesity, any length of hormone replacement therapy for post menopausal women, cigarette smoking, and low activity levelThe mother of a 3-month-old infant states that her baby has not been gaining weight. With further questioning, the nurse finds that the infant falls asleep after nursing and wakes up after a short amount of time, hungry again. What other information would the nurse want to have?Presence of dyspnea or diaphoresis when sucking To screen for heart disease in an infant, the focus should be on feeding. Fatigue during feeding should be noted. An infant with heart failure takes fewer ounces each feeding, becomes dyspneic with sucking, may be diaphoretic, and then falls into exhausted sleep and awakens after a short time hungry againIn assessing the carotid arteries of an older patient with cardiovascular disease, the nurse would:Listen with the bell of the stethoscope to assess for bruits If cardiovascular disease is suspected, then the nurse should auscultate each carotid artery for the presence of a bruit. The nurse should avoid compressing the artery, which could create an artificial bruit and compromise circulation if the carotid artery is already narrowed by atherosclerosis. Excessive pressure on the carotid sinus area high in the neck should be avoided, and excessive vagal stimulation could slow down the heart rate, especially in older adults. Palpating only one carotid artery at a time will avoid compromising arterial blood to the brainDuring an assessment of a 68-year-old man with a recent onset of right-sided weakness, the nurse hears a blowing, swishing sound with the bell of the stethoscope over the left carotid artery. This finding would indicate:Blood flow turbulenceDuring an inspection of the precordium of an adult patient, the nurse notices the chest moving in a forceful manner along the sternal border. This finding most likely suggests a(n):Enlargement of the right ventricle Normally, the examiner may or may not see an apical impulse; when visible, it occupies the fourth or fifth intercostal space at or inside the midclavicular line. A heave or lift is a sustained forceful thrusting of the ventricle during systole. It occurs with ventricular hypertrophy as a result of increased workloadDuring an assessment of a healthy adult, where would the nurse expect to palpate the apical impulse?Fifth left intercostal space at the midclavicular lineThe nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true?Studies show that percussed cardiac borders do not correlate well with the true cardiac border Numerous comparison studies have shown that the percussed cardiac border correlates only moderately with the true cardiac border. Percussion is of limited usefulness with the female breast tissue, in a person who is obese, or in a person with a muscular chest wall. Chest x-ray images or echocardiographic examinations are significantly more accurate in detecting heart enlargementThe nurse is preparing to auscultate for heart sounds. Which technique is correct?Listening by inching the stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apexWhile counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse's response?No further response is needed because sinus arrhythmia can occur normallyWhen listening to heart sounds, the nurse knows that S1:Coincides with the carotid artery pulseDuring the cardiac auscultation, the nurse hears a sound immediately occurring after the S2 at the second left intercostal space. To further assess this sound, what should the nurse do?Watch the patients respirations while listening for the effect on the soundWhich of these findings would the nurse expect to notice during a cardiac assessment on a 4-year-old child?Murmur at the second left intercostal space when supineWhile auscultating heart sounds on a 7-year-old child for a routine physical, the nurse hears an S3, a soft murmur at left midsternal border, and a venous hum when the child is standing. Which of these would be a correct interpretation of these findings?These findings can all be normal in a childDuring the precordial assessment on an patient who is 8 months pregnant, the nurse palpates the apical impulse at the fourth left intercostal space lateral to the midclavicular line. This finding would indicate:Displacement of the heart from elevation of the diaphragmIn assessing for an S4 heart sound with a stethoscope, the nurse would listen with the:Bell of the stethoscope at the apex with the patient in the left lateral positionA 70-year-old patient with a history of hypertension has a blood pressure of 180/100 mmHg and a heart rate of 90 beats per minute. The nurse hears an extra heart sound at the apex immediately before the S1. The sound is heard only with the bell of the stethoscope while the patient is in the left lateral position. With these findings and the patients history, the nurse knows that this extra heart sound is most likely a(n):Atrial gallopThe nurse is performing a cardiac assessment on a 65-year-old patient 3 days after her myocardial infarction. Heart sounds were normal when she is supine, but when she is sitting and leaning forward, the nurse hears a high-pitched, scratchy sound with the diaphragm of the stethoscope at the apex. It disappears on inspiration. The nurse suspects:Inflammation of the precordiumThe mother of a 10-month-old infant tells the nurse that she has noticed that her son becomes blue when he is crying and that the frequency of this is increasing. He is also not crawling yet. During the examination the nurse palpates a thrill at the left lower sternal border and auscultates a loud systolic murmur in the same area. What would be the most likely cause of these findings?Tetralogy of FallotA 30-year-old woman with a history of mitral valve problems states that she has been very tired. She has started waking up at night and feels like her heart is pounding. During the assessment, the nurse palpates a thrill and lift at the fifth intercostal space midclavicular line. In the same area, the nurse also auscultates a blowing, swishing sound right after the S1. These findings would be most consistent with:Mitral regurgitationDuring a cardiac assessment on a 38 year old patient in the hospital for chest pain, the nurse finds the following: jugular vein pulsations 4 cm above the sternal angle when the patient is elevated at 45 degrees, blood pressure 98/60 mmHg, heart rate 130 bpm, ankle edema, difficulty breathing when supine, and an S3 on auscultation. Which of these conditions best explains the cause of these findingsHeart failurethe nurse knows that normal splitting of the S2 is associated withInspirationDuring a cardiovascular assessment, the nurse knows that a "thrill" is:Vibration that is palpableDuring a cardiovascular assessment, the nurse knows that an S4 heart sound is:heard at the end of ventricular diastoleDuring an assessment, the nurse notes that the patients apical impulse is laterally displaced and is palpable over a wide area. This finding indicates:Volume overload, as in heart failureWhen the nurse is auscultating the carotid artery for bruits, which of these statements reflects correct technique?While lightly applying the bell of the stethoscope over the carotid artery and listening, the patient is asked to take a breath, exhale, and briefly hold itThe nurse is preparing for a class on risk factors for hypertension and reviews recent statistics. Which racial group has the highest prevalence of hypertension in the world?BlacksThe nurse is assessing a patient with possible cardiomyopathy and assesses the hepatojugular reflux. If heart failure is present, then the nurse should recognize which finding while pushing on the right upper quadrant of the patients abdomen, just below the rib cage?The jugular veins will remain elevated as long as pressure on the abdomen is maintainedThe nurse is assessing the apical pulse of a 3-month-old infant and finds that the heart rate is 135 beats per minute. The nurse interprets this result asNormal for this ageThe nurse is presenting a class on risk factors for cardiovascular disease. Which of these are considered modifiable risk factors for myocardial infarction (MI)? Select all that apply.- Abnormal lipids - Smoking - Hypertension - DiabetesThe nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear?DullnessWhich structure is located in the left lower quadrant of the abdomen?Sigmoid colonA patient is having difficultry swallowing medications and food. The nurse would document that this patient has:DysphagiaThe nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?Percuss and palpate the midline area above the suprapubic boneThe nurse is aware that one change that may occur in the gastrointestinal system of an aging adult is: A) increased salivation. B) increased liver size. C) increased esophageal emptying. D) decreased gastric acid secretion.Decreased gastric acid secretionA 22-year-old man comes into the clinic for an examination after falling off his motorcycle and landing on his left side on the handle bars. The nurse suspects that he may have injured his spleen. Which of these statements is true regarding assessment of the spleen in this situation?An enlarged spleen should not be palpated because it can easily ruptureA patients abdomen is bulging and stretched in appearance. The nurse should describe this finding asProtruberantThe nurse is describing a scaphoid abdomen. To the horizontal plane, a scaphoid contour of the abdomen depicts a _____ profile.ConcaveWhile examining a patient, the nurse observes abdominal pulsations between the xiphoid process and umbilicus. The nurse would suspect that these are:Normal abdominal aortic pulsationsA patient has hypoactive bowel sounds. the nurse knows that a potential cause of hypoactive bowel sounds is:PeritonitisThe nurse is watching a new graduate nurse perform auscultation of a patient's abdomen. Which statement by the new graduate shows a correct understanding of the reason auscultation precedes percussion and palpation of the abdomen?Auscultation prevents distortion of bowel sounds that might occur after percussion and palpationThe nurse is listening to bowel sounds. Which of these statements is true of bowel sounds?Are usually high pitched, girgling, and irregular soundsThe physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to:Hyperactive bowel soundsDurin an abdominal assessment, the nurse would consider which of these findings as normal?Tympanic percussion note in the umbilical regionThe nurse is assessing the abdomen of a pregnant woman who is complaining of having acid indigestion all the time. The nurse knows that esophageal reflux during pregnancy can cause:PyrosisThe nurse is performing percussion during an abdominal assessment. Percussion notes heard during the abdominal assessment may include:Tympany, hyperresonance, and dullnessAn older patient has been diagnosed with pernicious anemia. The nurse knows that this condition could be related toDecreased gastric acid secretionA patient is complaining a sharp pain along the costovertebral angles. The nurse is aware that this symptom is most often indicative of:Kidney inflammationA nurse notices that a patient has ascites, which indicates the presence of:FluidThe nurse knows that during an abdominal assessment, deep palpation is used to determineEnlarged organsThe nurse notices that a patient has had a black, tarry stool and recalls that a possible cause would beGastrointestinal bleedingDuring an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse interprets that this finding could indicate a disorder of which of these structures?AppendixThe nurse is assessing the abdomen of an older adult. Which statement regarding the older adult and abdominal assessment is true?Abdominal musculature is thinnerDuring an assessment of a newborn infant, the nurse recalls that pyloric stenosis would be exhibited byProjectile vomitingThe nurse is reviewing the assessment of an aortic aneurysm. Which of these statements is true regarding an aortic aneurysm?A pulsating mass is usually presentDuring an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least:5 minutesA patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these tecniques to assess for this condition?Test for Murphy signJust before going home, a new mother asks the nurse about the infant's umbilical cord. Which of these statements is correct?It should fall off in 10 to 14 daysWhich of these percussion findings would the nurse expect to find in a patient with a large amount of ascites?Dullness across the abdomenA 40-year-old man states that his physician told him that he has a hernia. He asks the nurse to explain what a hernia is. Which response by the nurse is appropriate?A hernia is a loop of bowel protruding through a weak spot in the abdominal musclesA 45-year-old man is in the clinic for a physical examination. During the abdominal assessment, the nurse percusses the abdomen and notices an area of dullness above the right costal margin of approximately 11 cm. The nurse should:Consider this finding as normal and continue with the evaluationWhen palpating the abdomen of a 20-year-old patient, the nurse notices the presence of tenderness in the left upper quadrant with deep palpation. Which of these structures is most likely to be involved?SpleenThe nurse is reviewing statistics for lactose intolerance. In the United States, the incidence of lactose intolerance is higher in adults of which ethnic group?BlacksThe nurse is assessing a patient for possible peptic ulcer disease. Which condition or history often causes this problem?Frequent use of nonsteroidal antiinflammatory drugsDuring reporting, the student nurse hears that a patient has hepatomegaly and recognizes that this term refers toEnlarged liverDuring an assessment, the nurse notices that a patients umbilicus is enlarged and everted. It is positioned midline with no change in skin color. The nurse recognizes that the patient may have which conditionUmbilical herniaDuring an abdominal assessment, the nurse tests for a fluid wave. A positive fluid wave test occurs withAscitesThe nurse is preparing to examine a patient who has been complaining of right lower quadrant pain. Which technique is correct during the assessment?Examine the tender area lastDuring a health history, the patient tells the nurse, "I have pain all the time in my stomach. It's worse 2 hours after I eat, but it gets better if I eat again!" Based on these symptoms, the nurse suspects that the patient has which condition?Duodenal ulcerThe nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix?- Test for the Blumberg sign - Perform the iliopsoas muscle testThe nurse recognizes which of these persons is at greatest risk for undernutrition?5 month old infantWhen assessing a patients nutritional status, the nurse recalls that the best definition of optimal nutritional status is sufficient nutrients thatProvide for daily body requirements and support increased metabolic demandsThe nurse is providing nutrition information to the mother of a 1 year old child. Which of these statements represents accurate information for this age groupMaintaining adequate fat and caloric intake is important for a child in this age groupA pregnant woman is interested in breastfeeding her baby and asks several questions about the topic. Which information is appropriate for the nurse to share with her?Breast milk provides the nutrients necessary for growth, as well as natural immunityA mother and her 13-year-old daughter express their concern related to the daughter's recent weight gain and increase in appetite. Which of the following represents information the nurse should discuss with them?Snacks should be high in protein, iron, and calciumThe nurse is assessing a 30 year old unemployed immigrant from an underdeveloped country who has been in the US for 1 month. Which of these problems related to his nutritional status might the nurse expect to find?Osteomalacia (softening of the bones)For the first time, the nurse is seeing a patient who has no history of nutrition-related problems. The initial nutritional screening should include which activity?Measurement of weight and weight historyA patient is asked to indicate on a form how many times he eats a specific food. This method describes which of these tools for obtaining dietary information?Food frequency questionairreThe nurse is providing care for a 68 year old woman who is complaining of constipation. What concern exists regarding her nutritional status?Absorption of nutrients may be impairedDuring a nutritional assessment, why is it important for the nurse to ask a patient what medications he or she is taking?Certain drugs can affect the metabolism of nutrientsA patient tells the nurse that his food simply does not have any taste anymore. The nurses best response would be:When did you first notice that change?The nurse is performing a nutritional assessment on a 15 year old girl who tells the nurse that she is so fat. Assessment reveals that she is 5 feet 4 inches and weighs 110 pounds. The nurses appropriate response would be:How much do you think you should weigh?The nurse is discussing appropriate foods with the mother of a 3 year old child. Which of these foods are recommended?Finger foods and nutritious snacks that cannot cause chokingThe nurse is reviewing the nutritional assessment of an 82 year old patient. Which of these factors will most likely affect the nutritional status of an older adult?Living alone on a fixed incomeWhen considering a nutritional assessment, the nurse is aware that the most common anthropometric measurements include:Height and weightIf a 29-year-old woman weighs 156 pounds, and the nurse determines her ideal body weight to be 120 pounds, then how would the nurse classify the woman's weight?ObeseHow should the nurse perform a triceps skinfold assessment?After applying the calipers, the nurse waits 3 seconds before taking a reading. After repeating the procedure 3 times, an average is recordedIn teaching a patient how to determine total body fat at home, the nurse includes instructions to obtain measurements ofHeight and weightThe nurse is evaluating patients for obesity-related diseases by calculating the waist-to-hip ratios. Which one of these patients would be at increased risk?29 year old woman whose waist measures 33 inches and hips measure 36 inchesA 50-year-old woman with elevated total cholesterol and triglyceride levels is visiting the clinic to find out about her laboratory results. What would be important for the nurse to include in patient teaching in relation to these tests?Provide information regarding a diet low in saturated fatIn performing an assessment on a 49 year old woman who has imbalanced nutrition as a result of dysphagia, which data would the nurse expect to findInadequate nutrient food intakeA 21-year-old woman has been on a low protein liquid diet for the past 2 months. She has had adequate intake of calories and appears well nourished. After further assessment, what would the nurse expect to find?Decreased serum albuminThe nurse is performing a nutritional assessment on an 80 year old patient. The nurse knows that physiologic changes can directly affect the nutritional status of the older adult and include:Slowed GI motilityWhich of these interventions is most appropriate when the nurse is planning nutritional interventions for a healthy, active 74-year-old woman?Decreasing the number of calories she is eating because of the decrease in energy requirements from the loss of lean body massA 16-year-old girl is being seen at the clinic for GI complaints and weight loss. The nurse determines that many of her complaints may be related to erratic eating patterns, eating predominantly fast foods, and high caffeine intake. In this situation, which is most appropriate when collecting current dietary intake information?Having the patient complete a food diary for 3 days, including 2 weekdays and 1 weekend dayThe nurse is preparing to measure fat and lean body mass and bone mineral density. Which tool is appropriate?Dual-energy x-ray absorptiometry (DEXA)Which of these conditions is due to an inadequate intake of both protein and calories?MarasmusDuring an assessment of a patient who has been homeless for several years, the nurse notices that his tongue is magenta in color, which is an indication of a deficiency in what mineral and/or vitaminRiboflavinA 50-year-old patient has been brought to the emergency department after a housemate found that the patient could not get out of bed alone. He has lived in a group home for years but for several months has not participated in the activities and has stayed in his room. The nurse assesses for signs of undernutrition, and an x-ray study reveals that he has osteomalacia, which is a deficiency of:Vitamin D and calciumAn older adult patient in a nursing home has been receiving tube feedings for several months. During an oral examination, the nurse notes that patients gums are swollen, ulcerated, and bleeding in some areas. The nurse suspects that the patient has what condition?Vitamin C deficiencyThe nurse is assessing the body weight as a percentage of ideal body weight on an adolescent patient who was admitted for suspected anorexia nervosa. The patients usual weight was 125 pounds, but today she weighs 98 pounds. The nurse calculates the patients ideal body weight and concludes that the patient isExperiencing moderate malnutritionThe nurse is assessing a patient who is obese for signs of metabolic syndrome. This condition is diagnosed when three or more certain risk factors are present. Which of these assessment findings are risk factors for metabolic syndrome?- Fasting plasma glucose level greater than or equal to 110 mg/dL - Blood pressure reading of 140/90 mmHg