Nokea
The client has undergone a wedge resection for cancer of the left breast. Which discharge instruction should the nurse teach?
- A. Don't lift more than five (5) pounds with the left hand until released by the HCP.
- B. The cancer has been totally removed and no follow-up therapy will be required.
- C. The client should empty the Hemovac drain about every 12 hours.
- D. The client should arrange an appointment with a plastic surgeon for reconstruction.
Correct Answer: A
Rationale: Limiting lifting with the affected arm prevents strain and lymphedema risk post-wedge resection. Claiming cancer is fully removed is misleading, Hemovac drains are uncommon in lumpectomy, and reconstruction is not universally needed.
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The nurse is assessing the client diagnosed with a rectocele. Which signs and symptoms should the nurse expect? Select all that apply.
- A. Rectal pressure.
- B. Flatus.
- C. Fecal incontinence.
- D. Constipation.
- E. Urinary frequency.
Correct Answer: A,B,C,D
Rationale: Rectocele causes rectal pressure, flatus, fecal incontinence, and constipation due to posterior vaginal wall protrusion. Urinary frequency is more associated with cystocele.
The client is diagnosed with benign uterine fibroid tumors. Which question should the nurse ask to determine if the client is experiencing a complication?
- A. How many periods have you missed?'
- B. Do you get short of breath easily?'
- C. How many times have you been pregnant?'
- D. Where is the location of the pain you are having?'
Correct Answer: D
Rationale: Pain location helps identify complications like fibroid degeneration or pressure on organs. Missed periods are common, shortness of breath is unrelated, and pregnancy history is less relevant.
While assessing a male client with tertiary syphilis, which finding is most characteristic of this stage of the disease?
- A. Stabbing leg pain
- B. Red, raised rash
- C. Fever
- D. Patchy hair loss
Correct Answer: A
Rationale: Tertiary syphilis can cause neurological symptoms like tabes dorsalis, characterized by stabbing leg pain due to nerve damage.
Which steps should the nurse provide clients who choose to perform breast self-examination (BSE) according to the American Cancer Society (ACS) guidelines? Rank in order of performance.
- A. Lie flat on the bed with a rolled towel placed under the scapula; perform palpation of each breast.
- B. Pinch each nipple to see if fluid can be expressed.
- C. With the breasts exposed, stand in front of a mirror and examine the breasts from front and each side.
- D. In the shower, soap the breasts, and perform palpation in a systematic manner on each breast.
- E. Find a private place where the self-examination can be performed.
Correct Answer: E,C,A,D,B
Rationale: ACS BSE steps: 1) Find a private place; 2) Visually inspect in mirror (front/sides); 3) Palpate lying down with towel; 4) Palpate in shower; 5) Check nipples for discharge.
Although it has not been conclusively proven, the nurse explains that some women with fibrocystic disease get relief from their symptoms by eliminating which substance from their diet?
- A. The blood
- B. Caffeine
- C. Saturated fat
- D. Refined sugar
Correct Answer: B
Rationale: Caffeine is thought to exacerbate fibrocystic breast symptoms in some women by stimulating breast tissue, and reducing intake may provide symptom relief, though evidence is not definitive.