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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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The client diagnosed with endometriosis experiences pain rated a '5' on a 1-to-10 pain scale during her menses. Which intervention should the nurse teach the client?
- A. Teach the client to take a stool softener when taking morphine, a narcotic.
- B. Instruct the client to soak in a tepid bath for 30 to 45 minutes when the pain occurs.
- C. Explain the need to take the nonsteroidal anti-inflammatory drugs with food.
- D. Discuss the possibility of a hysterectomy to help relieve the pain.
Correct Answer: C
Rationale: NSAIDs are first-line for endometriosis pain, taken with food to prevent GI upset. Morphine is excessive, tepid baths are less effective, and hysterectomy is a last resort.
A nurse has been asked to teach ovulation and menstruation to a class of secondary school students. Place the events listed below in the order in which they occur in the menstrual cycle after menstrual flow ends. Use all the options.
- A. Ovum is released.
- B. Progesterone decreases.
- C. Endometrium begins to thicken.
- D. Ovarian follicle matures.
- E. Endometrium is shed.
- F. Corpus luteum forms.
Correct Answer: C,D,A,F,B,E
Rationale: After menstruation, the sequence is: endometrium thickens (follicular phase), ovarian follicle matures, ovum is released (ovulation), corpus luteum forms, progesterone decreases (if no pregnancy), and endometrium is shed (next menstruation).
The nurse is planning the care of a client diagnosed with pelvic inflammatory disease secondary to an STD. Which collaborative diagnosis is appropriate for this client?
- A. Risk for infertility.
- B. Knowledge deficit.
- C. Fluid volume deficit.
- D. Noncompliance.
Correct Answer: A
Rationale: PID from STDs increases infertility risk due to scarring. Knowledge deficit, fluid volume deficit, and noncompliance are less specific without evidence.
The Gravida 7 Para 6 client delivered a 9-pound 4-ounce infant two (2) hours ago. Which intervention is priority for the nurse to implement?
- A. Assess the client’s fundus every hour.
- B. Assess the client’s voiding pattern every shift.
- C. Discuss birth control options with the client.
- D. Discuss breastfeeding methods with the client.
Correct Answer: A
Rationale: Fundal assessment every hour post-delivery prevents postpartum hemorrhage, a life-threatening risk in high-parity clients with large infants. Voiding, birth control, and breastfeeding are secondary.
The nurse correctly informs the client that fibrocystic lesions may become larger and more tender at what time?
- A. The nurse has a normal cycle
- B. After sexual intercourse
- C. Nearer to beginning menopause
- D. Just before menstruation
Correct Answer: D
Rationale: Fibrocystic breast changes are hormone-dependent and typically worsen just before menstruation due to increased estrogen and progesterone levels, causing lesions to enlarge and become tender.