Breast & lymphatics
During a breast assessment, the nurse notes unilateral nipple retraction and recent onset of clear discharge. What is the most appropriate next action?
Report findings immediately—possible underlying carcinoma
A patient’s lung percussion reveals dullness over the right lower lobe. What condition should the nurse suspect?
Consolidation from pneumonia or presence of pleural effusion.
Which heart sound marks the beginning of systole?
Which heart sound signals end of systole/ beginning of diastole ?
S1 – closure of the AV valves.
S2 - closure of semilunar valves
A nurse performs the Allen test before radial puncture and notes delayed refill (>5 seconds). What does this imply?
Inadequate collateral circulation via the ulnar artery, do not use this arm for arterial blood sampling.
RLQ, RUQ, LUQ, LLQ
What is the correct order for the breast exam?
Inspect, palpate, then teach self-exam.
Name three abnormal lung sounds and one possible cause for each.
Crackles (pneumonia), wheezes (asthma), stridor (croup).
All heart sounds are described by
Frequency or pitch
Intensity or loudness
Duration
Timing
What condition causes brown discoloration of the legs?
Chronic venous stasis
What does rebound tenderness (Blumberg’s sign) indicate?
Peritoneal inflammation or appendicitis
During palpation, you find a firm, fixed, irregularly shaped lump in the upper outer quadrant of the breast. Which documentation elements are essential for accurate reporting?
Location (clock face), size (cm³), shape, consistency, mobility, tenderness, overlying skin changes, and lymph node involvement
A 70-year-old with a history of COPD presents with a barrel chest and decreased breath sounds bilaterally. What physiologic changes cause these findings?
Hyperinflation of lungs and loss of alveolar elasticity leading to increased Anteroposterior-to-transverse diameter
Conditions that can cause murmurs
Velocity of blood increases
Viscosity of blood decreases
Structural defects in valves
A positive Murphy’s sign indicates what condition, and how is the test performed?
Cholecystitis; pain and inspiratory arrest during deep palpation under the right costal margin
What is the clinical importance of assessing the Tail of Spence, and what technique ensures it is not missed?
It’s the most common site for breast malignancy; palpate it by extending fingers into the upper outer quadrant toward the axilla.
Characteristics of S3 and S4?
S3 (“Kentucky”): Occurs during rapid filling phases, immediately after S2, Associated with “ventricular gallop”; ventricle is noncompliant
S4 (“Tennessee”): Occurs as the atria pushes blood into stiff ventricle, indicates there is an issue with the left ventricle, Associated with “atrial gallop” , Occurs just before S1
Name the 6 F’s of abdominal distension.
Fat, Fluid, Fetus, Flatus, Feces, Fatal tumors
An adolescent female presents with unilateral breast enlargement and tenderness. What is the most likely cause, and how should the nurse respond?
Normal temporary asymmetry, reassure and re-evaluate at next visit.
How can you differentiate a carotid bruit from a cardiac murmur?
A bruit is heard over the neck, localized
Murmurs are intracardiac and vary with heart position.