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 B
Explanation
Choice A rationale
Canned tuna and salmon, while sources of protein and omega-3 fatty acids, are not particularly high in potassium. Clients taking potassium-wasting diuretics need foods rich in potassium to replace the electrolytes lost through increased urination.
Choice B rationale
Oranges and bananas are excellent sources of potassium. Potassium is an essential electrolyte that is often depleted by potassium-wasting diuretics like furosemide or hydrochlorothiazide. Consuming these fruits helps maintain adequate potassium levels, which are crucial for cardiac function and muscle contraction. The normal range for serum potassium is typically 3.5-5.0 mEq/L.
Choice C rationale
Dried fruits, such as apricots and raisins, are high in potassium. However, the question asks what the nurse *should* include, and while dried fruits are beneficial, fresh fruits like oranges and bananas are often more readily available and consumed in larger quantities.
Choice D rationale
Cow's milk contains potassium but is not specifically emphasized for clients on potassium-wasting diuretics. Other food sources like fruits and vegetables generally provide a more direct and often higher concentration of potassium without the added phosphorus and calcium found in milk, which may be considerations for some individuals.
Correct Answer is A
Explanation
Choice A rationale
A speech therapist specializes in diagnosing and treating swallowing disorders, such as dysphagia. They assess the client’s ability to swallow safely and provide interventions to improve swallowing techniques, including exercises and modifications to diet. Referral to a speech therapist is essential for managing dysphagia and preventing complications like aspiration pneumonia.
Choice B rationale
A respiratory therapist primarily deals with breathing problems and airway management, not swallowing difficulties. While respiratory therapists play a role in managing clients with respiratory distress, they do not specialize in dysphagia.
Choice C rationale
A dentist focuses on oral health, which is important for overall health, but they are not the appropriate specialist for managing dysphagia. While they may address oral conditions that could impact swallowing, dysphagia management requires the expertise of a speech therapist.
Choice D rationale
A physical therapist focuses on physical movement and rehabilitation. While physical therapy may assist in mobility and motor coordination, dysphagia management falls within the domain of a speech therapist, not a physical therapist.
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