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?

Correct Answer: C

Rationale: In this scenario, the missing information from the documentation is the size of the lump (Option C). Understanding the size of a breast lump is crucial in assessing its significance and determining the appropriate course of action. Size helps in categorizing the lump as small, medium, or large, which is essential in clinical decision-making. Option A (Shape of the lump) and Option B (Consistency of the lump) are important aspects of a thorough breast examination, but in this case, the key missing detail is the size of the lump. Knowing whether the lump is solitary or multiple (Option D) is also relevant but is secondary to determining the size, which is more critical for clinical assessment and follow-up. Educationally, emphasizing the importance of documenting the size of a breast lump helps students and healthcare providers understand the significance of this detail in the overall assessment of breast health. It highlights the need for comprehensive documentation to ensure accurate communication and appropriate patient care.

Correct Answer: C

Rationale: Torsion is caused by the twisting of the testicle on its spermatic cord and blood vessels, leading to severe pain. The scrotum becomes red and tense. Torsion is usually seen in adolescents and is a true surgical emergency. If not quickly surgically repaired, the testicle's function is lost and it has to be removed. The presence of a cremasteric reflex is reassuring, but in this case a thorough evaluation must take place as soon as possible.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Examine the patient's lower arm and hand, and check for the presence of infection or lesions. The presence of an enlarged right epitrochlear lymph node indicates a local inflammatory process or infection in the hand, lower arm, or fingers on the same side. By examining the lower arm and hand, the nurse can assess for signs of infection, lesions, or any other abnormalities that could be causing the lymph node enlargement. Option A is incorrect because assessing the abdomen for tenderness is not directly related to the finding of an enlarged epitrochlear lymph node. Option B is incorrect as assessing the cervical lymph nodes, while important in general assessment, is not the priority when a specific lymph node enlargement is noted. Option C is incorrect as asking about recent ear infections or sore throats is not likely to provide relevant information related to the localized finding of an enlarged epitrochlear lymph node. Educationally, understanding the significance of lymph node enlargement in specific locations and the importance of localizing the assessment to the affected area can help nurses make accurate clinical judgments and provide appropriate care to patients. It reinforces the importance of thorough physical assessment and the relevance of connecting assessment findings to potential underlying causes.

Correct Answer: D

Rationale: The correct answer is D) An ABI of 0.9 to 0.7 indicates the presence of peripheral vascular disease and mild claudication. This statement is accurate because a normal ABI ranges from 1.0 to 1.4, and a lower ABI suggests the presence of peripheral arterial disease. An ABI between 0.91 and 0.7 is considered borderline, indicating mild to moderate peripheral vascular disease and potential claudication. Option A is incorrect because normal ABI indices range from 1.0 to 1.4, not 0.5 to 1.0. Option B is incorrect as normal ankle pressure is expected to be higher than brachial pressure due to the hydrostatic pressure gradient in the lower extremities. Option C is incorrect because while ABI is a valuable tool in assessing peripheral vascular disease, it is not exclusive to individuals with diabetes but is applicable to a broader population. In an educational context, understanding ABI is crucial for nurses in assessing peripheral vascular disease, especially in patients with conditions like diabetes or hypertension. Correctly interpreting ABI results can aid in early detection, intervention, and prevention of complications related to vascular diseases, emphasizing the importance of accurate assessment and interpretation of vital signs in clinical practice.

Correct Answer: C

Rationale: In the context of vital signs and pain assessment, the correct answer is C) Cough. The reason is that a cough is not typically considered a vital sign or directly related to the general survey or initial assessment of a patient's overall health status. Changes in weight (option A) are important to assess as they can indicate underlying health conditions such as fluid retention or nutritional issues. Fatigue and weakness (option B) are common symptoms that can point to various health issues, including anemia or chronic illnesses. Fever and chills (option D) are crucial symptoms to assess as they can indicate infection or systemic inflammation. Educationally, understanding the significance of each symptom in the context of vital signs and general survey helps healthcare professionals prioritize and assess patients effectively. By excluding symptoms like cough from the vital signs assessment, providers can focus on more critical indicators of a patient's health status. This knowledge aids in comprehensive patient evaluations and timely interventions based on the most relevant information gathered during assessments.