Nokea
The nurse correctly informs the client that the breast self-examination (BSE) technique involves palpating each breast moving in small concentric circles, following imaginary spokes in a wheel, or moving in rows from superior to inferior stress of the breast. Besides the breast, which other body area is essential to palpate?
- A. The axillae
- B. The sternum
- C. The clavicles
- D. The ribs
Correct Answer: A
Rationale: The axillae (armpits) contain lymph nodes that drain the breast, and palpating this area is essential to detect any abnormal lymph node enlargement, which could indicate breast pathology.
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The nurse writes a client problem of urinary retention for a client diagnosed with Stage IV cancer of the prostate. Which intervention should the nurse implement first?
- A. Catheterize the client to determine the amount of residual.
- B. Encourage the client to assume a normal position for urinating.
- C. Teach the client to use the Valsalva maneuver to empty the bladder.
- D. Determine the client’s normal voiding pattern.
Correct Answer: A
Rationale: Catheterization assesses residual urine, confirming retention and guiding treatment in advanced prostate cancer. Positioning, Valsalva, and voiding patterns are secondary.
Which nursing diagnosis is most appropriate for the nurse to add to the client's care plan at this time?
- A. Risk for ineffective airway clearance
- B. Risk for imbalanced nutrition
- C. Ineffective coping
- D. Impaired verbal communication
Correct Answer: A
Rationale: General anesthesia and abdominal surgery increase the risk of respiratory complications, making ineffective airway clearance a priority diagnosis.
The client is diagnosed with tertiary syphilis. Which signs and symptoms should the nurse expect the client to exhibit?
- A. Lymphadenopathy and hair loss.
- B. Warts in the genital area.
- C. Dementia and psychosis.
- D. Raised rash covering the body.
Correct Answer: C
Rationale: Tertiary syphilis affects the nervous system, causing dementia and psychosis. Lymphadenopathy/hair loss and rashes occur in earlier stages, and warts are HPV-related.
The client has had an exploratory laparotomy to remove an ovarian tumor. The pathology report classifies the tumor as a 'low malignancy potential' (LMP) tumor. Which statement explains the scientific rationale for this pathology report?
- A. The client does not have cancer but will need adjuvant therapy.
- B. The client would have developed cancer if the tumor had not been removed.
- C. These borderline tumors resemble ovarian cancer but have better outcomes.
- D. The client has a very poor prognosis and has less than six (6) months to live.
Correct Answer: C
Rationale: LMP tumors (borderline ovarian tumors) have malignant features but lower metastatic potential, with better prognosis than invasive ovarian cancer. They are cancerous, not precancerous, and do not inherently require adjuvant therapy or indicate poor prognosis.
When the nurse provides the client with pretest instructions, which statement is most correct?
- A. You'll need to fast from midnight the night before the test.
- B. You'll need to empty your bladder just before the test begins.
- C. You'll need to consume at least a quart of water an hour before the test.
- D. You'll need to self-administer an enema 1 hour before the test.
Correct Answer: C
Rationale: A full bladder is required for a transabdominal prostate sonogram to provide a clear acoustic window for imaging.