A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include?
Expect some breast dimpling or discharge with age.
Using the palm of the hand, feel for lumps using a circular motion.
Breasts can be examined in the shower with soapy hands.
For those who have a menstrual cycle, perform a BSE every month, 2 or 3 days before menstruation.
The Correct Answer is C
Choice A rationale
While it’s true that some changes in the breast, such as dimpling or discharge, can occur with age, these are not normal and could be signs of a serious condition like breast cancer.
Therefore, this instruction should not be included in the pamphlet.
Choice B rationale
While using the palm of the hand to feel for lumps using a circular motion is a common method, it’s not the most effective. The pads of the three middle fingers should be used instead, as they are more sensitive to changes in the breast tissue.
Choice C rationale
This is the correct answer. Performing a breast self-exam in the shower with soapy hands is recommended because the soap helps your fingers glide smoothly over your skin, making it easier to feel for any lumps or changes.
Choice D rationale
While it’s true that women who have a menstrual cycle should perform a breast self-exam every month, the timing suggested here is not accurate. The best time to perform a breast self- exam is a few days after the menstrual period ends, when the breasts are less likely to be tender or swollen.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale
The G in GTPAL stands for gravida, which is the number of times an individual has conceived, including any current pregnancy. In this case, G3 means the client has had three pregnancies, which includes two prior pregnancies and the current one.
Choice B rationale
The client’s record does not indicate that she is currently pregnant with twins, making this choice incorrect.
Choice C rationale
The A in GTPAL stands for the number of abortions, which refers to all times the individual has lost a pregnancy before 20 weeks. In this case, A1 means the client has had one abortion, indicating a risk for miscarriage.
Choice D rationale
The T in GTPAL stands for term births, which refers to the number of times an individual has carried a pregnancy to at least 37 weeks of gestation and delivered. In this case, T1 means the client has had one full-term birth.
Choice E rationale
The L in GTPAL stands for living children. In this case, L1 means the client has one living child.
Correct Answer is A
Explanation
Choice A rationale
Evaluating the firmness of the uterus is the first action the nurse should take when a client’s blood pressure is 60/50 mm Hg after giving birth. A soft or “boggy” uterus can indicate uterine atony, a condition in which the uterus fails to contract after birth. Uterine atony can lead to significant postpartum hemorrhage, which can cause hypotension.
Choice B rationale
Oxygenating by rebreather mask may be necessary if the client shows signs of hypoxia or difficulty breathing, but it is not the first action the nurse should take.
Choice C rationale
Administering oxytocin infusion can stimulate uterine contractions and help control postpartum bleeding. However, the nurse should first assess the firmness of the uterus.
Choice D rationale
Obtaining a type and crossmatch may be necessary if the client needs a blood transfusion, but it is not the first action the nurse should take.
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