Nokea
The nurse is teaching a group of women to perform breast self-examination. The nurse should explain that the purpose of performing the examination is to discover:
- A. Cancerous lumps.
- B. Changes from previous self-examinations.
- C. Areas of thickness or fullness.
- D. Fibrocystic masses.
Correct Answer: A
Rationale: The primary purpose of performing breast self-examination is to detect any abnormal changes in the breast tissue, including the presence of cancerous lumps. By regularly examining their breasts, women can become familiar with the normal look and feel of their breasts, making it easier to identify any new lumps or other changes that may indicate a potential problem, such as breast cancer. Detecting cancerous lumps early through self-examination can lead to early detection and improved treatment outcomes. It is important for women to perform breast self-examinations regularly and report any concerning findings to their healthcare provider for further evaluation.
You may also like to solve these questions
The nurse is caring for a client in acute addisonian crisis. Which laboratory data would the nurse expect to find?
- A. Hyperkalemia
- B. Hypernatremia
- C. Reduced blood urea nitrogen (BUN)
- D. Hyperglycemia
Correct Answer: A
Rationale: In acute Addisonian crisis, the adrenal glands do not produce enough cortisol and aldosterone, leading to a decrease in blood volume and blood pressure. This can cause hyperkalemia (high potassium levels) due to the lack of aldosterone, which normally helps regulate potassium excretion from the body. Additionally, clients in Addisonian crisis may experience hyponatremia (low sodium levels) rather than hypernatremia. Reduced blood urea nitrogen (BUN) and hyperglycemia would not be typical findings in acute Addisonian crisis.
Hemolytic disease is suspected in a mother's second newborn. Which factor is important in understanding how this could develop?
- A. The mother's first child was Rh positive.
- B. The mother is Rh positive.
- C. Both parents have type O blood.
- D. RhIG (RhoGAM) was given to the mother during her first pregnancy.
Correct Answer: A
Rationale: Hemolytic disease of the newborn, also known as erythroblastosis fetalis, is a condition in which a mother's antibodies attack the red blood cells of the unborn baby. This most commonly occurs due to Rh incompatibility. The mother produces Rh antibodies during her first pregnancy with an Rh positive baby. During subsequent pregnancies with an Rh positive baby, these antibodies can cross the placenta and attack the baby's red blood cells, leading to hemolytic disease. Therefore, if the mother's first child was Rh positive, it increases the risk of hemolytic disease in subsequent pregnancies if the babies are also Rh positive.
Which should the nurse consider when preparing a school-age child and the family for heart surgery?
- A. Unfamiliar equipment should not be shown.
- B. Let the child hear the sounds of an ECG monitor.
- C. Avoid mentioning postoperative discomfort and interventions.
- D. Explain that an endotracheal tube will not be needed if the surgery goes well.
Correct Answer: B
Rationale: When preparing a school-age child and the family for heart surgery, it is essential to provide honest and age-appropriate information to help the child feel more comfortable and reduce anxiety. Letting the child hear the sounds of an ECG monitor is beneficial as it allows them to become familiar with medical equipment and procedures, making them less intimidated by the unfamiliar sounds they may encounter during and after surgery. Familiarizing the child with the sounds can also help alleviate fears and promote understanding of what is happening during the procedure. It is important to maintain open communication, address concerns, and prepare the child and family for what to expect before, during, and after surgery.
Which of the following terms indicates that the patient has a hearing loss caused by aging?
- A. Otoplasty
- B. Presbycusis
- C. Otalgia
- D. Tinnitus
Correct Answer: B
Rationale: Presbycusis is the term that indicates that the patient has a hearing loss caused by aging. It is a type of sensorineural hearing loss that occurs gradually as a result of aging and affects the ability to hear high-pitched sounds. Otoplasty is a surgical procedure to correct the shape or position of the ears. Otalgia refers to ear pain. Tinnitus is the perception of ringing or buzzing sounds in the ears.
Which of the following BP changes alerts the nurse to increasing ICP, and should be reported immediately?
- A. Gradual increase
- B. Widening pulse pressure
- C. Rapid drop followed by gradual increase
- D. Rapid fluctuations
Correct Answer: B
Rationale: Widening pulse pressure is indicative of increasing intracranial pressure (ICP) and must be reported immediately. Pulse pressure is calculated by subtracting the diastolic blood pressure from the systolic blood pressure. An increasing pulse pressure can suggest a rise in ICP due to factors like cerebral edema or hemorrhage. This change indicates increased pressure exerted on blood vessels within the brain, potentially leading to serious consequences like brain herniation. Thus, recognizing and promptly reporting a widening pulse pressure is crucial to prevent further complications and enable appropriate interventions for the patient.