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 B
Explanation
Choice A rationale
Low birth weight is defined as a birth weight of less than 2500 grams. This newborn weighs 3200 grams, so it does not fall into this category.
Choice B rationale
A newborn is considered appropriate for gestational age if its weight falls between the 10th and 90th percentile for its gestational age. This newborn’s weight is in the 60th percentile for its gestational age of 38 weeks, so it is appropriate for gestational age.
Choice C rationale
Large for gestational age refers to a newborn whose weight is above the 90th percentile for its gestational age. This newborn’s weight is in the 60th percentile, so it does not fall into this category.
Choice D rationale
Small for gestational age refers to a newborn whose weight is below the 10th percentile for its gestational age. This newborn’s weight is in the 60th percentile, so it does not fall into this category.
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
Choice A rationale
Intravenous fluids (IVF) at maintenance rate is anticipated for the client. Dehydration can increase the viscosity of the blood and promote sickling in clients with sickle cell disease. Therefore, maintaining hydration is crucial in managing sickle cell crises.
Choice B rationale
Meperidine IV for pain is contraindicated for the client. Meperidine has been associated with a higher risk of seizures, especially in clients with kidney dysfunction, which can occur in sickle cell disease due to sickling in the renal vasculature.
Choice C rationale
Ice packs to the affected area for 15 min on/15 min off is nonessential for the client. While cold therapy can help reduce inflammation and numb pain, it can also lead to vasoconstriction, which can potentially exacerbate sickling. Therefore, it’s generally recommended to use warm compresses rather than ice packs in clients with sickle cell disease.
Choice D rationale
Oxygen 2 L/min via nasal cannula is anticipated for the client. Hypoxia can trigger sickling in clients with sickle cell disease, so oxygen therapy is often used to increase oxygen saturation and reduce the risk of sickling.
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