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 D
Explanation
Choice A rationale
Checking gastric residual volume is essential before administering enteral feedings and medications to assess for delayed gastric emptying, which could increase the risk of aspiration. A high residual volume (typically >500 mL or >250 mL on two consecutive checks) may indicate intolerance to the feeding.
Choice B rationale
Turning the client on their left side after administering enteral feedings and medications is not the recommended position. The right lateral decubitus position is preferred as it promotes gastric emptying by allowing gravity to assist the flow of the feeding into the small intestine.
Choice C rationale
Elevating the head of the bed to a 30-45 degree angle during and for at least 30-60 minutes after enteral feedings significantly reduces the risk of aspiration pneumonia. This position utilizes gravity to help keep the feeding within the stomach and prevent reflux into the esophagus and airway.
Choice D rationale
Leaving the client in their position of comfort while feeding them is incorrect. Maintaining an elevated head of bed position (30-45 degrees) is crucial during and after feeding to prevent aspiration, regardless of the client's perceived comfort. A flat or semi-recumbent position increases the risk of regurgitation and subsequent aspiration into the lungs.
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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