Nokea
A 52-year old female tells the nurse that she has found a painless lump in her right breast during her monthly self-examination. Which assessment finding would strongly suggest that this client's lump is cancerous?
- A. Eversion of the right nipple and mobile
- B. Mobile mass that is soft and easily mass delineated
- C. Non-mobile mass with irregular edges
- D. Non palpable right axillary lymph nodes
Correct Answer: C
Rationale: A non-mobile mass with irregular edges is a strong indicator of a cancerous lump in the breast. Cancerous lumps often feel fixed or attached to the surrounding tissue and may have irregular shapes rather than smooth, round contours. The lack of mobility and irregular edges increase suspicion for malignancy and warrant further investigation, such as imaging studies and biopsies. It is important for this patient to follow up with a healthcare provider promptly for further evaluation and appropriate management.
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A child has been diagnosed with enuresis. TCA imipramine (Tofranil) has been prescribed for the child. The nurse understands that this medication is in which category?
- A. Antidepressant
- B. Antidiuretic
- C. Antispasmodic
- D. Analgesic
Correct Answer: A
Rationale: Imipramine (Tofranil) is a tricyclic antidepressant (TCA) that is commonly used to treat enuresis in children. Enuresis is a condition characterized by involuntary urination, especially observed during sleep in children who are old enough to have bladder control. Imipramine works by affecting the balance of certain neurotransmitters in the brain, which helps regulate the bladder and reduce involuntary urination. While imipramine has antidepressant properties, it is also effective in treating enuresis by reducing the frequency of bedwetting episodes.
A client comes to the clinic complaining of weight loss, fatigue, and a low-grade fever. Physical examination reveals a slight enlargement of the cervical lymph nodes. To assess possible causes for the fever, it would be most appropriate for the nurse to initially ask: a."Have you bee sexually active lately?" b, "Do you have a sore throat at the present time?"
- A. "Have you been exposed recently to anyone with an infection?"
- B. "When did you first notice that your temperature had gone up?"
Correct Answer: A
Rationale: When assessing a client with symptoms of weight loss, fatigue, low-grade fever, and lymphadenopathy (enlarged lymph nodes), it is important to investigate potential causes of infection. In this scenario, considering the client's symptoms and signs, asking if they have been exposed recently to anyone with an infection helps in determining the possibility of an infectious etiology for their symptoms. This question can provide valuable information to guide further assessment and diagnostic evaluation.
An infant with gastroschisis is MORE likely than one with an omphalocele to have which of the following conditions?
- A. Congenital heart disease
- B. History of prematurity
- C. Imperforate anus
- D. N/A
Correct Answer: B
Rationale: Infants with gastroschisis are more likely to have a history of prematurity compared to those with omphalocele, though neither condition is strongly associated with congenital heart disease or imperforate anus.
One of the side effects of INH administration is peripheral neuropathy. To prevent this effect, Nurse Carlos teaches Andrew to:
- A. have a strict low cholesterol diet
- B. get extra bed rest 
- C. supplement the diet with pyridoxine
- D. avoid excessive sun exposure
Correct Answer: C
Rationale: Pyridoxine, also known as vitamin B6, is necessary for the prevention of INH-induced peripheral neuropathy. INH can lead to a deficiency of vitamin B6 in the body, which in turn can cause nerve damage and peripheral neuropathy. By supplementing the diet with pyridoxine, the risk of developing peripheral neuropathy as a side effect of INH administration can be minimized. It is an important preventive measure recommended for those undergoing treatment with INH to ensure the proper functioning of the nervous system and prevent nerve damage.
The nurse is caring for a patient, age 68, who is receiving digoxin (Lanoxin) 0.125 mg qd for cardiac myopathy. Which of the following assessments of the patient would indicate that he is experiencing a side effect of digoxin that requires follow-up?
- A. Skin flushing c.Hypertension
- B. Anorexia
- C. Constipation
Correct Answer: B
Rationale: Anorexia, or loss of appetite, is a common side effect of digoxin. It can lead to weight loss, weakness, and fatigue. Monitoring for anorexia is important because it may indicate digoxin toxicity, which can be serious and require intervention. Skin flushing is not a common side effect of digoxin. Hypertension is also not associated with digoxin use. Constipation is generally not a common side effect of digoxin. Therefore, anorexia is the assessment that indicates a potential side effect of digoxin that requires follow-up.