Nokea
Which of the following procedures is necessary to establish a definitive diagnosis of breast cancer?
- A. Diaphanography
- B. Mammography
- C. Thermography
- D. Breast tissue biopsy
Correct Answer: D
Rationale: Diaphanography, also known as transillumination, is a painless, noninvasive imaging technique that involves shining a light source through the breast tissue to visualize the interior. It must be used in conjunction with a mammogram and physical examination. Mammography is a useful tool for screening but is not considered a means of diagnosing breast cancers. Thermography is a pictorial representation of heat patterns on the surface of the breast. Breast cancers appear as a 'hot spot' owing to their higher metabolic rate. Biopsy either by needle aspiration or by surgical incision is the primary diagnostic technique for confirming the presence of cancer cells.
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A 14-year-old client has a history of lying, stealing, and destruction of property. Personal items of peers have been found missing. After group therapy, a peer approaches the nurse to report that he has seen the 14-year-old with some of the missing items. The best response of the nurse is to:
- A. Request that he explain to the group why he took personal items from peers
- B. Approach him when he is alone to inquire about his involvement in the incident
- C. Imply to him that you doubt his involvement in the incident and request his denial
- D. Confront him openly in group and request an apology
Correct Answer: B
Rationale: This answer is incorrect. There is no proof that he removed the missing items. This answer is correct. Anxiety and defensiveness are lessened if the individual is approached in this manner. This answer is incorrect. It is difficult for one to admit to wrongdoing with this approach. This answer is incorrect. He has not yet been proved guilty. Confrontation will only increase defensiveness and anxiety.
A client is being evaluated for carpal tunnel syndrome. The nurse is observed tapping over the median nerve in the wrist and asking the client if there is pain or tingling. Which assessment is the nurse performing?
- A. Phalen's maneuver
- B. Tinel's sign
- C. Kernig's sign
- D. Brudzinski's sign
Correct Answer: B
Rationale: Tinel’s sign involves tapping the median nerve to elicit pain/tingling in carpal tunnel syndrome. Phalen’s maneuver (A) involves wrist flexion, Kernig’s (C) and Brudzinski’s (D) are for meningitis.
In admitting a client to the psychiatric unit, the nurse must explain the rules and regulations of the unit. A client with antisocial personality disorder makes the following remark, 'Forget all those rules. I always get along well with the nurses.' Which nursing response to him would be most effective?
- A. OK, don't listen to the rules. See where you end up.'
- B. I'm pleased that you get along so well with the staff. You must still know and abide by the rules.'
- C. It is irrelevant whether you get along with the nurses.'
- D. I'm not the other nurses. You better read the rules yourself.'
Correct Answer: B
Rationale: This answer is incorrect. A nurse should be an appropriate role model. Threats are not appropriate. No limit setting was stated. This answer is correct. The nurse made a positive statement followed by a simple, clear, concise setting of limits. This answer is incorrect. It appears to have a negative connotation. There was no limit setting. This answer is incorrect. The nurse obviously responded in a negative manner. Learning takes place more readily when one is accepted, not rejected. No limits were set.
A 68-year-old client developed acute respiratory distress syndrome while hospitalized for pneumonia. After a respiratory arrest, an endotracheal tube was inserted. Several days later, numerous attempts to wean him from mechanical ventilation were ineffective, and a tracheostomy was created. For the first 24 hours following tracheostomy, it is important to minimize bleeding around the insertion site. The nurse can accomplish this by:
- A. Deflating the cuff for 10 minutes every other hour instead of 5 minutes every hour
- B. Avoiding manipulation of the tracheostomy including cuff deflation
- C. Reporting any signs of crepitus immediately to the physician
- D. Changing tracheostomy dressing only as necessary using one-half strength hydrogen peroxide to cleanse the site
Correct Answer: B
Rationale: The tracheal cuff should not be deflated within the first 24 hours following surgery. To minimize bleeding, any manipulation, including cuff deflation, should be avoided. Small amounts of crepitus are expected to occur; however, large amounts or expansion of the area of crepitus should be reported to the physician. The tracheostomy site may be changed as often as necessary, but site care should be done with normal saline.
A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:
- A. Bleeding, bruising, and hemorrhage
- B. Increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase
- C. Pain, pallor, pulselessness, paresthesia, and paralysis
- D. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus
Correct Answer: C
Rationale: Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemia. An increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase is related to the disruption of muscle integrity. Classic signs of ischemia related to vascular injury secondary to long bone fractures include the five 'P's': pain, pallor, pulselessness, paresthesia, and paralysis. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus are common clinical manifestations of a fracture but not ischemia.