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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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Before the client leaves the office, on which topic should the nurse provide health teaching?
- A. Ask about the qualifications of the person who did the tattoos and piercings
- B. Whether the client is practicing safe, protected sex
- C. The client's sexual experiences with members of both sexes
- D. The names of all of the client's sexual partners
Correct Answer: B
Rationale: Tattoos and piercings increase infection risk, but safe sex practices are critical to discuss due to potential STI transmission, especially with vaginal bleeding.
Which statement is most accurate when discussing hair loss with the client?
- A. The hair loss is permanent, but attractive wigs are available.
- B. The hair loss is permanent, but hair transplantation is a possible solution.
- C. The hair loss is temporary; hair may grow back in several years.
- D. The hair loss is temporary; hair will regrow after chemotherapy is finished.
Correct Answer: D
Rationale: Hair loss from chemotherapy is typically temporary, with regrowth occurring after treatment ends, usually within months.
The client is diagnosed with left mastitis. Which assessment findings should the nurse observe?
- A. Dimpling of the left breast when the client raises the arm.
- B. A round lump in the left breast that is tender during menses.
- C. A dull pain in the left breast and tough, doughy feeling skin.
- D. Bloody discharge from the nipple and a hard palpable mass.
Correct Answer: C
Rationale: Mastitis causes dull pain and tough, doughy skin due to inflammation. Dimpling suggests cancer, cyclical lumps are fibrocystic, and bloody discharge/mass indicates malignancy.
Which specific complication should the nurse assess for in the client with a uterine prolapse recovering from an anterior and posterior repair?
- A. Orthostatic hypotension.
- B. Atelectasis.
- C. Allen sign.
- D. Deep vein thrombosis.
Correct Answer: D
Rationale: Deep vein thrombosis is a significant risk post-pelvic surgery due to immobility and venous stasis. Orthostatic hypotension is unrelated, atelectasis is a respiratory risk, and Allen sign pertains to arterial occlusion.
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.