A nurse is teaching a female young adult client about performing a breast self-examination. Which of the following instructions should the nurse include in the teaching?
"Report a firm ridge below the breasts to the provider."
"Keep your arm relaxed at your side on the side you are examining."
"Use your thumb and forefinger to palpate each breast for lumps."
"Use firm pressure to palpate near the area of the ribs and chest wall."
The Correct Answer is D
A. "Report a firm ridge below the breasts to the provider." A firm ridge along the bottom curve of the breast can be normal. It’s important to distinguish between normal breast tissue and abnormal lumps. Encouraging clients to report any changes or new lumps to the provider is more appropriate.
B. "Keep your arm relaxed at your side on the side you are examining." The correct technique involves raising the arm on the side being examined to help spread out the breast tissue, making it easier to palpate for lumps and abnormalities.
C. "Use your thumb and forefinger to palpate each breast for lumps." The correct technique involves using the pads of the fingers (not the thumb and forefinger) to palpate the breast in a systematic pattern, such as circular motions or vertical strips, to thoroughly check all areas of the breast.
D. "Use firm pressure to palpate near the area of the ribs and chest wall." Using firm pressure is appropriate for palpating deeper tissues closer to the ribs and chest wall, as this helps detect lumps that may not be superficial.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Ask the client's son to explain the preoperative interventions. This is not appropriate as it may lead to miscommunication and is not in line with professional standards for interpretation.
B. Inform the provider about the situation with the client. This is correct. The provider should be informed to address the client's refusal of preoperative care appropriately.
C. Reinforce the benefits of the surgery to the client. Reinforcing the benefits does not address the communication barrier and the client's immediate refusal.
D. Request another client who speaks the same language to act as an interpreter. This is inappropriate and breaches confidentiality. Professional interpreters should be used.
Correct Answer is D
Explanation
A. Decrease in heart rate: Acute pain typically causes an increase in heart rate, not a decrease.
B. Increase in vagal nerve tone: An increase in vagal nerve tone can actually result in a decreased heart rate and is not a direct indicator of acute pain.
C. Decrease in respiratory rate: Acute pain usually causes an increase in respiratory rate, not a decrease.
D. Increase in muscle tone: This is correct. An increase in muscle tone can indicate acute pain as the body tenses in response to pain.
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