Nokea
A nurse is providing breast care education to a client after mammography. Which information regarding fibrocystic changes in the breast is important for the nurse to share?
- A. Fibrocystic breast disease is a disease of the milk ducts and glands in the breasts.
- B. It is a premalignant disorder characterized by lumps found in the breast tissue.
- C. Healthy women with fibrocystic breast disease find lumpiness with pain and tenderness in varying degrees in the breast tissue during menstrual cycles.
- D. Lumpiness is accompanied by tenderness after menses.
Correct Answer: C
Rationale: Fibrocystic changes are palpable thickenings in the breast usually associated with pain and tenderness. The pain and tenderness fluctuate with the menstrual cycle. They are not premalignant changes and tenderness most often occurs before menses.
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Which patient may require more help and understanding when integrating the newborn into the family?
- A. A primipara from an upper income family
- B. A primipara who comes from a large family
- C. A multipara (gravida 2) who has a supportive husband and mother
- D. A multipara (gravida 6) who has two children younger than 3 years
Correct Answer: D
Rationale: The correct answer is D. A multipara with 6 pregnancies and 2 children younger than 3 years may require more help and understanding when integrating the newborn into the family due to potential challenges of caring for multiple young children simultaneously. This situation can lead to increased stress, fatigue, and difficulty in managing the needs of all children effectively. In contrast, choices A, B, and C have factors that may provide more support and resources for the new mother, such as being from an upper-income family (A), coming from a large family (B), or having a supportive husband and mother (C), which can help in the integration process.
Which statement about the development of cultural competence is inaccurate?
- A. Local health care workers and community advocates can help extend health care to underserved populations.
- B. Nursing care is delivered in the context of the client's culture but not in the context of the nurse's culture.
- C. Nurses must develop an awareness of and a sensitivity to various cultures.
- D. Culture's economic, religious, and political structures influence practices that affect childbearing.
Correct Answer: B
Rationale: Nurses' cultural context also influences the care they provide. Cultural competence involves both understanding the client's culture and being aware of the nurse's own cultural background, along with the impact of economic, religious, and political factors.
What is the primary role of practicing nurses in the research process?
- A. Designing research studies
- B. Collecting data for other researchers
- C. Identifying researchable problems
- D. Seeking funding to support research studies
Correct Answer: C
Rationale: When problems are identified, research can be properly conducteResearch of healthcare issues leads to evidence-based practice guidelines.
The nurse is assessing a 25-year-old female patient when the patient becomes tearful. The patient states that she has thin milky discharge from her nipples and two small masses on her left breast. She has lost over 40 pounds in the past year due to intensive exercises and finds that she needs to wear a sports bra during her sessions. The patient states that she is afraid that she will become the first member of her family to have breast cancer. Besides a negative mammogram, what other symptoms would correlate with this being a benign finding? Select all that apply.
- A. Milky discharge from nipples
- B. Extensive weight loss
- C. Painful masses
- D. Mood swings
Correct Answer: A
Rationale: The correct answer is A: Milky discharge from nipples. Milky discharge from nipples in a young female with no other concerning symptoms can be indicative of benign conditions such as hormonal imbalances or medication side effects. In this case, the patient's age, weight loss due to exercise, and negative mammogram are all factors that suggest a low likelihood of breast cancer. Extensive weight loss (choice B) is likely attributed to the intensive exercises mentioned and not directly correlated with breast cancer. Painful masses (choice C) could indicate an inflammatory or infection process but are not necessarily indicative of malignancy. Mood swings (choice D) are unrelated to the breast symptomatology described.
The nurse is writing an expected outcome for the nursing diagnosis—acute pain related to
tissue trauma, secondary to vaginal birth, as evidenced by patient stating pain of 8 on a scale
of 10. Which expected outcome is correctly stated for this problem?
- A. Patient will state that pain is a 2 on a scale of 10.
- B. Patient will have a reduction in pain after administration of the prescribed
- C. Patient will state an absence of pain 1 hour after administration of the prescribed
- D. Patient will state that pain is a 2 on a scale of 10, 1 hour after the administration of
Correct Answer: D
Rationale: The correct answer is D because it aligns with the SMART criteria for expected outcomes. Specific: It clearly states the desired pain level of 2 on a scale of 10. Measurable: It provides a quantifiable measure to assess the outcome. Achievable: The goal is realistic and attainable within a specified time frame. Relevant: It directly addresses the nursing diagnosis of acute pain related to tissue trauma. Time-bound: It includes a timeframe of 1 hour after administration for evaluation.
Choices A, B, and C are incorrect because they do not meet all the SMART criteria. Choice A only focuses on the pain level without a specific timeframe. Choice B mentions pain reduction but lacks a specific target level or timeframe. Choice C mentions pain absence but lacks a specific timeframe for evaluation.