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
Explanation
Choice A rationale
Carbohydrates are the body's primary source of energy. They are broken down into glucose, which cells use for fuel to perform various functions, including muscle contraction, nerve impulse transmission, and maintaining body temperature.
Choice B rationale
Electrolytes, such as sodium, potassium, and chloride, are minerals that carry an electrical charge and are crucial for fluid balance, nerve function, and muscle contraction. While some foods containing carbohydrates may also contain electrolytes, providing energy is not their primary function. Normal ranges for serum sodium are 135-145 mEq/L, potassium is 3.5-5.0 mEq/L, and chloride is 95-105 mEq/L.
Choice C rationale
Minerals are inorganic substances that the body needs for various functions, including building strong bones, transmitting nerve impulses, and maintaining fluid balance. Examples include calcium, iron, and zinc. While essential, they are not primarily known for providing direct energy. Normal ranges for serum calcium are 8.5-10.5 mg/dL, iron varies by gender (males: 65-175 mcg/dL, females: 50-170 mcg/dL), and zinc is 70-120 mcg/dL.
Choice D rationale
Vitamins are organic compounds that the body needs in small amounts for various metabolic processes. They do not directly provide energy but help the body utilize energy from carbohydrates, fats, and proteins. Examples include vitamin C, vitamin D, and B vitamins. Normal ranges vary widely depending on the specific vitamin.
Correct Answer is D
Explanation
Choice A rationale
NPO (nothing by mouth) might be a temporary measure immediately following a stroke if aspiration risk is very high. However, prolonged NPO can lead to malnutrition and dehydration, hindering recovery. Nutritional support is crucial for stroke patients, so alternative feeding methods should be explored.
Choice B rationale
Total parenteral nutrition (TPN) is a method of providing nutrients intravenously, bypassing the gastrointestinal tract. It is usually reserved for patients with severe gastrointestinal dysfunction or when enteral feeding is not feasible or tolerated. While it provides nutrition, it carries risks of infection and metabolic complications and is not the first-line treatment for dysphagia.
Choice C rationale
A mechanical soft diet consists of foods that are easy to chew and swallow, reducing the risk of choking and aspiration in patients with mild to moderate dysphagia. This diet provides necessary nutrients while minimizing the effort required for safe oral intake, promoting better nutrition and hydration compared to NPO.
Choice D rationale
Supplements via NG tube provide enteral nutrition directly into the stomach or small intestine, bypassing the oral cavity and pharynx. This is an appropriate nutritional therapy for patients with severe dysphagia who cannot safely swallow even modified textures, ensuring adequate caloric and nutrient intake to support recovery and prevent malnutrition.
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