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 tissue, and palpating this area is essential to detect any abnormal lymph node enlargement, which could indicate breast pathology.
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Which tumor marker information is used to follow the progress of a client diagnosed with testicular cancer?
- A. CA-125.
- B. Carcinogenic embryonic antigen (CEA).
- C. DNA ploidy test.
- D. Human chorionic gonadotropin (hCG).
Correct Answer: D
Rationale: hCG is a key tumor marker for testicular cancer, used to monitor disease progression and treatment response. CA-125 is for ovarian cancer, CEA is nonspecific, and DNA ploidy is not a marker.
Besides assessing the dressing for signs of bleeding, which other postoperative nursing assessment is a priority after this surgical procedure?
- A. Checking the client's deep-breathing efforts
- B. Assessing the client's ability to achieve an erection
- C. Monitoring the volume of urine output
- D. Monitoring the infusion of I.V. antibiotics
Correct Answer: C
Rationale: Monitoring urine output is critical post-circumcision to ensure no urinary retention or complications from swelling.
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.
What intervention should the nurse implement for a client diagnosed with a rectocele?
- A. Limit oral intake to decrease voiding.
- B. Encourage a low-residue diet.
- C. Administer a stool softener daily.
- D. Arrange for the client to take sitz baths.
Correct Answer: C
Rationale: Stool softeners prevent straining during bowel movements, reducing rectocele pressure. Limiting intake is inappropriate, low-residue diets increase constipation risk, and sitz baths are less specific.
The client has an infected Bartholin’s cyst and the HCP has performed an incision and drainage (I&D) of the area. Which discharge instructions should the nurse teach the client?
- A. Complete all antibiotics as ordered.
- B. Report any drainage immediately.
- C. Keep all water away from the area.
- D. Lie prone as much as possible.
Correct Answer: A
Rationale: Completing antibiotics prevents recurrence of infection post-I&D. Drainage is expected, water avoidance is impractical, and prone positioning is unnecessary.