A client is diagnosed with an enterocele. The nurse interprets this condition as:
Protrusion of the posterior bladder wall downward through the anterior vaginal wall
Bulging of the small intestine through the posterior vaginal wall
Descent of the uterus through the pelvic floor into the vagina
Sagging of the rectum with pressure exerted against the posterior vaginal wall
The Correct Answer is B
Choice A: Protrusion of the posterior bladder wall downward through the anterior vaginal wall is not the correct answer because it describes a different condition called cystocele. A cystocele occurs when the bladder pushes into the vagina due to weakened pelvic support structures.
Choice B: Bulging of the small intestine through the posterior vaginal wall is the correct answer because it describes an enterocele. Enterocele occurs when the small intestine slides into a pouch between the rectum and vagina due to weakened pelvic support structures.
Choice C: Descent of the uterus through the pelvic floor into the vagina is not the correct answer because it describes a different condition called uterine prolapse. Uterine prolapse occurs when the uterus drops down into or out of the vagina due to weakened pelvic support structures.
Choice D: Sagging of the rectum with the pressure exerted against the posterior vaginal wall is not the correct answer because it describes a different condition called rectocele. Rectocele occurs when the rectum bulges into or out of the vagina due to weakened pelvic support structures.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is B
Explanation
Choice A: Danazol is not the correct answer because it is a drug that can be used to treat fibrocystic breast disease. Danazol is a synthetic hormone that reduces the production of estrogen and progesterone, which are involved in the development of breast cysts.
Choice B: Penicillin is the correct answer because it is a drug that has no effect on fibrocystic breast disease. Penicillin is an antibiotic that is used to treat bacterial infections, such as strep throat or syphilis. It has no role in the management of fibrocystic breast disease.
Choice C: Bromocriptine is not the correct answer because it is a drug that can be used to treat fibrocystic breast disease. Bromocriptine is a dopamine agonist that inhibits the secretion of prolactin, which is a hormone that stimulates breast tissue growth and milk production.
Choice D: Tamoxifen is not the correct answer because it is a drug that can be used to treat fibrocystic breast disease. Tamoxifen is an anti-estrogen that blocks the action of estrogen on breast cells, which can reduce the size and number of breast cysts.
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