A nurse is reinforcing teaching about the frequency of breast self-examination (BSE) with a young adult client. Which of the following statements by the client indicates an understanding of the teaching?
"I will perform BSE the first day of each month."
"The best day to perform BSE is the first day of the menstrual cycle."
"The best day to perform BSE is 7 days after the menstrual cycle begins."
"I will perform BSE every month during ovulation."
The Correct Answer is A
A. Performing breast self-examination (BSE) on the first day of each month provides a consistent schedule for the client to conduct the examination, making it easier to remember and ensuring regularity.
B. The first day of the menstrual cycle may not be the best time to perform BSE for all women, as breast tissue may be more tender or swollen during menstruation.
C. Seven days after the menstrual cycle begins may not be the best time for BSE, as hormonal fluctuations and breast changes may not yet have stabilized.
D. Performing BSE every month during ovulation is not necessary, as ovulation does not directly affect breast tissue changes that need to be monitored.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","D","E","F"]
Explanation
A. Remove restrictive clothing or objects from the patient: This helps to promote comfort and improve circulation.
B. Administer IV Morphine per MD order: Morphine is a common medication used to manage severe pain associated with sickle cell crisis.
C. Administer oxygen per MD order: Oxygen may be needed to improve oxygen saturation and support respiratory function, especially if the patient is hypoxic.
D. Place on NPO: This is appropriate in case the patient needs any procedures or interventions that require fasting.
E. Start intravenous fluids per MD order: Intravenous fluids help to hydrate the patient and improve blood flow, which can help alleviate symptoms of sickle cell crisis.
F. Keep patient on bed rest: Bed rest is important to conserve energy and minimize the risk of further complications during a sickle cell crisis.
Correct Answer is D
Explanation
A. Risk for Injury related to compromised blood volume is not the most appropriate nursing diagnosis for a patient with sickle cell disease in crisis. While patients may experience anemia and blood volume loss during a crisis, the primary concern is tissue perfusion due to vascular occlusion by sickled cells.
B. Risk for Deficient Fluid Volume related to infection is not directly related to the pathophysiology of sickle cell disease or sickle cell crisis.
C. Ineffective Airway Clearance related to sickled cells may be a concern for patients with sickle cell disease, especially during acute chest syndrome, but it is not the primary nursing diagnosis for a patient admitted for sickle cell crisis.
D. Ineffective Tissue Perfusion related to vascular occlusion is the most appropriate nursing diagnosis for a patient with sickle cell disease in crisis. Sickle cell crisis involves the occlusion of blood vessels by sickled cells, leading to impaired tissue perfusion and potential organ damage.
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