Which is the best statement by the nurse to ensure that a patient is performing breast self-examination correctly?
“When was your last mammography?”
“Do you receive annual breast examination?”
“How often do you perform breast self-examination?”
“How often do you visit your physician?”
The Correct Answer is C
Choice A reason: Asking about the last mammography focuses on screening, not the technique or frequency of self-examination. Inquiring about self-exam frequency ensures the patient performs it regularly, so this is incorrect for ensuring proper practice.
Choice B reason: Annual breast exams are clinical, but this question doesn’t confirm the patient patient performs self-exams. Asking about self-examination frequency directly addresses the practice, so this is not the best statement.
Choice C reason: Asking how often the patient performs breast self-examination confirms whether they do it regularly (e.g., monthly) and opens discussion on technique, ensuring correct practice. This is the best statement, so it’s correct.
Choice D reason: Physician visits are unrelated to self-performing self-examination at home. Frequency of breast self-exams is key to ensuring compliance, so this is incorrect for the nurse’s goal.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Intelligence cannot be assessed in a 3-month-old, as cognitive abilities are not yet developed enough for evaluation. Sucking and grasping are innate behaviors driven by reflexes, not conscious thought, making this an incorrect assessment focus.
Choice B reason: Cerebral cortex function is immature in a 3-month-old, and sucking and grasping are primarily brainstem-mediated reflexes. These actions do not directly assess higher cortical functions like memory or reasoning, making this an incorrect choice.
Choice C reason: Sucking and grasping in a 3-month-old are primitive reflexes (sucking reflex and palmar grasp reflex), mediated by the brainstem. Assessing these evaluates normal neurological development, making this the correct focus of the nurse’s inquiry.
Choice D reason: While sucking involves Cranial Nerves V, VII, IX, and XII, and grasping involves spinal reflexes, the nurse is assessing the presence of these reflexes, not the cranial nerves directly. Reflex assessment is the primary focus, making this less precise.
Correct Answer is D
Explanation
Choice A reason: Measuring respirations during pulse assessment can lead to inaccurate counts, as patients may alter their breathing when aware of pulse measurement. Conscious awareness often causes irregular or controlled breathing, which does not reflect the true respiratory rate, making this an unreliable time.
Choice B reason: Auscultation involves listening to lung or heart sounds, which requires patient cooperation and often affects breathing patterns. Patients may consciously modify their respirations during this process, leading to inaccurate respiratory rate measurements, rendering this an unsuitable time for assessment.
Choice C reason: Interviewing involves patient interaction, which can influence breathing due to speech or emotional responses. This conscious activity often results in irregular or controlled breathing patterns, making it an unreliable time to accurately measure the patient’s natural respiratory rate.
Choice D reason: Measuring respirations when the patient is sleeping ensures an undisturbed, natural breathing pattern, as the patient is unaware of the assessment. This allows the nurse to count the respiratory rate accurately, reflecting the true resting state, making it the optimal time.
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