A patient states during the interview that she noticed a new lump in the shower a few days ago.
It was on her left breast near her axilla.
How should the nurse proceed?
Palpated the unaffected breast first.
Palpate the breast with the lump first, but plan to palpate the axilla last.
Avoid palpating the lump because it could be a cyst, which might rupture.
Palpate the lump first.
The Correct Answer is A
Choice A rationale
Palpating the unaffected breast first establishes a baseline for what is normal for the patient. This allows the nurse to then compare any findings on the affected breast, where the patient has noted a lump, to the patient's normal breast tissue. This comparative approach aids in identifying any true abnormalities.
Choice B rationale
Palpating the breast with the lump first could introduce anxiety and may make it more difficult to thoroughly assess the unaffected breast due to the patient's potential apprehension. While axillary lymph node assessment is crucial, delaying it slightly after the initial breast examination allows for a more systematic approach.
Choice C rationale
Avoiding palpation of a newly discovered lump is inappropriate nursing practice. A new lump warrants investigation to determine its nature. Palpation is a key component of the physical examination and helps to assess the size, shape, consistency, and mobility of the lump, providing essential information for further evaluation.
Choice D rationale
Palpating the lump first, without establishing a baseline on the unaffected breast, makes it harder to determine if the finding is truly new or abnormal for this specific patient. Comparing findings to the contralateral breast is a standard technique in breast examination to identify deviations from the norm.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A rationale
Adding thickener to fluids helps to increase their viscosity, making them easier to swallow and reducing the risk of aspiration in clients with dysphagia. Dysphagia often results from impaired muscle control in the mouth and throat, and thicker fluids move more slowly, allowing more time for coordination of the swallowing reflex.
Choice B rationale
Placing food on the right side of the client's mouth addresses the left-sided weakness following a stroke. This allows the client to use the stronger, unaffected side of their mouth and throat for better control during chewing and swallowing, minimizing the risk of food pooling on the weaker side and potential aspiration.
Choice C rationale
Serving food at a very hot temperature can impair the client's ability to sense the food in their mouth and can increase the risk of burns, especially with sensory deficits that can occur after a stroke. Warm or room temperature foods are generally recommended for clients with dysphagia to enhance safety and comfort.
Choice D rationale
Instructing the client to tilt her head forward when swallowing helps to close the airway and open the esophagus, facilitating the passage of food and liquids down the throat and reducing the risk of aspiration into the trachea and lungs. This chin-tuck maneuver is a common compensatory strategy for dysphagia. .
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.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.