Nokea
When the office nurse gives the client instructions on how to prepare for the mammogram, which of the following statements offers accurate information? Select all that apply.
- A. I will perform a BSE 3 to 7 days after my period ends.
- B. Do not wear any underarm deodorant the day of the test.
- C. Wipe each breast with an antiseptic pad before the test.
- D. Do not wear constricting clothing to the test.
- E. Avoid wearing body powder the day of the test.
- F. Refrain from applying lotion to the breasts or axillae.
Correct Answer: B,E,F
Rationale: Deodorants, powders, and lotions can interfere with mammogram imaging by creating artifacts, so avoiding these on the day of the test is critical. Constricting clothing is not a concern, and antiseptic wipes are not required.
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The nurse correctly informs the client that the breast self-examination (BSE) technique involves palpating each breast moving in small concentric circles, following imaginary spokes in a wheel, or moving in rows from superior to inferior stress of the breast. Besides the breast, which other body area is essential to palpate?
- A. The axillae
- B. The sternum
- C. The clavicles
- D. The ribs
Correct Answer: A
Rationale: The axillae (armpits) contain lymph nodes that drain the breast, and palpating this area is essential to detect any abnormal lymph node enlargement, which could indicate breast pathology.
The nurse is assessing a male client for symptoms of gonorrhea. Which data support the diagnosis?
- A. Presence of a chancre sore on the penis.
- B. No symptoms.
- C. A CD4 count of less than 200.
- D. Pain in the testes and scrotal edema.
Correct Answer: B
Rationale: Gonorrhea in males can be asymptomatic, especially early. Chancre sores indicate syphilis, low CD4 is HIV-related, and testicular pain/edema suggest epididymitis, not gonorrhea.
The licensed practical nurse (LPN) realizes that the nursing assistant requires further instruction when observing which activities after the client's hysterectomy? Select all that apply.
- A. Frequently offering the client a variety of oral fluids
- B. Helping the client ambulate in the hall
- C. Raising the knee gatch on the hospital bed
- D. Reporting to the physician that the client's dressing is loose
- E. Changing the client's perineal pad without using gloves
Correct Answer: C,E
Rationale: Raising the knee gatch can impair circulation, and changing pads without gloves risks infection. Other actions are appropriate post-hysterectomy care.
Before taking the client to the room where the pelvic examination will be performed, which nursing action is most appropriate?
- A. Ask the client to sign a consent form.
- B. Give the client a gown to wear.
- C. Offer the client a mild analgesic.
- D. Help the client instill a vaginal lubricant.
Correct Answer: B
Rationale: Providing a gown ensures the client's privacy and comfort during the pelvic examination, which is a priority before the procedure.
The nurse is assessing a 34-year-old female client with fibrocystic breasts. Which question should the nurse ask the client during the assessment?
- A. Are your breasts more tender during your period?'
- B. Have you ever developed an allergy to chocolate?'
- C. Can you tell me more about your feelings of having fibrocystic breast changes?'
- D. Have you considered having a prophylactic mastectomy?'
Correct Answer: A
Rationale: Fibrocystic breast changes cause cyclical tenderness, worse premenstrually; this question assesses symptoms. Chocolate allergies, feelings, and prophylactic mastectomy are irrelevant.