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When performing a breast assessment, the nurse is inspecting the woman’s skin for which of the following? Select all that apply.
- A. Color
- B. Thickening
- C. Size and symmetry
- D. Venous pattern
Correct Answer: A
Rationale: The correct answer is A: Color. When performing a breast assessment, inspecting the skin color is important to assess for any signs of redness, bruising, or discoloration which could indicate underlying issues. Thickening (B) is assessed through palpation, not inspection. Size and symmetry (C) is evaluated by comparing the breasts visually and through measurement. Venous pattern (D) is not typically a primary focus of skin inspection during a breast assessment.
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The nurse is reviewing the chart of a client who is complaining of heavy bleeding with her menstrual cycles. The nurse is aware that which of the following is a possible cause?
- A. Uterine fibroids
- B. Excessive exercise
- C. Normal finding in pregnancy
- D. Diet high in fat
Correct Answer: A
Rationale: The correct answer is A: Uterine fibroids. Uterine fibroids are noncancerous growths in the uterus that can lead to heavy menstrual bleeding. The nurse should consider this as a possible cause based on the client's symptoms.
Incorrect Choices:
B: Excessive exercise - While excessive exercise can sometimes affect menstrual cycles, it is not a common cause of heavy bleeding.
C: Normal finding in pregnancy - Heavy bleeding during menstrual cycles is not a normal finding in pregnancy.
D: Diet high in fat - While diet can impact overall health, a diet high in fat is not a direct cause of heavy menstrual bleeding.
A patient, 32 weeks pregnant with severe headache, is admitted to the hospital with preeclampsia. In addition to obtaining baseline vital signs and placing the client on bed rest, the physician ordered the following four items. Which of the orders should the nurse perform first?
- A. Assess deep tendon reflexes.'
- B. Obtain complete blood count.'
- C. Assess baseline weight.'
- D. Obtain routine urinalysis.'
Correct Answer: A
Rationale: The correct answer is A: Assess deep tendon reflexes. This is the priority because preeclampsia can progress to eclampsia, a life-threatening condition characterized by seizures. Assessing deep tendon reflexes helps in identifying signs of impending eclampsia. Obtaining a complete blood count (option B) and routine urinalysis (option D) are important in monitoring for complications of preeclampsia but do not address the immediate risk of seizures. Assessing baseline weight (option C) is also important but does not take precedence over assessing deep tendon reflexes in this scenario.
A nurse is providing preoperative teaching for a woman who is undergoing a total mastectomy. Which will this teaching include? Select all that apply.
- A. Explain that she will have an IV, a drain, and a dressing in place on awakening. Tell her about expectations she may have regarding physical appearance, pain management, equipment that will be used (IVs, drains, etc.).
- B. Explain that she will be provided pain management as needed; monitor and review the pain scale to be used to identify level of intensity.
- C. Have her elevate the affected arm with pillows.
- D. Turn the woman every 4 hours, alternating between the unaffected side and affected side. To prevent pneumonia and complications, have her cough and take deep breaths every 2 hours, while nurse applies support to the chest.
Correct Answer: C
Rationale: Rationale for Answer C (Correct Answer):
1. Elevating the affected arm with pillows post-mastectomy helps reduce swelling and promote lymphatic drainage, aiding in preventing lymphedema.
2. By elevating the arm, it reduces strain on the surgical site and surrounding tissues, promoting comfort and aiding in the healing process.
3. This positioning also helps in preventing postoperative complications such as shoulder stiffness and contractures.
Summary of Why Other Choices are Incorrect:
- Choice A: While important aspects of preoperative teaching, it does not specifically address the need to elevate the affected arm post-mastectomy.
- Choice B: Pain management is crucial, but it does not directly relate to the need for arm elevation post-mastectomy.
- Choice D: Turning every 4 hours and coughing exercises are important for preventing complications but do not address the specific need for arm elevation post-mastectomy.
The client calls the nurse and states she has not had a menstrual cycle in 3 months. What does the nurse know is the most common cause of secondary amenorrhea?
- A. Weight loss
- B. Pregnancy
- C. Cancer
- D. Menopause
Correct Answer: B
Rationale: The correct answer is B: Pregnancy. In the case of secondary amenorrhea, where a woman stops menstruating after previously having regular cycles, pregnancy is the most common cause. Pregnancy leads to a halt in the menstrual cycle due to hormonal changes to support the developing fetus. Other choices are incorrect: A) Weight loss can affect menstruation but is not the most common cause of secondary amenorrhea. C) Cancer can also disrupt the menstrual cycle, but it is not the primary cause in this scenario. D) Menopause typically occurs in women in their late 40s to early 50s, and would not be the most common cause of secondary amenorrhea in a younger woman.
A 40-year-old woman has just been diagnosed with stage 2 breast cancer. Which of the following are common reactions? Select all that apply.
- A. Anxiety regarding changes in family reactions, body image, disability, and pain
- B. Concern about disruptions related to treatment
- C. Fear of death
- D. Decisional conflict related to controversies about treatment options
Correct Answer: A
Rationale: The correct answer is A. Anxiety is common due to the impact on family, body image, disability, and pain. Concern about treatment disruptions is valid but not as common as anxiety. Fear of death is a general fear but may not be as prominent as anxiety. Decisional conflict can occur but is more specific to treatment options rather than a common reaction.