Nokea
A client is scheduled for surgery after a recent breast cancer diagnosis. The nurse is discussing the procedure with the client. To allay her fears, which explanation best describes a skin-sparing mastectomy?
- A. Removal of the breast, nipple, and areola, leaving only the skin
- B. Removal of the breast, nipple, areola, and axillary node dissection
- C. Incision on the outside of the breast, leaving the nipple intact
- D. Removal of both breasts in their entirety
Correct Answer: A
Rationale: A skin-sparing mastectomy involves removing the breast, nipple, and areola while keeping the skin intact for possible reconstruction.
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A nurse is discussing recommendations for daily nutrient intake during pregnancy with a client who is at 10 weeks of gestation. For which of the following nutrients should the nurse instruct the client to increase intake during pregnancy?
- A. Vitamin E
- B. Vitamin D
- C. Fiber
- D. Calcium
Correct Answer: D
Rationale: Calcium is crucial for fetal bone and teeth development during pregnancy.
Dysfunctional uterine bleeding (DUB) is defined as excessive uterine bleeding without a demonstrable cause. Which statement regarding this condition is most accurate?
- A. DUB is most commonly caused by anovulation
- B. DUB most often occurs in middle age
- C. The diagnosis of DUB should be the first consideration for abnormal menstrual bleeding
- D. Steroids are the most effective medical treatment for DUB
Correct Answer: A
Rationale: Anovulation is the most common cause of DUB especially in women at the beginning or end of their reproductive years. Other causes should be ruled out before diagnosing DUB.
Which statement regarding human trafficking is correct?
- A. Human trafficking is a multibillion-dollar business that primarily exists in the United States.
- B. Victims often experience the Stockholm syndrome.
- C. Vast majority of the victims are young boys and girls.
- D. Human trafficking primarily refers to commercial sex work.
Correct Answer: B
Rationale: The Stockholm syndrome is a common response where the victim develops feelings for their captor. Victims of trafficking can be forced into sex work, labor, or organ donation.
A nurse is providing teaching to a client who has fibrocystic breast changes and is experiencing breast discomfort during menstruation. Which of the following instructions should the nurse include?
- A. Increase potassium intake.
- B. Increase fluid intake to 3 liters per day.
- C. Decrease sodium intake before menstruation.
- D. Decrease daily fiber intake.
Correct Answer: C
Rationale: Reducing sodium intake can help decrease fluid retention and reduce breast discomfort associated with fibrocystic breast changes.
With regard to an obstetric litigation case, a nurse working in labor and birth is found to be negligent. Which intervention performed by the nurse indicates that a breach of duty has occurred?
- A. The nurse did not document fetal heart tones (FHR) during the second stage of labor.
- B. The patient was only provided ice chips during the labor period, which lasted 8 hours.
- C. The nurse allowed the patient to use the bathroom rather than a bedpan during the first stage of labor.
- D. The nurse asked family members to leave the room when she prepared to do a pelvic exam on the patient.
Correct Answer: A
Rationale: In an obstetric setting, failure to document fetal heart tones (FHR) during the second stage of labor is a critical breach of duty by the nurse. Monitoring FHR is essential to assess fetal well-being and detect any signs of distress or complications during labor. Neglecting to document this important vital sign could result in delayed recognition of fetal distress, potentially leading to adverse outcomes for the baby and the mother. Therefore, this intervention indicates negligence on the part of the nurse in this scenario.