The nurse is using inspection to assess the breasts of a female client. Which finding should the nurse document?
Explanation & Rationale
A. Palpable lymph nodes are assessed through palpation, not inspection. The nurse would use their hands to feel for lymph nodes in areas such as the axilla (armpit) and supraclavicular regions. This is a tactile examination and therefore not documented as part of the inspection. B. Symmetry refers to the visual observation of whether the breasts are equal in size and shape. During the inspection phase, the nurse notes whether the breasts appear symmetrical or if there are any visible asymmetries. C. Breast sensitivity is typically assessed through palpation or the client’s report of symptoms rather than through inspection alone. Sensitivity involves asking the client about their experience of pain or discomfort in the breasts, which cannot be observed visually. D. Tenderness is assessed through palpation, where the nurse would gently press on the breast tissue to determine if the client experiences pain. Tenderness is not a visual finding and therefore is not documented during the inspection phase.