The nurse is caring for a client with breast cancer. On evaluation of axillary findings, a potential sign of cancer spread is documented and brought to the physician's attention. Which finding is documented?

Fluid accumulation under the arm.

Drainage from the area.

Reddened area around the breast.

Enlargement of the arm or hand.

Answer and Explanation

The Correct Answer is A

Fluid accumulation under the arm. The presence of fluid accumulation (edema) under the arm may indicate the spread of breast cancer to the lymph nodes. The physician should be notified, and further evaluation and treatment may be necessary.

Option B: Drainage from the area is not a correct answer as it may indicate a surgical site infection or an abscess, but not necessarily the spread of cancer.

Option C: Reddened area around the breast is not a correct answer as it may indicate a skin infection or inflammation, but not necessarily the spread of cancer.

Option D: Enlargement of the arm or hand is not a correct answer as it may indicate lymphedema, which is a swelling due to lymphatic system damage, but not necessarily the spread of cancer.

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Correct Answer is A

Explanation

drug allergy. A skin rash is a common symptom of an allergic reaction to a medication, and a drug allergy can occur at any time during drug therapy. A drug allergy may be due to an immune response, causing the immune system to overreact to a medication that it identifies as harmful to the body. The symptoms of a drug allergy may include a rash, hives, itching, or difficulty breathing. It is important for the nurse to determine which medication the client is taking and if the client has a history of allergies.

Heat stroke (B) occurs when the body is exposed to high temperatures, leading to symptoms such as high body temperature, confusion, and loss of consciousness. Hormone changes (C) can cause various changes in the body but do not usually cause skin rashes. A suntan (D) is a reaction of the skin to ultraviolet light and is not a cause of a skin rash.

A. "I am at lower risk for developing cervical warts.". B. " ". C. "This vaccine lowers my risk for cervical cancer.". D. "This vaccine will prevent human papillomavirus (HPV) from occurring.".

Correct Answer is A

Explanation

"I am at lower risk for developing cervical warts." This is an incorrect statement because the Gardasil vaccine does not protect against genital warts caused by HPV types other than types 6 and 11. The vaccine protects against HPV types 16 and 18, which cause most cases of cervical cancer.

B: This option is incomplete and does not provide any information for the nurse to determine if further teaching is needed.

C: This statement is correct and indicates that the client understands the purpose of the Gardasil vaccine.

D: This statement is incorrect because the Gardasil vaccine does not prevent HPV infection from occurring.

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The nurse is caring for a client with breast cancer. On evaluation of axillary findings, a potential sign of cancer spread is documented and brought to the physician's attention. Which finding is documented?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client on a prescribed medication for a skin disorder visits the clinic complaining of a skin rash. Which of the following would explain the client's condition?

Correct Answer is A

Explanation

A young client has just completed the 6-month series of Gardasil vaccine. Which comment by the client would alert the nurse that further teaching is needed?

Correct Answer is A

Explanation

A client, who is recovering from bariatric surgery, is eating from a po [portable commode]. Nursing assessment is of greatest concern in the immediate postoperative period for which of the following?

The emergency room nurse is reporting the location of a fracture to the client's primary car. When stating the location of the fracture on the long shaft of the femur, the nurse would be most correct to state which terminology locating the fractured site?

During a sexual history, the client states that she has had multiple sex partners. Which statement by the nurse is most correct?

The nurse is talking with a group of clients that are older than age 50 years about the recognition of colon cancer to access early intervention. What should the nurse inform the clients to report immediately to their primary care provider?

The nurse is checking the blood glucose of a client and has a reading of 48. The client is not easily awakened and only responds with a groan. What will the nurse administer to raise the blood glucose level?

The nurse in the clinic is assessing a young child brought in by the parents with symptoms of meningitis. The nurse will assess for dropdown by asking the child to flex the chin to the neck.

A suspicious breast lump is noted on a mammogram. The client asks the nurse which diagnostic test confirms if the lump is cancerous or benign. Which response by the nurse is most correct?