A nurse is responding to a 54-year-old patient who does not perform monthly breast self-examination (BSE) because she believes mammograms are better at finding lumps.
What would the nurse include in the response?
"You are correct; mammography is a good replacement for BSEs.”.
"You do not need to perform BSEs as long as a physician checks your breast annually.”.
"While mammograms are effective, BSEs can help you become familiar with your breasts and notice changes between mammograms.”.
"Mammograms are the only reliable way to detect breast cancer, so BSEs are unnecessary.”.
The Correct Answer is C
Choice A rationale
While mammography is a crucial tool for detecting breast cancer, particularly in women over 40, it is not a replacement for breast self-examination (BSE). Mammograms are radiographic images that can detect abnormalities, but BSE helps women become familiar with their own breasts and identify changes that may occur between mammograms.
Choice B rationale
Although annual clinical breast exams by a physician are important, they are not a substitute for monthly BSE. BSE allows women to regularly assess their breasts for any new lumps, changes in size or shape, skin thickening, or nipple discharge. These changes might occur between annual physician visits.
Choice C rationale
Mammograms are indeed effective in detecting breast cancer, often before a lump can be felt. However, BSE plays a vital role in increasing a woman's awareness of her breasts' normal texture and appearance. This familiarity enables her to notice subtle changes that may warrant further medical evaluation, complementing the benefits of mammography.
Choice D rationale
Mammograms are a highly reliable method for detecting breast cancer, especially in early stages. However, BSE is not unnecessary. It empowers women to take an active role in their breast health by promoting early detection of changes that might be indicative of cancer and can occur between scheduled mammograms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Normoactive bowel sounds are the typical, intermittent gurgling sounds heard during a bowel assessment, indicating normal peristalsis and intestinal activity. The absence of any sounds for 30 seconds suggests a significant reduction or cessation of this activity, which is not consistent with normoactive findings.
Choice B rationale
Hypoactive bowel sounds are characterized by infrequent and faint gurgling sounds, indicating a decrease in intestinal motility. While a pause of 30 seconds without any sounds might precede hypoactive sounds, the complete absence of sounds for this duration is more indicative of a further reduction in bowel activity than simply hypoactivity.
Choice C rationale
Absent bowel sounds are documented when no bowel sounds are heard after listening in each of the four abdominal quadrants for a specified period, typically ranging from 2 to 5 minutes per quadrant. A 30-second period without any sounds in one area is a significant finding that should be documented as absent in that specific quadrant, warranting further assessment.
Choice D rationale
Hyperactive bowel sounds are loud, high-pitched, and frequent gurgling sounds, often described as "borborygmi" or stomach rumbling. These sounds indicate increased intestinal motility, which is the opposite of the finding of no bowel sounds for 30 seconds.
Correct Answer is C
Explanation
Choice A rationale
Listening for bowel sounds for only 1 minute in one area is insufficient to determine their presence or absence accurately. Bowel motility and thus bowel sounds can be intermittent, and listening for a brief period might miss infrequent sounds. A more extended auscultation is necessary to assess bowel activity adequately.
Choice B rationale
Listening for 2 minutes in each quadrant totals 8 minutes of auscultation, which is more comprehensive than 1 minute. However, bowel sounds can still be sporadic. A longer duration of listening in at least one quadrant where sounds might be present is needed before concluding they are absent.
Choice C rationale
Auscultating for bowel sounds for a total of 5 minutes (not necessarily 5 minutes in each quadrant, but listening attentively in different areas for a cumulative of 5 minutes) is the generally accepted minimum duration to confidently declare bowel sounds absent, termed "silent bowel sounds.”. This extended listening time increases the likelihood of detecting any intermittent bowel activity.
Choice D rationale
Listening for 10 minutes is even more thorough, but if no bowel sounds are heard after a continuous and attentive 5-minute auscultation, it is generally considered clinically significant for absent bowel sounds. Prolonged auscultation beyond 5 minutes is usually not necessary unless there are specific clinical indications.
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