After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the client's electronic medical record? (Select all that apply.)

Peau d'orange

Skin ulceration

Nipple retraction

Nontender axillary nodes

Mobile mass at 2 o'clock

Dense breast tissue

Answer and Explanation

Correct Answer : A,B,C,D,E

Choice A rationale: This is a condition where the skin of the breast becomes dimpled and resembles an orange peel. It is caused by blockage of the lymphatic vessels by cancer cells or inflammation.

Choice B rationale: This is a condition where the skin of the breast breaks down and forms an open sore. It can be a sign of advanced or inflammatory breast cancer.

Choice C rationale: This is a condition where the nipple becomes inverted or pulled inward. It can be caused by scarring, infection, or cancer in the breast tissue or ducts.

Choice D rationale: These are lymph nodes in the armpit that are enlarged and hard but not painful. They can be a sign of cancer spreading from the breast to the lymphatic system.

Choice E rationale: This is a lump in the breast that can be felt and moved around. It is located at the upper outer quadrant of the right breast, as if looking at a clock face. It can be benign or malignant, depending on its size, shape, consistency, and borders.

Choice F rationale: Dense breast tissue is not an abnormal finding that indicates possible breast cancer. It is a normal variation that makes it harder to detect lumps or

abnormalities on mammograms. Women with dense breasts may need additional screening tests such as ultrasound or MRI.

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Correct Answer is D

Explanation

Choice A rationale: While gastrointestinal issues like loose stools can occur in Parkinson's disease due to impaired bowel movements, they are not the highest risk related to dietary considerations. Choking might occur due to dysphagia, but it's not specifically the highest risk.

Choice B rationale: Drooling, due to weakened or uncoordinated swallowing muscles, is common in Parkinson's disease but might not pose the highest risk. A loss of appetite can occur but might not be the highest dietary risk for the client.

Choice C rationale: Constipation is a common gastrointestinal issue in Parkinson's disease, but though problematic, it's not the highest risk concerning dietary considerations. Drooling can also be present but might not be the primary dietary concern.

Choice D rationale: Parkinson's disease often leads to dysphagia (difficulty swallowing) and aspiration (inhalation of food or liquids into the lungs). These present significant risks related to dietary considerations, as they can lead to serious complications such as pneumonia due to aspiration.

A. A 60-year-old patient with diabetes who has cellulitis of the left ankle. B. A 50-year-old patient with diabetes just returned from the post-anesthesia care unit after a below-knee amputation. C. A 72-year-old patient with diabetes with diabetic ketoacidosis who is receiving IV insulin. D. A 70-year-old patient with diabetes who is showing signs of hyperglycemia.

Correct Answer is A

Explanation

Choice A rationale: Cellulitis management typically involves wound care, antibiotics, and monitoring. It's a suitable assignment for a new graduate nurse to begin learning about wound management and diabetic care.

Choice B rationale: Post-operative care for an amputation requires experience in assessing and managing post-surgical complications, which might not be suitable for a new graduate nurse.

Choice C rationale: Diabetic ketoacidosis management involves complex insulin therapy and critical care, which might be overwhelming for a new graduate nurse.

Choice D rationale: While hyperglycemia requires monitoring and intervention, the cause and severity need to be determined before assigning this patient to a new

graduate nurse.

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After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the client's electronic medical record? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is teaching a client with Parkinson's disease about dietary considerations. The nurse understands that this client is at highest risk for:

Correct Answer is D

Explanation

The RN is serving as preceptor to a new graduate nurse who has recently passed the RN licensure (NCLEX®) examination. The new nurse has only been on the unit for 2 days. Which patient should be assigned to the new graduate nurse?

Correct Answer is A

Explanation

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