Nokea
The nurse is teaching a client who suspects that she has a lump in her breast. The nurse instructs the client that a diagnosis of breast cancer is confirmed by:
- A. Breast self-examination
- B. Fine needle aspiration
- C. Mammography
- D. Chest x-ray
Correct Answer: B
Rationale: The correct answer is B: Fine needle aspiration. This is because fine needle aspiration involves extracting cells from the lump in the breast for examination under a microscope to determine if they are cancerous. This procedure provides a definitive diagnosis of breast cancer. Breast self-examination (A) is a screening tool for detecting lumps but does not confirm a diagnosis. Mammography (C) is used for screening and detecting abnormalities but requires further testing for confirmation. Chest x-ray (D) is not useful for diagnosing breast cancer.
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A client asks the nurse about the four-point gait when partial weight bearing is permitted. What is the nurse’s BEST response?
- A. move the right crutch ahead, then follow with the left foot
- B. move both crutches forward together, then swing legs through
- C. move the left crutch and the right foot forward together
- D. move both crutches and the weaker leg forward at the same time
Correct Answer: A
Rationale: The correct answer is A because in the four-point gait with partial weight bearing, the client should move the right crutch ahead first to provide support and stability, followed by the left foot. This sequence ensures proper weight distribution and balance. Moving both crutches together (B) may compromise stability. Moving the left crutch and right foot together (C) may cause uneven weight distribution. Moving both crutches and weaker leg together (D) may not provide adequate support for the weaker leg.
A patient verbalizes a low pain level of 2 out of 10 but exhibits extreme facial grimacing while moving around in bed. What is the nurse’s initial action in response to these observations?
- A. Proceed to the next patient’s room to make rounds.
- B. Determine the patient does not want any pain medicine.
- C. Ask the patient about the facial grimacing with movement.
- D. Administer the pain medication ordered for moderate to severe pain.
Correct Answer: C
Rationale: The correct initial action for the nurse is to ask the patient about the facial grimacing with movement (Choice C). This is because the patient's non-verbal cues (facial grimacing) are contradicting their verbal report of low pain level. By asking the patient directly, the nurse can clarify the discrepancy and gain a better understanding of the patient's actual pain level and needs.
Choice A is incorrect as it disregards the patient's observed discomfort. Choice B assumes the patient does not want pain medicine without clarifying the situation first. Choice D is premature as administering pain medication without further assessment may not be appropriate or safe.
In summary, asking the patient about the facial grimacing is essential to ensure accurate pain assessment and appropriate intervention.
After a transsphenoidal adenohypophysectomy, a client is likely to undergo hormone replacement therapy. A transsphenoidal adenohypophysectomy is performed to treat which type of cancer?
- A. Esophageal carcinoma
- B. Laryngeal carcinoma
- C. Pituitary carcinoma
- D. Colorectal carcinoma
Correct Answer: C
Rationale: Rationale:
1. Transsphenoidal adenohypophysectomy is the surgical removal of the pituitary gland's adenohypophysis.
2. The procedure is used to treat pituitary tumors, which can be benign or malignant, but commonly referred to as pituitary adenomas.
3. Pituitary adenomas may secrete hormones excessively, leading to various endocrine disorders.
4. Hormone replacement therapy is required post-surgery to manage hormonal deficiencies.
5. Therefore, the correct answer is C (Pituitary carcinoma).
Summary:
A, B, and D are incorrect as they do not involve the pituitary gland, which is the primary target of a transsphenoidal adenohypophysectomy.
A nurse finds Mr. Gabatan under the wreckage of the car. He is conscious, breathing satisfactorily, and lying on the back complaining of pain in the back and an inability to move his legs. The nurse should first:
- A. Leave Mr. Gabatan lying on his back with instructions to move and then go seek additional help
- B. Gently raise Mr. Gabatan to a sitting position to see if the pain either
- C. Roll Mr. Gabatan on his abdomen, place, a pad under his head, and cover him with any material available
- D. Gently lift Mr. Gavatan into a flat piece of lumber and using any available transportation, rush him to the nearest medical institution
Correct Answer: C
Rationale: The correct answer is C because in cases of suspected spinal injury, it is crucial to keep the spine immobilized to prevent further damage. Rolling Mr. Gabatan onto his abdomen helps protect his spine by maintaining alignment. Placing a pad under his head provides support and covering him with any material available helps maintain his body temperature. Moving him without proper spinal precautions (options A, B, D) could worsen his condition. Seeking additional help is important, but ensuring spinal immobilization comes first. Sitting him up or moving him onto a flat piece of lumber can exacerbate spinal injuries. Therefore, option C is the most appropriate initial action.
A client has a serum calcium level of 7.2mg/dl. During the physical examination, the nurse expects to assess:
- A. Trousseau’s sign
- B. Hegar’s sign
- C. Homan’s sign
- D. Goodell’s sign
Correct Answer: A
Rationale: The correct answer is A: Trousseau's sign. A serum calcium level of 7.2mg/dl indicates hypocalcemia. Trousseau's sign is a clinical manifestation of hypocalcemia, characterized by carpal spasm induced by inflating a blood pressure cuff above systolic pressure. This occurs due to increased neuromuscular excitability from low calcium levels. Hegar's sign (B) is associated with pregnancy, Homan's sign (C) is a clinical test for deep vein thrombosis, and Goodell's sign (D) is a softening of the cervix during pregnancy. These signs are not relevant to a client with hypocalcemia.