The client has been diagnosed with cancer of the breast. Which referral is most important for the nurse to make?
- A. The hospital social worker.
- B. CanSurmount.
- C. Reach to Recovery.
- D. I CanCope.
Correct Answer: C
Rationale: Reach to Recovery provides peer support from breast cancer survivors, addressing emotional and practical needs post-diagnosis. Social workers, CanSurmount, and I CanCope are valuable but less specific to breast cancer support.
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The nurse is assessing a 34-year-old female client with fibrocystic breasts. Which question should the nurse ask the client during the assessment?
- A. Are your breasts more tender during your period?'
- B. Have you ever developed an allergy to chocolate?'
- C. Can you tell me more about your feelings of having fibrocystic breast changes?'
- D. Have you considered having a prophylactic mastectomy?'
Correct Answer: A
Rationale: Fibrocystic breast changes cause cyclical tenderness, worse premenstrually; this question assesses symptoms. Chocolate allergies, feelings, and prophylactic mastectomy are irrelevant.
The nurse is teaching a class on breast health to a group of ladies at a senior citizen's center. Which risk factor is the most important to emphasize to this group?
- A. The clients should find out about their family history of breast cancer.
- B. Men at this age can get breast cancer also and should be screened.
- C. Monthly breast self-examination is the key to early detection.
- D. The older a woman gets, the greater the chance of developing breast cancer.
Correct Answer: D
Rationale: Age is the most significant risk factor for breast cancer, with risk increasing as women age, especially in seniors. Family history is important but less universal, male breast cancer is rare, and BSE is secondary to awareness and screening.
The nurse is caring for a client diagnosed with uterine cancer who has been receiving systemic therapy for six (6) months. Which intervention should the nurse implement first?
- A. Determine which antineoplastic medication the client has received.
- B. Ask the client if she has had any problems with mouth ulcers at home.
- C. Administer the biologic response modifier filgrastim (Neupogen).
- D. Encourage the client to discuss feelings about having cancer.
Correct Answer: B
Rationale: Mouth ulcers are a common chemotherapy side effect, requiring immediate assessment to manage pain and infection risk. Medication history, filgrastim administration, and emotional support are secondary.
The charge nurse is making rounds on the genitourinary surgery floor. Which action by the primary nurse warrants immediate intervention?
- A. The nurse elevates the scrotum of a client who has had an orchiectomy.
- B. The nurse encourages the client to cough, although he complains of pain.
- C. The nurse empties the client’s JP drain and leaves it rounded.
- D. The nurse asks the UAP to empty a catheter drainage bag.
Correct Answer: B
Rationale: Encouraging coughing despite pain risks complications (e.g., bleeding) post-surgery; pain control is needed first. Scrotal elevation, JP drain management, and UAP delegation are appropriate.
The nurse is admitting a client diagnosed with trichomoniasis. Which assessment data support this diagnosis?
- A. Odorless, white, curdlike vaginal discharge.
- B. Strawberry spots on the vaginal surface and itching.
- C. Scant white vaginal discharge and dyspareunia.
- D. Purulent discharge from the endocervix and pelvic pain.
Correct Answer: B
Rationale: Trichomoniasis causes strawberry spots (petechiae) on the vagina and itching due to inflammation. Curdlike discharge is candidiasis, scant discharge/dyspareunia is nonspecific, and purulent discharge suggests PID.
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