Nokea
The nurse provides information to a client about performing a breast self-examination (BSE). The nurse determines that the client needs additional teaching if the client makes which statements? Select all that apply.
- A. The BSE must be done monthly.
- B. Lumps in my armpit area are normal.
- C. I can palpate my breasts with soapy water while showering.
- D. I should perform the examination on the day that I start my period.
- E. When I squeeze my nipples, I should expect to note some discharge.
- F. I should stand before a mirror and inspect each breast for anything unusual.
Correct Answer: B,D,E
Rationale: Any lumps in the armpit or nipple discharge are abnormal and require reporting to a healthcare provider. The BSE should be performed 2 to 3 days after menstruation ends, not on the first day, when breasts are tender. Monthly BSE, palpation with soapy water in the shower, and mirror inspection are correct techniques.
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The nurse is caring for a client diagnosed with syphilis. The client presents with a widespread, symmetric maculopapular rash on the palms and soles. The nurse understands that the client is in which stage of the infection?
- A. primary syphilis
- B. secondary syphilis
- C. early latent syphilis
- D. latent phase syphilis
Correct Answer: B
Rationale: A maculopapular rash on palms and soles is characteristic of secondary syphilis, following the primary chancre.
The nurse has given instructions to a client who is returning home after an arthroscopy of the knee. The nurse determines that the client understands the home care instructions if the client states the need to follow which instruction?
- A. Resume strenuous exercise the following day.
- B. Stay off the leg entirely for the rest of the day.
- C. Refrain from eating food for the remainder of the day.
- D. Report fever or site inflammation to the primary health care provider.
Correct Answer: D
Rationale: After arthroscopy, signs/symptoms of infection should be reported to the primary health care provider. The client is instructed to avoid strenuous exercise for at least a few days; however, the client can usually walk carefully on the leg after sensation has returned. The client may resume the usual diet.
The nurse instructs a client who is hospitalized and on a low-fat diet. Which menu does the nurse provide for the client?
- A. Shrimp, avocado, and tomato salad
- B. Calf's liver, potato salad, and sherbet
- C. Lean steak, mashed potatoes, and gravy
- D. Turkey breast, boiled rice, and strawberries
Correct Answer: D
Rationale: Turkey breast without the skin, boiled rice, and strawberries offer the client nourishing foods that are low in fat. Some sources of fat include meats, avocado, salad dressing, mayonnaise, butter, cheese, and bacon. The remaining options contain high-fat foods.
The clinic nurse provides instructions to a client who will begin taking oral contraceptives. Which statement by the client indicates the need for further teaching?
- A. I will take one pill daily at the same time every day.
- B. If I miss a pill, I must take it as soon as I remember.
- C. I will not need to use an additional birth control method after I start these pills.
- D. If I miss two pills, I will take them both as soon as I remember, and then two pills the next day.
Correct Answer: C
Rationale: The client must use a second birth control method during the first pill cycle of oral contraceptives to ensure protection against pregnancy. Taking the pill at the same time daily, taking a missed pill as soon as remembered, and taking two missed pills as soon as remembered with two the next day are correct actions.
The community health nurse provides an educational session regarding the risk factors for cervical cancer to women in the local community. The nurse determines that further teaching is needed if a woman attending the session identifies which as a risk factor for this type of cancer?
- A. Smoking tobacco
- B. Single sex partner
- C. Early age of first intercourse
- D. Human papillomavirus (HPV) infection
Correct Answer: B
Rationale: Having a single sex partner is not a risk factor for cervical cancer. Some risk factors for cervical cancer include having multiple sexual partners or a partner who had multiple sexual partners, smoking tobacco, early age of first intercourse, and HPV infection.