A nurse is reinforcing teaching with a client who is premenopausal.
Which of the following statements by the nurse is appropriate regarding breast self-examinations?
Use the palm of your hand to detect the presence of any large masses under the skin.
Perform small, circular motions, working vertically up and down across the breast.
Perform breast self-examinations during the middle of your cycle.
Perform breast self-examinations while lying on your side.
The Correct Answer is B
Choice A rationale
Using the palm of the hand is not an effective method for detecting masses. The fingertips provide better sensitivity due to their high density of sensory nerve endings, allowing for more precise identification of abnormalities such as lumps or masses.
Choice B rationale
Small circular motions allow for thorough examination of breast tissue, covering all areas including superficial and deep tissue layers. This systematic vertical pattern ensures no area is overlooked, improving detection rates for abnormalities.
Choice C rationale
Performing self-examinations during the middle of the cycle is inappropriate as hormonal fluctuations cause breast tenderness and swelling, leading to potential misinterpretation. Post-menstrual timing minimizes these effects, ensuring more accurate detection.
Choice D rationale
Lying on the side does not provide adequate support for the breast tissue, potentially limiting detection of abnormalities. Lying flat with one arm raised helps to evenly distribute and expose breast tissue for more effective palpation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Removing personal protective equipment outside the client’s room increases the risk of environmental contamination with pathogens. Contact precautions require careful containment of contaminants within the room to prevent the spread of infectious agents to other areas of the healthcare facility, thus making this action inappropriate.
Choice B rationale
An N95 mask is not required for contact precautions but is designated for airborne precautions, such as for tuberculosis or measles. Contact precautions focus on minimizing the spread of infections via touch or contact with bodily fluids, requiring gowns and gloves rather than high-filtration masks.
Choice C rationale
Using an alcohol swab to clean the temperature probe before removing it from the room may not eliminate all pathogens. Probes that contact mucous membranes or bodily fluids should undergo high-level disinfection or sterilization. Ensuring single-patient use of equipment is more effective in preventing cross-contamination in this context.
Choice D rationale
Assigning a dedicated stethoscope for the client during their hospital stay minimizes the risk of transmitting pathogens to other clients. Equipment designated for single-client use remains in the client’s room, reducing the chance of contamination and maintaining infection control measures effectively, aligning with best practices for contact precautions.
Correct Answer is A
Explanation
Choice A rationale
Vitamin C is crucial for collagen synthesis, which is necessary for tissue repair and wound healing. It also enhances the immune response and promotes iron absorption, supporting the overall healing process.
Choice B rationale
Thiamine, a B-vitamin, facilitates carbohydrate metabolism and neural function. While essential, it does not have a direct role in wound healing or tissue regeneration.
Choice C rationale
Niacin supports energy production and DNA repair but lacks a specific role in promoting collagen synthesis or wound healing, making it less critical for this purpose.
Choice D rationale
Vitamin D maintains calcium-phosphorus homeostasis and bone health. While important for skeletal support, it does not directly enhance wound healing mechanisms.
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