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."

Answer and Explanation

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.

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Correct Answer is A

Explanation

A. Date of client's admission to the facility The background step includes relevant information such as the admission date, diagnosis, and medical history.
B. Summary of a change in the client's condition This information belongs in the assessment or situation step.
C. Brief explanation of the client's current condition This information belongs in the assessment step.
D. Request for provider to consult physical therapy This information belongs in the recommendation step.

A. "Your doctor has been performing this surgery for a long time now." B. "Would it help you to talk more with me about how you feel?" C. I have prayed for you and everything is going to be fine." D. "Why are you afraid to have surgery all of a sudden?"

Correct Answer is B

Explanation

A. "Your doctor has been performing this surgery for a long time now." While this statement aims to reassure the client by emphasizing the doctor's experience, it does not address the client's feelings or encourage further discussion about their fears.
B. "Would it help you to talk more with me about how you feel?" This is a therapeutic response that encourages the client to express their feelings and concerns, showing empathy and providing an opportunity for the client to discuss their fears in more detail.
C. "I have prayed for you and everything is going to be fine." While this statement may be comforting to some, it can be inappropriate and may not address the client's specific fears or promote open communication. It also assumes the client's belief system, which might not be the same as the nurse's.
D. "Why are you afraid to have surgery all of a sudden?" This response can be perceived as dismissive and might make the client feel judged or misunderstood. It does not encourage a supportive discussion about the client's fears.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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