Nokea
During a breast examination, which finding most strongly suggests that the client has breast cancer?
- A. Slight asymmetry of the breasts
- B. A fixed nodular mass with dimpling of the overlying skin
- C. Bloody discharge from the nipple
- D. Multiple firm, round, freely movable masses that change with the menstrual cycle
Correct Answer: B
Rationale: The correct answer is B because a fixed nodular mass with dimpling of the overlying skin is highly indicative of breast cancer. This finding suggests an invasive tumor pulling on the skin, causing dimpling. Other choices are incorrect because slight breast asymmetry (A) is common, bloody nipple discharge (C) can be benign or due to other conditions, and multiple freely movable masses (D) are more indicative of benign breast conditions like fibrocystic changes.
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Which of the following hormones retains sodium in the body?
- A. Antidiuretic hormone
- B. Aldosterone
- C. Thyroid hormone
- D. Insulin
Correct Answer: B
Rationale: The correct answer is B: Aldosterone. Aldosterone is a hormone produced by the adrenal glands that helps regulate sodium and water balance in the body. It acts on the kidneys to increase reabsorption of sodium, leading to water retention and increased blood volume. This helps maintain blood pressure and electrolyte balance.
A: Antidiuretic hormone (ADH) mainly acts on the kidneys to increase water reabsorption, not sodium retention.
C: Thyroid hormone does not directly influence sodium retention.
D: Insulin regulates blood sugar levels by promoting glucose uptake, it does not have a direct role in sodium retention.
During preoperative teaching for a client who will undergo subtotal thyroidectomy, the nurse should include which statement?
- A. “The head of your bed must remain flat for 24 hours after surgery.”
- B. “You should avoid deep breathing and coughing after surgery.”
- C. “You won’t be able to swallow for the first day or two.”
- D. “You must avoid hyperextending your neck after surgery.”
Correct Answer: D
Rationale: The correct answer is D: “You must avoid hyperextending your neck after surgery.” This is because hyperextending the neck can put excessive strain on the surgical site, leading to potential complications such as bleeding or injury to the incision. Keeping the neck in a neutral position helps promote healing and reduces the risk of complications.
A: “The head of your bed must remain flat for 24 hours after surgery.” - Incorrect. Elevating the head of the bed can help reduce swelling and promote drainage after thyroidectomy.
B: “You should avoid deep breathing and coughing after surgery.” - Incorrect. Deep breathing and coughing are important to prevent respiratory complications such as pneumonia.
C: “You won’t be able to swallow for the first day or two.” - Incorrect. Swallowing may be difficult initially but should improve gradually after surgery.
Which of the ff. nursing actions is most appropriate when doing perineal care on an uncircumcised male patient?
- A. Leave the foreskin retracted so air can keep the area dry
- B. Do not retract the foreskin during washing
- C. Replace the foreskin over the head of the penis after washing
- D. Use alcohol and a cotton swab to clean under the foreskin
Correct Answer: C
Rationale: The correct answer is C, which is to replace the foreskin over the head of the penis after washing. This is important to prevent any irritation or injury to the sensitive foreskin and glans. Leaving the foreskin retracted (A) can lead to discomfort and potential injury. Not retracting the foreskin (B) may not allow for proper cleaning. Using alcohol and a cotton swab (D) can be too harsh and irritating to the delicate tissues. Therefore, option C is the most appropriate and gentle approach to maintain proper hygiene and prevent any complications.
The nurse is caring for a 32-year old client admitted with pernicious anemia. Which set of findings should the nurse expect when assessing the client?
- A. Pallor, bradycardia, and reduced pule
- B. Sore tongue, dyspnea, and weight gain
- C. Angina, double vision, and anorexia
- D. Pallor, tachycardia, and a sore tongue
Correct Answer: D
Rationale: The correct answer is D: Pallor, tachycardia, and a sore tongue. Pernicious anemia is caused by a deficiency in vitamin B12, leading to symptoms such as pallor (due to decreased red blood cells), tachycardia (as the heart works harder to compensate for decreased oxygen-carrying capacity of the blood), and a sore tongue (due to inflammation of the tongue).
Choice A is incorrect because bradycardia would not be expected in pernicious anemia, and reduced pulse is not a typical finding. Choice B is incorrect because weight gain is not a common symptom of pernicious anemia. Choice C is incorrect because angina and double vision are not typical findings of pernicious anemia, and anorexia is more likely due to other causes.
After assessing a patient, a nurse develops a standard formal nursing diagnosis. What is the rationale for the nurse’s actions?
- A. To form a language that can be encoded only by nurses
- B. To distinguish the nurse’s role from the physician’s role
- C. To develop clinical judgment based on other’s intuition
- D. To help nurses focus on the scope of medical practice
Correct Answer: D
Rationale: The correct answer is D: To help nurses focus on the scope of medical practice. Developing a standard formal nursing diagnosis helps nurses to identify and focus on the patient's specific health issues within the nursing scope of practice. This enables nurses to provide targeted and effective care interventions.
A: To form a language that can be encoded only by nurses - This choice is incorrect because the purpose of a nursing diagnosis is not exclusive to nurses and should be comprehensible to all healthcare professionals caring for the patient.
B: To distinguish the nurse’s role from the physician’s role - While this distinction is important, the main purpose of developing a nursing diagnosis is to guide nursing interventions based on the patient's nursing care needs, rather than solely differentiating roles.
C: To develop clinical judgment based on other’s intuition - This choice is incorrect as clinical judgment should be based on evidence-based practice and critical thinking, rather than solely relying on intuition or others' opinions.