Which assessment finding in a 36-year-old client is most indicative for further evaluation?

A breast lump that is small, mobile and rubbery in consistency.

A breast nodule that is 1 cm in size, nontender, and fixed.

Bilateral breast nodules that are tender with palpation.

A breast lump that increases in size before the menstrual period.

Answer and Explanation

The Correct Answer is B

A. A small, mobile, rubbery lump is often benign, such as a fibroadenoma.

B. A nontender, fixed breast nodule is concerning for malignancy, and further evaluation is necessary, such as imaging or biopsy.

C. Tender, bilateral nodules are commonly seen in benign conditions like fibrocystic breast changes, especially related to the menstrual cycle.

D. A lump that changes in size before menstruation is also typical of benign conditions like fibrocystic changes.

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Correct Answer is B

Explanation

A. The excitement of family does not indicate an infection risk. Emotional support can aid recovery.

B. Handling cat litter, which can contain bacteria, is a potential source of infection. Given the client's sternal wound, exposure to such bacteria increases the risk of infection, including sepsis.

C. Attending a party may present social interaction risks, but it is not as directly related to infection risk as handling cat litter.

D. Having the water turned on does not pose a significant risk for infection or sepsis.

A. Administer multiple vitamins and minerals in the IV solution. B. Infuse total parenteral nutrition via a central catheter. C. Encourage an oral intake of at least 3000 kcal per day. D. Insert a feeding tube and initiate enteral feedings.

Correct Answer is D

Explanation

A. Administering multiple vitamins and minerals via IV alone would not be sufficient for adequate nutrition in this patient, especially given the large burn surface area.

B. Total parenteral nutrition (TPN) may be used if enteral feeding is not possible, but enteral feeding is usually preferred when feasible.

C. Encouraging oral intake is not appropriate for a client with a 60% TBSA burn, as they would likely require more significant nutritional support than oral intake can provide.

D. Enteral feeding is the preferred method for nutrition in burn patients as it maintains gut integrity and prevents the complications associated with parenteral nutrition. Although the client has absent bowel sounds and a distended abdomen, this can be common early in burn care, and enteral feedings should be started as soon as feasible to prevent malnutrition and promote recovery.

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Which assessment finding in a 36-year-old client is most indicative for further evaluation?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is being discharged home after a large myocardial infarction and subsequent coronary artery bypass grafting surgery. The client's sternal wound has not yet healed. What statement by the client most indicates a higher risk of developing sepsis after discharge?

Correct Answer is B

Explanation

A client has just been admitted with a 60% total body surface area (TBSA) burn injury. The nurse notes a distended abdomen with absent bowel sounds in all quadrants. To maintain adequate nutrition, the nurse should plan to take which action?

Correct Answer is D

Explanation

The nurse is teaching a client diagnosed with benign prostatic hyperplasia (BPH). What statement indicates the client needs further information?

A 36-yr-old client who has a diagnosis of fibrocystic breast changes calls the nurse in the clinic reporting symptoms. Which information is likely to change the treatment plan?

During the administration of finasteride (Proscar), the nurse must remember which important precaution?

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