Scanning speechCauses enunciation of individual syllables: “the British parliament” becomes “the Brit-tish Par-la-ment.” Show
NystagmusFast phase toward side of cerebellar lesion. Finger to nose & finger to finger testAsk patient to fully extend arm then touch nose or ask them to touch their nose then fully extend to touch your finger. You increase the difficulty of this test by adding resistance to the patient's movements or move your finger to different locations. Abnormality of this is called dysmetria. Rapid alternating movementsAsk patient to place one hand over the next and have them flip one hand back and forth as fast as possible (alternatively you can ask the patient to quickly tap their foot on the floor as fast as possible) if abnormal, this is called dysdiadochokinesia. Rebound phenomenon (of Stewart & Holmes)Have the patient pull on your hand and when they do, slip your hand out of their grasp. Normally the antagonists muscles will contract and stop their arm from moving in the desired direction. A positive sign is seen in a spastic limb where the exaggerated "rebound" occurs with movement in the opposite direction. However in cerebellar disease this response is completely absent causing to limb to continue moving in the desired direction. (Be careful that you protect the patient from the unarrested movement causing them to strike themselves.) Heel to shin testHave patient run their heel down the contralateral shin (this is equivalent the finger to nose test). Abnormal exam occurs when they are unable to keep their foot on the shin. Hypotonia“Pendular” knee jerk, leg keeps swinging after knee jerk more than 4 times (4 or less is normal). Gait (Acute Cerebellar Ataxia)Acute cerebellar ataxia is a wide based and staggering gait. (See "Gaits" section to learn more about acute cerebellar ataxia and other gaits.) They may fall to the side of the lesion NOTE: patients with disease of the vermis and flocculonodular lobe will be unable to stand at all as they will have truncal ataxia–they may not be able to sit. NOTE: THE ROMBERG TEST IS NOT A SIGN OF CEREBELLAR DISEASE. It is a sign of a disturbance of proprioception, either from neuropathy or posterior column disease. The patient does not know where their joint is in space and so uses their eyes. In the dark or with eyes closed they have problems. What does S.O.A.P. stand for? S- Subjective It is used to organize assessments findings into written or charted communication What does S.B.A.R. stand for? S- Situation While collecting data, the nurse uses the Snellen chart. What does the nurse examine in the patient? Vision acuity The nurse finds a positive Babinski reflex in an adult during a physical assessment. What could be the reason for such an abnormality? Neurologic impairment The nurse wants to palpate the rectal walls and the prostate gland of a bedridden male patient. In which position does the nurse place the patient to ensure proper assessment? Left lateral position with the right leg drawn up. Which intervention does the nurse follow while assessing cerebellar function in a patient? Ask the patient to move the heel down along the opposite shin. Ask the patient to walk on the toes and heels alternately for a few steps. While examining a patient, the nurse suspects that the patient may have injury to cranial nerve XII. Which finding enabled the nurse to reach this conclusion? CNXII-Hypoglossal Nerve Muscles of Tongue The patient is unable to stick out the tongue. The nurse is performing breast examination on a female patient. Which position of the patient does the nurse find most suitable during the assessment? An adult patient has a body temperature of 98.6° F (37° C), shallow breathing with a respiratory rate of 16 breaths/minute (BPM), excessive cough, and blood pressure of 142/100 mm Hg. What does the nurse infer about the patient's condition? HTN and ineffective airway clearance During the examination of a patient's heart, the nurse documents "No abnormal thrill." Which assessment did the nurse perform on the patient? Palpation of the precordium What intervention does the nurse perform to test the stereognosis of a patient? Ask the patient to identify an object placed in the hand without visual clues.
The nurse asks a patient to bend the head forward and back, turn the head to either side, and to shrug the shoulders. What does the nurse assess from these tests? The functioning of cranial nerve XI-Spinal Accessory Nerve The nurse is assisting the health care provider in performing a vaginal, pelvic, and rectal examination of a patient. Which intervention does the nurse perform in this situation? What does the nurse palpate while assessing the inguinal area of a patient? What would the nurse assess using a speculum during the examination of the nose? Select all that apply. The nasal septum The student nurse is assessing the neck of a patient under the supervision of a nurse educator. Which intervention by the student nurse needs correction? Palpation of the carotid pulse on both sides at a time While assessing a patient, the nurse finds facial asymmetry. For which cranial nerve damage does the nurse screen in the patient? Cranial nerve VII Facial Nerve The student nurse is examining the external genitalia in a female patient under the supervision of the nurse. Which action of the student nurse needs correction? Sitting on a stool near the foot of the table to perform bimanual examination Which is a normal assessment finding in an adult patient? The cervix and uterus are freely moveable on palpation. Which instructions does the nurse give to the patient while assessing the spinal range of motion? Select all that apply. Hyperextend your neck What interventions does the nurse perform during the examination of a male patient's rectum? Select all that apply. Inspect the perianal area The nurse is planning to test the functioning of the extraocular muscles in a patient with vision problems. Which interventions does the nurse perform during the test? Select all that apply. The nurse checks the corneal light reflex. While assessing a male patient, the nurse asks the patient to close his eyes and places a familiar object in his hand. The nurse then asks the patient to identify the object. What does the nurse check through this assessment? When does the nurse document the assessment finding, "anterior-posterior diameter less than lateral diameter"? During an adult's respiratory examination Which intervention does the nurse perform while assessing the breasts in a patient? Inspect the supraclavicular and infraclavicular areas Which tests does the nurse perform while assessing the cerebellar function of a patient? Select all that apply. Finger-to-nose test The nurse plans to assess the deep tendon reflexes of a patient. Which reflexes does the nurse check? Select all that apply. biceps
reflex While performing a genital examination of a female patient, the nurse concludes that a patient has normal genitalia. Which observation by the nurse supports this conclusion? Absence of acetowhitening on swabbing of the vaginal mucosa with acetic acid While testing the extraocular muscles, the nurse notes that the patient has improper eye movements. Which cranial nerve damage does the nurse suspect in the patient? Select all that apply. Cranial nerve III While assessing the genitalia of a male patient, the nurse finds a hard mass on palpation of the scrotal sac. Which intervention should the nurse perform in this situation? transiluminate scrotal area The nurse documents normocephalic as an assessment finding. What did the nurse assess in the patient? Which assessment includes size, shape, and strength parameters? Musculoskeletal examination While performing an oral examination, the nurse instructs the patient to say "ahh." What is the reason for giving this instruction? The nurse, while checking the vital signs, finds that the patient's blood pressure is decreased in the lower extremities. Which test does the nurse perform to evaluate the patient's condition? Ankle brachial index test The health care provider has prescribed an occult blood test for a patient. Which specimen does the nurse collect for the test? The nurse is assessing an older adult's functional
ability. Which definition correctly describes one's functional ability? Refers to one's ability to perform activities necessary to live in modern society. (driving, using phone) The nurse is preparing to perform a functional assessment of an older patient and knows that a good approach would be to: observe pt ability to perform tasks The nurse needs to assess a patient's ability to perform activities of daily living and should choose which tool for this assessment? Barthel Index is used to assess activities of daily living. The nurse is preparing to use the Lawton IADL instrument as part of an assessment. Which statement about the Lawton IADL instrument is true? It is designed as a self-report measure of performance rather than ability. The nurse is assessing an older adult's advanced activities of daily living, which would include: When using the various instruments to assess an older person's activities of daily living (ADLs), the nurse needs to remember that a disadvantage of these instruments includes: Self or proxy report of functional activities. The nurse is administering a test that is timed over 15 minutes and assesses a patient's upper body fine motor and coarse motor activities, balance, mobility, coordination, and endurance. During this test, activities such as dressing and stair climbing are timed. Which test is described by these activities? The Physical Performance Test A patient will be ready to be discharged from the hospital soon, and the patient's family membersare concerned about whether the patient is able to walk outside alone safely. The nurse will perform which test to assess this? the up and go test (it quantifies functional ability and is a good tool to predict a person's ability to go outside alone safely) The nurse is assessing the forms of support an older patient has before she is discharged. Which of these examples is an informal source of support? Her neighbor, who visits with her daily An 85-year-old man has been hospitalized after a fall at home, and his 86-year-old wife is at his bedside. She tells the nurse that she is his primary caregiver. The nurse should assess the caregiver for signs of possible caregiver burnout, such as: During a morning assessment, the nurse notices that an older patient is less attentive and is unable to recall yesterday's events. Which test is appropriate for assessing the patient's mental status? Mini-Cog (is a mental status test that tests immediate and delayed recall and visuospatial ability.) An elderly patient has been admitted to the intensive care unit (ICU) after falling at home. Within 8 hours, his condition has stabilized and he is transferred to a medical unit. The family is wondering whether he will be able to go back home. Which assessment instrument is most appropriate for the nurse to choose at this time? During a functional assessment of an older person's home environment, which statement or question by the nurse is most appropriate regarding common environmental hazards? "Do you have a relative or friend who can help to install grab bars in your shower?" When beginning to assess a person's spirituality, which question by the nurse would be most appropriate? "How does your spirituality relate to your health care decisions?" The nurse is preparing to assess an older adult and discovers that the older adult is in severe pain.Which statement about pain and the older adult is true? Alleviating pain should be a priority over other aspects of the assessment. The nurse is assessing the abilities of an older adult. Which of these following activities are considered instrumental activities of daily living? Select all that apply. preparing a meal, balancing check book, grocery
shopping During an examination, the nurse can assess mental status by which activity? Observing the patient and inferring health or dysfunction The nurse is assessing mental status of a child. Which of these statements about children and mental status is true? All aspects of mental status in children are interdependent. The nurse is assessing a 75-year-old man. As the nurse begins the mental status portion of the assessment, the nurse expects that this patient: May take a little longer to respond, but his general knowledge and abilities should not have declined. When assessing aging adults, the nurse knows that one of the first things that should be assessed before making judgments about their mental status is: Their sensory-perceptive abilities. The nurse is preparing to do a mental status examination. Which statement is true regarding the mental status examination? It is usually sufficient to gather mental status information during the health history interview. A woman brings her husband to the clinic for an examination. She is particularly worried because after a recent fall, he seems to have lost a great deal of his memory of recent events. Which statement reflects the nurse's best course of action? The nurse should: Plan to perform a complete mental status examination. The nurse is conducting a patient interview. Which statement made by the patient should the nurse more fully explore during the interview? “I never did too good in school.” A patient is admitted to the unit after an automobile accident. The nurse begins the mental status examination and finds that the patient's speech is dysarthric and that she is lethargic. plan to defer the rest of the mental status exam A 19-year-old woman comes to the clinic at the insistence of her brother. She is wearing black combat boots and a black lace nightgown over the top of her other clothes. Her hair is dyed pink with black streaks throughout. She has several pierced holes in her nares and ears and is wearing an earring through her eyebrow and heavy black makeup. The nurse concludes: That more information should be gathered to decide whether her dress is appropriate. A patient has been in the intensive care unit for 10 days. He has just been moved to the medical-surgical unit, and the admitting nurse is planning to perform a mental status examination on him. During the tests of cognitive function the nurse would expect that he: Will be oriented to place and person but may not be certain of the date. During a mental status examination, the nurse wants to assess a patient’s affect. The nurse should ask the patient which question? The nurse is planning to assess new memory with a patient. The best way for the nurse to do this would be to: Give him the Four Unrelated Words Test. A 45-year-old woman is at the clinic for a mental status assessment. In giving her the Four Unrelated Words Test, the nurse would be concerned if she could not ____ four unrelated words ____. Recall; after a 30-minute delay During a mental status assessment, which question by the nurse would best assess a person's judgment? "Tell me about what you plan to do once you are discharged from the hospital." Which of these individuals would the nurse consider at highest risk for a suicide attempt? Elderly man who tells the nurse that he is going to "join his wife in heaven" tomorrow and plans to use a gun The nurse is performing a mental status assessment on a 5-year-old girl. Her parents are undergoing a bitter divorce and are worried about the effect it is having on their daughter. Which action or statement might lead the nurse to be concerned about the girl's mental status? Her mother states that her daughter prefers to play with toddlers instead of kids her own age while in daycare. The nurse is planning to assess a child using the Behavioral Checklist. This tool is most appropriate for a(n): 8-year-old child. The nurse is assessing orientation in a 79-year-old patient. Which of these responses would lead the nurse to conclude that this patient is oriented? "I know that my name is John. I am at the hospital in Spokane. I couldn't tell you what date it is, but I know that it is February of a new year—2010." The nurse is performing the Denver II screening test on a 12-month-old infant during a routine well-child visit. The nurse should tell the infant’s parents that the Denver II: Is a screening instrument designed to detect children who are slow in development. A patient drifts off to sleep when she is not being stimulated. The nurse can arouse her easily when calling her name, but she remains drowsy during the conversation. The best description of this patient's level of consciousness would be: A patient has had a cerebrovascular accident (stroke). He is trying very hard to communicate. He seems driven to speak and says, “I buy obie get spirding and take my train.” What is the best description of this patient’s problem? A patient repeatedly seems to have difficulty coming up with a word. He says, “I was on my way to work, and when I got there, the thing that you step into that goes up in the air was so full that I decided to take the stairs.” The nurse will note on his chart that he is using or experiencing: During an examination, the nurse notes that a patient is exhibiting flight of ideas. Which statement by the patient is an example of flight of ideas? "Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby's bottom." A patient describes feeling an unreasonable, irrational fear of snakes. His fear is so persistent that he can no longer comfortably look at even pictures of snakes and has made an effort to identify all the places he might encounter a snake and avoids them. The nurse recognizes that he: A patient has been diagnosed with schizophrenia. During a recent interview, he shows the nurse a picture of a man holding a decapitated head. He describes this picture as horrifying but then laughs loudly at the content. This behavior is a display of: During reporting, the nurse hears that a patient is experiencing hallucinations. Which is an example of a hallucination? Man believes that his dead wife is talking to him. A 20-year-old construction worker has been brought into the emergency department with heat stroke. He has delirium as a result of a fluid and electrolyte imbalance. For the mental status examination, the nurse should first assess the patient’s: Level of consciousness and cognitive abilities A patient states, “I feel so sad all of the time. I can’t feel happy even doing things I used to like to do.” He also states that he is tired, sleeps poorly, and has no energy. To differentiate between a dysthymic disorder and a major depressive disorder, the nurse should ask which question? “How long have you been feeling this way?” A 26-year-old woman was robbed and beaten a month ago. She is returning to the clinic today for a follow-up assessment. The nurse will want to ask her which one of these questions? "Are you having any disturbing dreams?” The nurse is performing a mental status examination. Which statement is true regarding the assessment of mental status? Mental status functioning is inferred through assessment of an individual's behaviors. It cannot be assessed directly like characteristics of the skin or heart sounds. A 23-year-old patient in the clinic appears anxious. Her speech is rapid, and she is fidgety and in constant motion. Which of these questions or statements would be most appropriate for the nurse to use in this situation to assess attention span? "Please pick up the pencil in your left hand, move it to your right hand, and place it on the table." The nurse is planning health teaching for a 65-year-old woman who has had a cerebrovascular accident, or stroke, and is aphasic. Which of these questions is most important to use when assessing mental status in this situation? Please point to articles in the room and parts of the body as I name them." A 30-year-old female patient is describing feelings of hopelessness and depression. She has attempted self-mutilation and has a history of suicide attempts. She describes difficulty sleeping at night and has lost 10 pounds in the past month. Which of these statements or questions is the nurse’s best response in this situation? “Are you feeling so hopeless that you feel like hurting yourself now?” The nurse is providing instructions to newly hired graduates about the Mini-Mental State Examination. Which statement best describes this examination? It is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness. A 45-year-old woman is brought to the emergency department with a head injury after her car hit a tree. A few months after recovering from her injuries, the nurse notes during an examination that she is unable to learn new information or recall previously learned information. This is an example of: The nurse discovers speech problems in a patient during an assessment. The patient has spontaneous speech, but it is mostly absent or is reduced to a few stereotyped words or sounds. This finding reflects which type of aphasia? A patient repeats, "I feel hot. Hot, cot, rot, tot, got. I'm a spot." The nurse documents this as an illustration of: During an interview, the nurse notes that the patient gets up several times to wash her hands even though they are not dirty. This is an example of: The nurse is administering a Mini-Cog test to an elderly woman. When asked to draw a clock showing the time of 10:45, the patient drew a clock with the numbers out of order and with the time incorrect. This result indicates which finding? During morning rounds, the nurse asks a patient, "How are you today?" The patient responds, "You today, you today, you today!" and mumbles the words. This speech pattern is an example of: The nurse is assessing a patient who was admitted with possible delirium. Which of these are manifestations of delirium? Select all that apply. -develops over a short period A 68-year-old patient who is hospitalized with pneumonia is disoriented and confused 3 days after admission. Which information indicates that the patient is experiencing delirium rather than dementia? The patient was oriented and alert when admitted. Which intervention will the nurse include in the plan of care for a patient with moderate dementia who had an appendectomy 2 days ago? Remind the patient frequently about being in the hospital. When administering a mental status examination to a patient with delirium, the nurse should choose
a place without distracting stimuli. The nurse is concerned about a postoperative patient's risk for injury during an episode of delirium. The most appropriate action by the nurse is to assign unlicensed assistive personnel (UAP) to stay with the patient and offer reorientation. A 56-year-old patient in the outpatient clinic is diagnosed with mild cognitive impairment (MCI).Which action will the nurse include in the plan of care? Schedule the patient for more frequent appointments. The nurse is administering a mental status examination to a 48-year-old patient who has hypertension. The nurse suspects depression when the patient responds to the nurse's questions with A 68-year-old patient is diagnosed with moderate dementia after multiple strokes. During assessment of the patient, the nurse would expect to find loss of recent and long-term memory. Which action will help the nurse determine whether a new patient's confusion is caused by dementia or delirium? Use the Confusion Assessment Method tool. A 72-year-old female patient is brought to the clinic by the patient's spouse, who reports that she is unable to solve common problems around the house. To obtain information about the patient's current mental status, which question should the nurse ask the patient? what did you eat for breakfast A patient is being evaluated for Alzheimer's disease (AD). The nurse explains to the patient's adult children that a diagnosis of AD is made only after other causes of
dementia are ruled out. Which nursing action will be most effective in ensuring daily medication compliance for a patient with mild dementia? . Having the patient's family member administer the medication patient who has severe Alzheimer's disease (AD) is being admitted to the hospital for surgery. Which intervention will the nurse include in the plan of care? Maintain a consistent daily routine for the patient's care. A 71-year-old patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility has had several episodes of wandering away from home. Which action will the nurse include in the plan of care? Place the patient in a room close to the nurses' station. The day shift nurse at the long-term care facility learns that a patient with dementia experienced sundowning late in the afternoon on the previous two days. Which action should the nurse take? Keep blinds open during the daytime hours. The nurse's initial action for a patient with moderate dementia who develops increased restlessness and agitation should be to assess for factors that might be causing discomfort. When administering the Mini-Cog exam to a patient with possible Alzheimer's disease, which action will the nurse take? Ask the person to use a clock drawing to indicate a specific time. Which hospitalized patient will the nurse assign to the room closest to the nurses' station? Patient with new-onset confusion, restlessness, and irritability after surgery After change-of-shift report on the Alzheimer's disease/dementia unit, which patient will the nurse assess first? Patient who developed a new cough after eating breakfast
The spouse of a 67-year-old male patient with early stage Alzheimer's disease (AD) tells the nurse, "I am exhausted from worrying all the time. I don't know what to do." Which actions are best for the nurse to take next (select all that apply)? -offer ideas for ways to distract or redirect pt Which nursing actions could the nurse delegate to a licensed practical/vocational nurse (LPN/LVN) who is part of the team caring for a patient with Alzheimer's disease (select all that apply)? -administer meds Which of the following statements is true regarding the internal structures of the breast? Fibrous, glandular, and adipose tissues. In performing a breast examination, the nurse knows that it is especially important to examine the upper outer quadrant of the breast. The reason for this is that the upper outer quadrant is The location of most breast tumors. In performing an assessment of a woman's axillary lymph system, the nurse should assess which of these nodes? Central, lateral, pectoral, and subscapular If a patient reports a recent breast infection, then the nurse should expect to find _____ node enlargement. A 9-year-old girl is in the clinic for a sports physical. 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?" The nurose's best response would be: I understand that it is hard to feel different from your friends. Breasts usually develop between 8 and 10 years old 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 nurse's best response? Although an examination of her daughter would rule out a problem, her breast development is most likely normal. A 14-year-old girl is anxious about not having reached menarche. When taking the history, the nurse should ascertain which of the following? The age: The girl began to develop breasts. 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 nurse’s best response? Tell her that, because of the
changing hormones during the monthly menstrual cycle, cyclic breast changes are common. A woman has just learned that she is pregnant. What are some things the nurse should teach her about her breasts? She can expect her areolae to become larger and darker in color. The nurse is teaching a pregnant woman about breast milk. Which statement by the nurse is correct? “You may notice a thick, yellow fluid expressed from your breasts as early as the fourth month of pregnancy.” A 65-year-old patient remarks that she just can’t believe that her breasts sag so much. She states it must be from 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. 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? Explain that this condition may be the result of hormonal changes, and recommend that he see his physician. 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? Assess the girl's weight and body mass index (BMI). The nurse is reviewing statistics regarding breast cancer. Which woman, aged 40 years in the United States, has the highest 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 During a breast health interview, a patient states that she has noticed pain in her left breast. The nurse's most appropriate response to this would be: "I would like some more information about the pain in your left breast." 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? Ask the patient some additional questions about the meds she is taking.
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?” 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. During an annual physical exam, a 43-year-old patient states that she doesn't perform monthly breast self-examinations (BSE). 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. 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 with regard to breastfeeding? "Breastfeeding provides the perfect food and antibodies for your baby." 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? 65 year old whose mother had breast cancer 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 is assisting with a self-breast examination clinic. Which of these women reflect abnormal findings during the inspection phase of breast examination? Woman whose nipples are in different planes (deviated) 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 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 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? Supine with arms raised over her head Which of these clinical situations would the nurse consider to be outside normal (abnormal) 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. 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. The nurse should plan to: palpate the unaffected breast first. 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. There is no associated retraction of skin or nipple, no erythema, and no axillary lymphadenopathy. Which of these statements reveals the information that is missing from the documentation? It is missing information about: The nurse is conducting a class about breast self-examination (BSE). Which of these statements indicates proper BSE technique? he best time to perform BSE is 4 to 7 days after the first day of the menstrual period. The nurse is preparing to teach a woman about breast self-examination (BSE). Which statement by the nurse is correct? BSE on a monthly basis will help you feel familiar with your own breasts and their normal variations." A 55-year-old postmenopausal woman is being seen in the clinic for a yearly 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." The nurse's best reply would be: "Decreases in hormones after menopause causes atrophy of the glandular tissue in the breast. This 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 o'clock, approximately 5 cm from the nipple. It is firm, mobile, nontender, with borders that are not well defined. The nurse's recommendation to her is: "Because of the change in consistency of the lump, it should be further evaluated by a physician." During a discussion about breast self-examination 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 nurse is discussing breast self-examination with a postmenopausal woman. The best time for postmenopausal women to perform breast self-examination is: While inspecting a patient's breasts, the nurse finds that the left breast is slightly larger than the right with the presence of Montgomery's glands bilaterally. The nurse should: consider these normal findings and proceed with the examination. 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? It is a normal variation and not a significant finding. Which tests would the nurse perform while assessing the cerebellar function of patient?Specific tests used to evaluate cerebellar function include assessment of gait and balance, pronator drift, the finger-to-nose test, rapid alternating action, and the heel-to-shin test.
Which test does the nurse use to assess a child's cerebellar function quizlet?The finger-to-nose test is an indication of cerebellar function. The cover test is used to assess eye alignment.
Which technique is used to assess the cerebellum quizlet?The Romberg test is used to assess cerebellar function.
Which assessment would the nurse perform during the neurologic examination of a patient?Routine neurological exams performed by registered nurses during their daily clinical practice include assessing mental status and level of consciousness, pupillary response, motor strength, sensation, and gait.
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Which tests would the nurse perform while assessing the cerebellar function of a patient
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