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The nurse is reviewing the physicians notes from the patient who has just left the clinic. The nurse learns that the physician suspects a malignant breast tumor. On palpation, the mass most likely had what characteristic?
- A. Nontenderness
- B. A size of 5 mm
- C. Softness and a regular shape
- D. Mobility
Correct Answer: D
Rationale: The correct answer is D: Mobility. A malignant breast tumor typically lacks mobility due to its fixed attachment to surrounding tissues. This characteristic is concerning for malignancy as it suggests invasive growth.
Incorrect answers:
A: Nontenderness - Tenderness does not reliably indicate malignancy or benignancy.
B: A size of 5 mm - Tumor size alone does not determine malignancy.
C: Softness and a regular shape - Malignant tumors are often firm and irregular in shape.
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The nurse should recognize the greatest risk for the development of blindness in which of the following patients?
- A. A 58-year-old Caucasian woman with macular degeneration
- B. A 28-year-old Caucasian man with astigmatism
- C. A 58-year-old African American woman with hyperopia
- D. A 28-year-old African American man with myopia
Correct Answer: A
Rationale: The correct answer is A because macular degeneration is a leading cause of blindness in older adults. The macula is responsible for central vision, crucial for tasks like reading and driving. Macular degeneration can lead to permanent vision loss if not managed promptly. The other choices are less likely to result in blindness: astigmatism, hyperopia, and myopia are refractive errors that can be corrected with glasses or contacts, and they do not typically lead to blindness. The age and condition of the patient are important factors in determining the risk of blindness.
A nursing student is learning how to perform sexual assessments using the PLISSIT model. According to this model, the student should begin an assessment by doing which of the following?
- A. Briefly teaching the patient about normal sexual physiology
- B. Assuring the patient that what he says will be confidential
- C. Asking the patient if he is willing to discuss sexual functioning
- D. Ensuring patient privacy
Correct Answer: D
Rationale: The correct answer is D: Ensuring patient privacy. In the PLISSIT model, ensuring patient privacy is crucial as it creates a safe and confidential environment for discussing sensitive topics like sexual health. This step helps build trust and allows the patient to feel comfortable sharing intimate details. Briefly teaching about normal sexual physiology (A) may come later in the assessment process. Assuring confidentiality (B) is important but doesn't address the immediate need for privacy. Asking if the patient is willing to discuss sexual functioning (C) assumes patient readiness without first establishing a private setting.
A patient comes to the ophthalmology clinic for an eye examination. The patient tells the nurse that he often sees floaters in his vision. How should the nurse best interpret this subjective assessment finding?
- A. This is a normal aging process of the eye.
- B. Glasses will minimize this phenomenon.
- C. The patient may be exhibiting signs of glaucoma.
- D. This may be a result of weakened ciliary muscles.
Correct Answer: A
Rationale: The correct answer is A because floaters are commonly caused by age-related changes in the vitreous humor of the eye, such as the formation of tiny fibers or clumps. These floaters are typically harmless and not a cause for concern. Choice B is incorrect because glasses do not affect floaters in the eye. Choice C is incorrect because floaters are not a primary symptom of glaucoma. Choice D is incorrect because weakened ciliary muscles are not typically associated with floaters. Therefore, the most appropriate interpretation is that seeing floaters is a normal aging process of the eye.
A nurse is performing an admission assessment on a patient with stage 3 HIV. After assessing the patients gastrointestinal system and analyzing the data, what is most likely to be the priority nursing diagnosis?
- A. Acute Abdominal Pain
- B. Diarrhea
- C. Bowel Incontinence
- D. Constipation
Correct Answer: B
Rationale: The correct answer is B: Diarrhea. In stage 3 HIV, gastrointestinal issues are common due to weakened immune system. Diarrhea can lead to dehydration and electrolyte imbalances, making it the priority nursing diagnosis. Acute Abdominal Pain (A) may be a symptom but not the priority. Bowel Incontinence (C) and Constipation (D) are less likely in stage 3 HIV.
Which findings should the nurse follow up on afterremoval of a catheter from a patient? (Select allthat apply.)
- A. Increasing fluid intake
- B. Dribbling of urine
- C. Voiding in small amounts
- D. Voiding within 6 hours of catheter removal
Correct Answer: B
Rationale: The correct answer is B: Dribbling of urine. This finding should be followed up on after catheter removal because it may indicate urinary retention or incomplete bladder emptying, which can lead to complications such as urinary tract infection.
A: Increasing fluid intake is important for overall hydration but is not a specific finding that requires follow-up after catheter removal.
C: Voiding in small amounts may be a normal response initially after catheter removal and does not necessarily indicate a problem.
D: Voiding within 6 hours of catheter removal is a positive sign of bladder function recovery and does not require immediate follow-up.