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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Free Nursing Study Resources

Correct Answer is B

Explanation

Before and after applying a cast, it is essential to assess the client's circulation, movement, and sensation to ensure there is no damage to the nerves or blood vessels. Assessing cardiac and respiratory status is not as relevant to cast application. ROM status is important but can be assessed by assessing movement and sensation. Renal and hepatic function are not directly related to cast application.

A. Pode the client with non-prescription laxatives. B. Measure abdominal girth according to a set routine. C. Ask the client about food intake. D. Check for signs of hepatic encephalopathy.

Correct Answer is A

Explanation

Giving non-prescription laxatives to a client with cirrhosis can cause severe dehydration and electrolyte imbalances, which can be life-threatening. The nurse should report this intervention immediately to the physician.

Choice B is incorrect because measuring abdominal girth is a standard nursing intervention for clients with cirrhosis to assess for ascites.

Choice C is incorrect because asking the client about food intake is a standard nursing intervention for assessing nutritional status.

Choice D is incorrect because checking for signs of hepatic encephalopathy is a standard nursing intervention for clients with cirrhosis.

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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

The nurse is caring for a client who has had a fracture reduction using a cast. Which of the following would be most important for the nurse to assess before and after the cast application?

Correct Answer is B

Explanation

While performing a physical examination on a client with cirrhosis, which of the following interventions should the nurse report immediately to the physician?

Correct Answer is A

Explanation

The nursing instructor is having a group discussion about the functions of the skin prior to reviewing common skin disorders. The instructor is pleased when the students answer (SATA).

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?

An older adult male client is participating in bladder training for urinary incontinence. The nurse advises him to wear a pad. Which suggestion would be most appropriate to help the client?

An older adult female has a bone density test that reveals severe osteoporosis. What does the nurse understand can be a problem for this client due to the decrease in bone mass and density?

You are taking care of a client who suffers from Meniere's disease. On assessment, you note what common symptoms of this disorder? Select all that apply.

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?

A client is suspected of having acromegaly. What definitive diagnostic testing is the most reliable for confirming acromegaly?

Examination of a client's bladder stones reveals that they are primarily composed of uric acid. The nurse would expect to provide the client with which type of diet?