The nurse is discussing Breast Self Examination (BSE) with a postmenopausal client. What instructions should the nurse give to the client about the correct time to perform BSE?

Daily, during the shower or bath

One week after the menstrual period

On the same day every month

Weekly, at the client's convenience

Answer and Explanation

The Correct Answer is C

A) Daily, during the shower or bath:
This is incorrect. Performing a breast self-examination (BSE) daily is not necessary. The goal of BSE is to check for any changes over time, not to examine the breasts every day. It's more effective to perform the exam regularly at a consistent time each month.

B) One week after the menstrual period:
This is incorrect. This instruction is relevant for pre-menopausal women, where the hormonal changes associated with the menstrual cycle can cause breast tissue to feel lumpy or swollen. The best time for them to perform a BSE is one week after the menstrual period ends when the breasts are least likely to be swollen or tender. However, for postmenopausal women, this is not necessary, as their hormonal levels are stable throughout the month.

C) On the same day every month:
This is the correct answer. For postmenopausal women, who no longer have menstrual cycles, the best time to perform a breast self-exam is on the same day every month. This ensures consistency and makes it easier for the client to notice any changes in the breast tissue over time. The day chosen should be one that is convenient and easy to remember, and it does not matter whether it is during the shower or bath, as long as the examination is done regularly.

D) Weekly, at the client's convenience:
This is incorrect. While performing a BSE weekly is not necessary, the key is consistency rather than frequency. Performing the exam monthly is sufficient, and it should be on a specific day each month, rather than at the client’s convenience on an irregular basis.

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Correct Answer is C

Explanation

A) Both lungs are equal in size with varying numbers of lobes:
This is incorrect. The right lung is slightly larger than the left lung, as the left lung is somewhat smaller to accommodate the heart. The right lung has three lobes, while the left lung has only two lobes.

B) The diaphragm rises in the chest during inspiration:
This is incorrect. During inspiration (inhalation), the diaphragm contracts and moves downward to allow the lungs to expand and fill with air. It rises during exhalation as it relaxes and pushes air out of the lungs.

C) The left lung has two lobes to make room for the heart:
This is correct. The left lung has two lobes (upper and lower) compared to the three lobes of the right lung. The left lung is slightly smaller due to the space the heart occupies on the left side of the chest, allowing for asymmetry between the two lungs.

D) The right lung has two lobes to make room for the liver:
This is incorrect. The right lung has three lobes, not two. The liver is located lower in the abdomen and does not influence the number of lobes in the right lung. The asymmetry of the lungs is due to the position of the heart on the left side of the chest.

A. Demonstrate that both arteries will be palpated simultaneously to compare amplitude B. Instruct the client take a deep breath and "hold" while the nurse briefly auscultates C. Discuss that a light will be directed at the neck to observe for pulsations of the artery D. Show the client the diaphragm of the stethoscope that will be placed on the neck

Correct Answer is B

Explanation

A) Demonstrate that both arteries will be palpated simultaneously to compare amplitude: This is not recommended. Palpating both carotid arteries simultaneously can cause a decrease in blood flow to the brain, potentially leading to dizziness or syncope. It is important to palpate one carotid artery at a time to avoid reducing blood flow to the brain, especially in clients with cardiovascular disease or those at risk of stroke.

B) Instruct the client to take a deep breath and "hold" while the nurse briefly auscultates: This is the correct approach. Instructing the client to hold their breath helps minimize any interference from respiratory sounds while auscultating the carotid arteries for bruits. This technique ensures that breath sounds do not mask any abnormal vascular sounds, such as bruits, which could indicate a blockage or narrowing of the carotid arteries.

C) Discuss that a light will be directed at the neck to observe for pulsations of the artery: Observing pulsations with light is not an appropriate technique for assessing the carotid arteries. Pulsations may be visible in some cases, but palpation and auscultation are the more reliable methods for evaluating the carotid arteries for abnormalities such as bruits or reduced pulse amplitude.

D) Show the client the diaphragm of the stethoscope that will be placed on the neck: While it is appropriate to explain the process to the client, the action of showing the stethoscope is unnecessary at this stage. The focus should be on instructing the client to hold their breath for proper auscultation to listen for any abnormal vascular sounds.

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The nurse is discussing Breast Self Examination (BSE) with a postmenopausal client. What instructions should the nurse give to the client about the correct time to perform BSE?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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