Nokea
The client who is scheduled to have a breast biopsy with sentinel node dissection states, 'I don't understand. What does a sentinel node biopsy do?' Which scientific rationale should the nurse use to base the response?
- A. A dye is injected into the tumor and traced to determine spread of cells.
- B. The surgeon removes the nodes that drain the diseased portion of the breast.
- C. The nodes felt manually will be removed and sent to pathology.
- D. A visual inspection of the lymph nodes will be made while the client is sleeping.
Correct Answer: A
Rationale: Sentinel node biopsy involves injecting dye to identify the first lymph node(s) draining the tumor, assessing cancer spread. Removing all draining nodes is outdated, manual palpation is not specific, and visual inspection alone is insufficient.
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If the client is asymptomatic and at low risk for breast cancer, the nurse would be correct in advising her to have a baseline mammogram at what age?
- A. 35
- B. 45
- C. 50
- D. 55
Correct Answer: C
Rationale: The American Cancer Society recommends that women at average risk for breast cancer begin annual mammograms at age 45, but a baseline mammogram may be considered at age 40-50 depending on guidelines. For low-risk, asymptomatic women, age 50 is often the standard starting point for routine screening.
The 24-year-old female client presents to the clinic with lower abdominal pain on the left side she rates as a '9' on a 1-to-10 scale. Which diagnostic procedure should the nurse prepare the client for?
- A. A computed tomography scan.
- B. A lumbar puncture.
- C. An appendectomy.
- D. A pelvic sonogram.
Correct Answer: D
Rationale: Severe left-sided pelvic pain suggests ovarian pathology (e.g., cyst, torsion); a pelvic sonogram is the initial diagnostic tool. CT is less specific, lumbar puncture is irrelevant, and appendectomy is premature.
The nurse is instructing a group of workers at an industrial plant regarding the transmission of sexually transmitted diseases (STDs). Which information should be included in the presentation?
- A. The same behaviors causing one STD could lead to another.
- B. Once clients have had an STD, they develop immunity to it.
- C. An infection with syphilis protects the client from being infected with HIV.
- D. Herpes simplex 1 is a totally different disease from herpes simplex 2.
Correct Answer: A
Rationale: Behaviors like unprotected sex increase risk for multiple STDs. STDs do not confer immunity, syphilis increases HIV risk, and HSV-1/HSV-2 are related viruses.
When collecting a specimen from the client who may have gonorrhea, which nursing action is correct?
- A. Wearing latex gloves
- B. Using a disinfectant
- C. Asking the client to provide the specimen
- D. Refrigerating the specimen immediately
Correct Answer: A
Rationale: Wearing latex gloves protects the nurse from exposure to infectious material during specimen collection.
When the nurse does a physical assessment of this client, which technique is best for determining the extent of the prolapse?
- A. Examine the perineum when the client rolls from side to side.
- B. Examine the perineum as the client stands and bears down.
- C. Examine the perineum with the client in a dorsal recumbent position.
- D. Examine the perineum with a lubricated speculum and flashlight.
Correct Answer: B
Rationale: Standing and bearing down makes a prolapsed uterus more visible, allowing accurate assessment of its extent.