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The nurse is taking a history of a 68-year-old woman. What assessment findings would indicate a high risk for the development of breast cancer? (Select all that apply.)

Early menarche

Age greater than 65 years

Genetic factors

History of multiple births

Answer and Explanation

Correct Answer : A,B,C

A. Early menarche increases lifetime exposure to estrogen, raising breast cancer risk.

B. Age is a significant risk factor for breast cancer.

C. Genetic factors, like BRCA mutations, increase the risk.

D. History of multiple births is generally protective against breast cancer.

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Correct Answer is B

Explanation

A. Administering oxygen is unnecessary at this time, as the client’s oxygen saturation is normal at 96%.

B. The client has had a myocardial infarction, which can lead to complications such as orthostatic hypotension or cardiovascular strain with sudden position changes. A bedside commode minimizes the need for the client to get out of bed and reduces the risk of these complications.

C. Suggesting the use of a bedpan may be an alternative but is less comfortable and may not adequately address the risk of strain from getting out of bed.

D. Allowing continued bathroom privileges may be unsafe, as it may increase the risk of a fall or cardiovascular strain.

A. 2+ bilateral peripheral edema B. Heart rate 59 beats/min C. Temperature of 96 F D. Muffled heart sounds

Correct Answer is D

Explanation

A. Bilateral peripheral edema can occur after heart catheterization but is not as immediately life-threatening as cardiac tamponade.

B. A heart rate of 59 beats/min may be concerning, but bradycardia alone is not as immediately urgent as signs of cardiac tamponade.

C. A temperature of 96°F is low, but this is more of a concern for hypothermia or post-procedural effects and is not as urgent as muffled heart sounds indicating tamponade.

D. Muffled heart sounds can indicate cardiac tamponade, a medical emergency. Immediate intervention is required to relieve the pressure on the heart, which may involve pericardiocentesis to drain the fluid or blood.

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The nurse is taking a history of a 68-year-old woman. What assessment findings would indicate a high risk for the development of breast cancer? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is caring for a client after a heart catheterization. What complication must the nurse intervene for immediately?

Correct Answer is D

Explanation

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