Nokea
At a health screening clinic, a nurse is educating a young woman about breast self-examination (BSE). The nurse determines that the client demonstrates understanding when she makes which statement?
- A. BSE should be performed monthly after the menstrual period.
- B. BSE is performed after the menstrual period.
- C. Monthly BSE is a recommended method for early detection of breast cancer.
- D. Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down.
Correct Answer: D
Rationale: The correct answer is 'Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down.' BSE should be performed monthly after the menstrual period, not every other month or on the day menstruation begins. Performing BSE on the seventh day of the menstrual cycle when the breasts are smallest and least congested is recommended. While BSE is a useful tool for early detection, it is not the only method. Regular physical examinations and mammograms are also important. The correct technique for BSE includes inspecting the breasts in front of a mirror, palpating in the shower for easier detection, and conducting palpation while lying down for thorough examination.
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Why is Kleinman's Explanatory Model of Health and Illness significant?
- A. it focuses on the health beliefs of a particular family.
- B. it highlights the impact of culture on health explanations.
- C. it discusses the significant role of popular and folk domains of influence.
- D. it is based on an educational approach.
Correct Answer: C
Rationale: Kleinman's Explanatory Model of Health and Illness is significant because it emphasizes the influence of popular and folk domains on health perceptions. Kleinman distinguishes between disease, representing the biomedical view, and illness, reflecting individual understanding. The model underscores that cultural factors shape the significance of popular and folk influences on health beliefs. Choice A is incorrect as the model focuses on broader cultural influences, not individual family beliefs. Choice B is incorrect as it oversimplifies the model's emphasis on various cultural aspects. Choice D is incorrect as the model's significance lies in its cultural framework rather than an educational base.
A nurse assisting with data collection notes that the client's skin is very dry. The nurse documents this finding using which term?
- A. Xerosis
- B. Pruritus
- C. Seborrhea
- D. Actinic keratoses
Correct Answer: A
Rationale: Dry skin is also called xerosis. In this condition, the epidermis lacks moisture or sebum and is often marked by a pattern of fine lines, scaling, and itching. Xerosis is the correct term for very dry skin. Pruritus is the symptom of itching, an uncomfortable sensation that prompts the urge to scratch the skin, but it does not specifically refer to dry skin. Seborrhea is a skin condition characterized by overproduction of sebum, leading to excessive oiliness or dry scales, not necessarily indicating very dry skin. Actinic keratoses are sun-related skin lesions that are premalignant and not associated with dry skin.
Around what age do children typically start to develop 'stranger anxiety'?
- A. 9 months
- B. 6 months
- C. 3 months
- D. 12 months
Correct Answer: B
Rationale: The correct answer is '6 months.' At around this age, children typically start to develop 'stranger anxiety' as they become more aware of unfamiliar faces and may start showing signs of distress or anxiety around strangers. At 3 months, infants are still very young and unlikely to display stranger anxiety. While by 9 or 12 months, children have usually already developed some level of stranger anxiety, it typically starts around 6 months, making it the most appropriate answer in this context.
When a nurse asks a client to repeat the word 'ninety-nine' while listening through the stethoscope and is able to hear the word clearly, which assessment finding is being documented?
- A. Normal egophony
- B. Abnormal vesicular breath sounds
- C. Abnormal bronchophony
- D. Normal whispered pectoriloquy
Correct Answer: C
Rationale: The nurse is documenting an abnormal bronchophony assessment finding. Bronchophony is a technique where the nurse asks the client to repeat a specific word, such as 'ninety-nine,' while listening through the stethoscope. Normally, the voice transmission is soft, muffled, and indistinct. However, if there is a pathologic condition increasing lung density, the nurse will hear the word clearly, indicating an abnormality. Vesicular breath sounds are normal sounds heard over peripheral lung fields and are not related to vocal resonance assessment. Egophony involves the client phonating a long 'ee-ee-ee-ee' sound, not repeating a specific word. Whispered pectoriloquy involves whispering a phrase like 'one-two-three,' not repeating a specific word. In these cases, normal findings are 'eeeeee' for egophony and a muffled, almost inaudible sound for whispered pectoriloquy.
While assessing for costovertebral angle tenderness, a nurse percusses the area, and the client complains of sharp pain. The nurse interprets this finding as most indicative of which disorder?
- A. Liver enlargement
- B. Ovarian infection
- C. Spleen enlargement
- D. Kidney inflammation
Correct Answer: D
Rationale: When assessing for costovertebral angle tenderness, sharp pain on percussion of the area indicates inflammation of the kidney or paranephric area. The correct technique involves placing one hand over the 12th rib, at the costovertebral angle, and thumping that hand with the ulnar edge of the other fist. The client normally feels a thud and should not experience pain. Ovarian infection, liver enlargement, or spleen enlargement are not associated with the costovertebral angle tenderness. Therefore, the correct answer is kidney inflammation.