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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.
Which statement by the client indicates further teaching is needed about uterine cancer?
- A. A Pap test is used to diagnose uterine cancer.
- B. Uterine cancer is the most common cancer of the reproductive tract.
- C. I used estrogen for 2 years without progesterone. This puts me at risk for developing uterine cancer.
- D. Postmenopausal bleeding could indicate uterine cancer.
Correct Answer: A
Rationale: The correct answer is A because a Pap test is used to detect cervical cancer, not uterine cancer.
1. A Pap test screens for cervical cancer by detecting abnormal cells in the cervix.
2. Uterine cancer is the most common cancer of the reproductive tract, making choice B accurate.
3. Choice C is correct as using estrogen without progesterone can increase uterine cancer risk.
4. Choice D is also accurate as postmenopausal bleeding can be a symptom of uterine cancer.
In summary, the need for further teaching arises from the misconception that a Pap test can diagnose uterine cancer.
The nurse is assessing a client who has a suspected cystocele. Which signs and symptoms should the nurse expect? Select all that apply.
- A. Frequent bladder infections
- B. Sense of fullness in the vaginal area
- C. Leaking of urine
- D. Irregular vaginal bleeding
Correct Answer: D
Rationale: The correct answer is D: Irregular vaginal bleeding. A cystocele is a condition where the bladder protrudes into the vagina. This can cause pressure on surrounding tissues and lead to irregular vaginal bleeding. A, B, and C are incorrect as they are more commonly associated with other conditions such as urinary tract infections (A), pelvic organ prolapse (B), and urinary incontinence (C). Irregular vaginal bleeding is a key sign specific to cystocele due to the physical displacement of organs.
A nurse is teaching a community health class of women and explains that an STI is associated with an increased risk of infertility in women. Which STIs should the nurse identify?
- A. HSV-2
- B. Syphilis
- C. Chlamydia
- D. HPV
Correct Answer: C
Rationale: The correct answer is C: Chlamydia. Chlamydia is associated with an increased risk of infertility in women due to its ability to cause pelvic inflammatory disease (PID), which can lead to scarring and damage to the reproductive organs. This scarring can result in blocked fallopian tubes, making it difficult for an egg to be fertilized by sperm. HSV-2 (Choice A) is a viral infection that primarily causes genital herpes but is not directly linked to infertility. Syphilis (Choice B) can lead to serious complications but infertility is not a common outcome. HPV (Choice D) is a sexually transmitted infection that can cause genital warts and cervical cancer, but it does not typically lead to infertility in women.
The nurse is grading a woman's reflexes. Which of the following grades would indicate reflexes that are slightly brisker than normal?
- A. +1.'
- B. +2.'
- C. +3.'
- D. +4.'
Correct Answer: C
Rationale: The correct answer is C: +3'. This indicates brisk reflexes. A: +1' indicates a low-normal response, B: +2' indicates a normal response, and D: +4' indicates hyperactive reflexes. +3' is slightly brisker than normal, reflecting an increased response without being hyperactive.