A breast biopsy indicates the presence of malignant cells, and the client is scheduled for a mastectomy. When preparing the client's preoperative plan of care, which area would the nurse most likely address as the priority?

Fluid balance

Body image

Urinary elimination

Activity

Answer and Explanation

The Correct Answer is B

Choice A: Fluid balance is not the most likely priority because it is not directly affected by the mastectomy. Fluid balance is the state of equilibrium between the intake and output of fluids in the body. It can be influenced by various factors such as hydration, nutrition, medication, or illness. It can be monitored by measuring vital signs, weight, urine output, or laboratory values. Fluid balance is important for maintaining homeostasis and preventing dehydration or edema, but it is not a specific concern for a client undergoing a mastectomy.

Choice B: Body image is the most likely priority because it is directly affected by the mastectomy. Body image is the perception and attitude that one has toward one's own physical appearance and function. It can be influenced by various factors such as culture, media, self-esteem, or feedback from others. It can be assessed by observing verbal and nonverbal cues, asking open-ended questions, or using standardized tools. Body image is a major psychosocial issue for a client undergoing a mastectomy, as it can affect one's sense of identity, femininity, sexuality, or attractiveness. The nurse should address body image by providing information, support, and referral to appropriate resources.

Choice C: Urinary elimination is not the most likely priority because it is not directly affected by the mastectomy. Urinary elimination is the process of expelling urine from the bladder through the urethra. It can be influenced by various factors such as fluid intake, kidney function, medication, or infection. It can be assessed by measuring urine volume, color, odor, or specific gravity. Urinary elimination is important for maintaining fluid balance and preventing urinary tract infection or retention, but it is not a specific concern for a client undergoing a mastectomy.

Choice D: Activity is not the most likely priority because it is not directly affected by the mastectomy. Activity is the level of physical movement and exercise that one engages in on a daily basis. It can be influenced by various factors such as age, health status, motivation, or environment. It can be assessed by observing mobility, endurance, strength, or coordination. Activity is important for maintaining muscle tone, joint range of motion, circulation, or metabolism, but it is not a specific concern for a client undergoing a mastectomy.

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Correct Answer is A

Explanation

Choice A: Reports of itching, tingling, and pain in the genital area are the correct answer because they are common symptoms of genital herpes. Genital herpes is a sexually transmitted infection (STI) caused by the herpes simplex virus (HSV). It can cause outbreaks of painful blisters or sores on or around the genitals, anus, or mouth. The blisters or sores usually heal within a few weeks, but the virus remains in the body and can reactivate at any time. Before an outbreak, some people may experience prodromal symptoms such as itching, tingling, or pain in the affected area.

Choice B: Painful urination with a penile discharge present is not the correct answer because it is more likely a symptom of another STI, such as gonorrhea or chlamydia. Gonorrhea and chlamydia are bacterial infections that can affect the urethra, cervix, rectum, or throat. They can cause symptoms such as burning or pain during urination, abnormal discharge from the penis or vagina, or bleeding between periods.

Choice C: Wart-like flesh-colored lesions on the scrotal area are not the correct answer because they are more likely a symptom of another STI, such as human papillomavirus (HPV). HPV is a viral infection that can cause genital warts or cervical cancer. Genital warts are small, soft, flesh-colored growths that can appear on or around the genitals, anus, or mouth. They may be flat, raised, or cauliflower-shaped.

Choice D: A chancre on the penis is not the correct answer because it is more likely a symptom of another STI, such as syphilis. Syphilis is a bacterial infection that can affect various organs and systems of the body. It has four stages: primary, secondary, latent, and tertiary. In the primary stage, syphilis causes a painless sore called a chancre that can appear on or around the genitals, anus, or mouth. The chancre usually heals within a few weeks, but the infection can progress to the next stages if left untreated.

A. Sporadic vaginal bleeding accompanied by chronic pelvic pain B. Menstrual irregularities and hirsutism on the chin C. Heavy leukorrhea with vulvar pruritus D. Stress incontinence with feeling of low abdominal pressure

Correct Answer is D

Explanation

Choice A: Sporadic vaginal bleeding accompanied by chronic pelvic pain is not the correct answer because it is not a symptom of cystocele or rectocele. This symptom may indicate other conditions such as endometriosis, fibroids, or cervical cancer.

Choice B: Menstrual irregularities and hirsutism on the chin are not the correct answers because they are not symptoms of cystocele or rectocele. These symptoms may indicate other conditions such as polycystic ovary syndrome (PCOS), thyroid disorder, or menopause.

Choice C: Heavy leukorrhea with vulvar pruritus is not the correct answer because it is not a symptom of cystocele or rectocele. This symptom may indicate other conditions such as bacterial vaginosis, yeast infection, or sexually transmitted infection (STI).

Choice D: Stress incontinence with a feeling of low abdominal pressure is the correct answer because it is a symptom of cystocele or rectocele. Stress incontinence is a condition that causes leakage of urine when there is increased pressure on the bladder, such as during coughing, sneezing, laughing, or lifting. Cystocele or rectocele can cause stress incontinence by weakening the pelvic floor muscles and connective tissue that supports the bladder and urethra. The feeling of low abdominal pressure is also a symptom of cystocele or rectocele, as it indicates that the bladder or rectum is protruding into the vagina.

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A breast biopsy indicates the presence of malignant cells, and the client is scheduled for a mastectomy. When preparing the client's preoperative plan of care, which area would the nurse most likely address as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a male client recently diagnosed with genital herpes. Which finding would most likely correlate with this diagnosis?

Correct Answer is A

Explanation

A woman is admitted for repair of cystocele and rectocele. She has nine living children. In taking her health history, what would the nurse expect to find?

Correct Answer is D

Explanation

Assessment of a female client reveals a thick, white vaginal discharge. She also reports intense itching and dyspareunia. Based on these findings, the nurse would suspect that the client has:

A nurse in a community clinic is counseling a client who received a positive test result for chlamydia. Which of the following statements should the nurse provide?

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