A nurse is conducting a class on Breast Self-Examination (BSE) for women of childbearing age. The nurse should include which of these statements that indicates the proper BSE technique?

The best time to perform BSE is immediately prior to the menstrual cycle

If pregnancy is suspected, BSE should not be performed until post delivery

The best time to perform BSE is 4 to 7 days after the first day of the menstrual period

The woman with diagnosed fibrocystic breast tissue should not rely on BSE

Answer and Explanation

The Correct Answer is C

A) The best time to perform BSE is immediately prior to the menstrual cycle:
Performing a breast self-examination (BSE) immediately prior to the menstrual cycle is not ideal because hormonal changes leading up to menstruation can cause the breasts to become swollen, tender, and lumpy. These changes could make it difficult to detect subtle lumps or changes in the breast tissue. For the most accurate assessment, it's recommended that women avoid performing BSE during the premenstrual phase when the breast tissue is most likely to be affected by hormonal fluctuations.

B) If pregnancy is suspected, BSE should not be performed until post-delivery:
This statement is incorrect. There is no contraindication to performing a breast self-examination during pregnancy, and it is important for pregnant women to continue self-monitoring for any changes in breast tissue. In fact, BSE should be performed regularly during pregnancy, as the breast tissue can undergo changes due to hormonal shifts, and early detection of any abnormalities is key to successful management.

C) The best time to perform BSE is 4 to 7 days after the first day of the menstrual period:
This is the correct recommendation. The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period because the breasts are least likely to be swollen or tender during this time. Hormonal levels are more stable at this point in the menstrual cycle, and any lumps or changes in the tissue are more likely to be noticeable. Performing BSE during this time increases the likelihood of detecting potential abnormalities.

D) The woman with diagnosed fibrocystic breast tissue should not rely on BSE:
While it is true that women with fibrocystic breast changes may experience lumpy, tender tissue, they should still perform BSE regularly. Fibrocystic tissue can sometimes make it more difficult to distinguish between normal and abnormal changes, but BSE remains an important tool for detecting significant changes, such as new lumps or changes in size, shape, or consistency. Women with fibrocystic breast tissue should be taught to perform BSE regularly and to report any unusual changes to their healthcare provider. Relying solely on BSE for breast cancer detection is not recommended, but it is an essential part of breast health awareness.

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Correct Answer is A

Explanation

A. Dysphagia:
Dysphagia, or difficulty swallowing, is a common issue in clients who have had a stroke, particularly when there is facial drooping or weakness on one side of the face, which can affect the muscles involved in swallowing. A stroke can cause motor impairment, affecting the coordination and strength required for effective swallowing. This condition increases the risk of aspiration (food or liquid entering the airway), which can lead to respiratory complications such as pneumonia. It is crucial to assess for dysphagia in stroke patients and provide appropriate interventions, such as speech therapy and modified diets, to ensure safe swallowing.

B. Rhinitis:
Rhinitis, which refers to inflammation of the nasal passages causing symptoms like congestion, sneezing, and runny nose, is not directly related to stroke. Although rhinitis can be caused by allergies, infections, or environmental irritants, it is not a typical finding following a stroke. The presence of facial drooping on one side is more suggestive of a neurological issue affecting motor control, rather than an issue with the nasal passages or upper respiratory system.

C. Xerostomia:
Xerostomia, or dry mouth, can occur for various reasons, such as medication side effects or dehydration, but it is not a primary concern directly associated with stroke-induced facial drooping. While facial nerve dysfunction can affect salivation (since the facial nerve helps control the salivary glands), dysphagia and facial drooping are more immediate concerns for stroke patients. Xerostomia may occur in some cases, but it is not as directly linked to stroke as dysphagia is.

D. Epistaxis:
Epistaxis, or nosebleeds, is not a typical complication of stroke and is not associated with facial drooping. While certain factors like dry air, medications (e.g., anticoagulants), or trauma could cause nosebleeds, they are not common findings directly related to a stroke. The focus should be on potential neurological deficits, such as difficulty swallowing, impaired speech, or weakness, rather than epistaxis.

A. Whisper random numbers letters, then have the client repeat them B. Shield the lips so that the sound is muffled C. Stand approximately 4 feet away from the client D. Have the client place a finger in the ear canal to occlude outside noise

Correct Answer is A

Explanation

A) Whisper random numbers and letters, then have the client repeat them:
This is correct. The voice test is a simple way to assess a client's hearing. The nurse should stand about 2 feet away from the client and whisper random numbers or letters. The client should repeat what they hear. This test checks the ability to hear and distinguish sounds, particularly for high-frequency tones. It's an effective screening method for detecting hearing loss.

B) Shield the lips so that the sound is muffled:
This is incorrect. The nurse should not shield their lips during the voice test because it could interfere with the client's ability to hear and potentially read the nurse's lips, which can help with understanding. The client should be allowed to observe lip movements to aid in comprehension of the sounds being spoken.

C) Stand approximately 4 feet away from the client:
This is incorrect. The recommended distance for performing the voice test is typically around 2 feet, not 4 feet. Standing too far away can make it more difficult for the client to hear the whispered numbers or letters and could affect the accuracy of the test. The nurse should stand close enough (about 2 feet) to ensure that the sound is audible to the client but not too close as to distort the test.

D) Have the client place a finger in the ear canal to occlude outside noise:
This is incorrect. While the client should be instructed to avoid distractions or loud environments during the test, placing a finger in the ear canal is not necessary. The test assesses the client's ability to hear sound, and occluding the ear could affect the results. The client should simply be in a quiet environment.

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A nurse is conducting a class on Breast Self-Examination (BSE) for women of childbearing age. The nurse should include which of these statements that indicates the proper BSE technique?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has had a stroke. id assesses right-sided facial drooping. The nurse should also anticipate which of the following assessment findings?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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