Nokea
The nurse is teaching a class on Breast Health Awareness. Which are the American Cancer Society’s recommended guidelines for the performance of breast self-examination (BSE)? List in order of recommended performance.
- A. Visualize the breast from the front while standing before a mirror.
- B. Gently squeeze the nipple to express any fluid.
- C. Turn to each side and view each breast in the mirror.
- D. Palpate each breast in a circular motion while lying on the back.
- E. Palpate each breast in a circular motion while in the shower.
Correct Answer: A,C,D,E,B
Rationale: ACS BSE steps: 1) Front mirror visualization; 2) Side visualization; 3) Lying palpation; 4) Shower palpation; 5) Nipple check for discharge.
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The client diagnosed with gestational diabetes delivered a 10-pound 5-ounce infant. Which is priority for the nursery nurse to monitor?
- A. Failure to latch on to the breast during feeding.
- B. Jaundice and clay-colored stools.
- C. Parchment-like skin and lack of lanugo.
- D. Low blood glucose readings.
Correct Answer: D
Rationale: Macrosomic infants from gestational diabetes are at risk for hypoglycemia; monitoring blood glucose is priority. Latching issues, jaundice, and skin changes are secondary.
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 client diagnosed with ovarian cancer is prescribed radiation therapy for regional control of the disease. Which statement indicates the client requires further teaching?
- A. I will not wash the marks off my abdomen.'
- B. I will have a treatment every day for six (6) weeks.'
- C. Nausea caused by radiation therapy cannot be controlled.'
- D. I need to drink a nutritional shake if I don’t feel like eating.'
Correct Answer: C
Rationale: Nausea from radiation can be managed with antiemetics; this statement indicates a misconception. Preserving marks, daily treatments, and nutritional shakes are correct.
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 client is diagnosed with breast cancer and is considering whether to have a lumpectomy or a more invasive procedure, a modified radical mastectomy. Which information should the nurse discuss with the client?
- A. Ask if the client is afraid of having general anesthesia.
- B. Determine how the client feels about radiation and chemotherapy.
- C. Tell the client she will need reconstruction with either procedure.
- D. Find out if the client has any history of breast cancer in her family.
Correct Answer: B
Rationale: Discussing feelings about radiation and chemotherapy is key, as lumpectomy often requires radiation, while mastectomy may involve chemotherapy. Anesthesia fears, mandatory reconstruction, and family history are less relevant to the procedure choice.