Nokea
A nurse is palpating a female client's breast while assessing for breast disease. In the illustration below, indicate the area of the breast in which tumors are most commonly found.
Correct Answer:
Rationale: Most breast tumors are found in the upper outer quadrant of the breast, as this area contains the most glandular tissue.
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A client with ulcerative colitis expresses serious concerns about her career as an attorney because of the effects of stress on ulcerative colitis. Which of the following stress interventions will be most helpful to the client?
- A. Review her current coping mechanisms and develop alternatives, if needed.
- B. Suggest a less stressful career in which she would still use her education and experience.
- C. Suggest that she ask her colleagues to help decrease her stress by giving her the easier cases.
- D. Prepare family members for the fact that she will have to work part-time.
Correct Answer: A
Rationale: Reviewing and developing coping mechanisms helps the client manage stress nbr without assuming drastic changes like altering her career or relying on others to adjust her workload. Preparing family for part-time work is premature and not directly stress-focused. CN: Psychosocial adaptation; CL: Synthesize
The nurse in the perioperative area is preparing a client for surgery and notices that the client looks sad. The client says, 'I'm scared of having cancer. It's so horrible and I brought it on myself. I should have quit smoking years ago.' What would be the nurse's best response to the client?
- A. It's okay to be scared. What is it about cancer that you're afraid of?'
- B. It's normal to be scared. I would be, too. We'll help you through it.'
- C. Don't be so hard on yourself. You don't know if your smoking caused the cancer.'
- D. Do you feel guilty because you smoked?'
Correct Answer: A
Rationale: Acknowledging fear and exploring specific concerns ('What is it about cancer that you're afraid of?') validates emotions and opens communication. Other responses dismiss feelings, speculate on causation, or focus on guilt, which are less therapeutic.
A client with acute renal failure has edema. The nurse should:
- A. Elevate the legs.
- B. Restrict fluids.
- C. Administer a diuretic.
- D. Increase sodium intake.
Correct Answer: B
Rationale: Fluid restriction helps manage edema in acute renal failure.
The rapid response team has been called to manage an unwitnessed cardiac arrest. The estimated maximum time a person can be without cardiopulmonary function and still not experience permanent brain damage is:
- A. 1 to 2 minutes.
- B. 4 to 6 minutes.
- C. 8 to 10 minutes.
- D. 12 to 15 minutes.
Correct Answer: B
Rationale: Brain damage begins after 4 to 6 minutes without oxygenation, making this the critical window for initiating CPR to prevent permanent damage.
A nurse is assessing a female who is receiving the second administration of chemotherapy for breast cancer. When obtaining this client's health history, what is the most important information the nurse should obtain?
- A. Has your hair been falling out in clumps?
- B. Have you had nausea or vomiting?
- C. Have you been sleeping at night?
- D. Do you have your usual energy level?
Correct Answer: B
Rationale: Nausea and vomiting are critical to assess during chemotherapy, as they can lead to dehydration, malnutrition, and treatment delays if not managed promptly.