A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include?

Expect some breast dimpling or discharge with age.

Using the palm of the hand, feel for lumps using a circular motion.

Breasts can be examined in the shower with soapy hands.

For those who have a menstrual cycle, perform a BSE every month, 2 or 3 days before menstruation.

Answer and Explanation

The Correct Answer is C

Choice A rationale
While it’s true that some changes in the breast, such as dimpling or discharge, can occur with age, these are not normal and could be signs of a serious condition like breast cancer.
Therefore, this instruction should not be included in the pamphlet.
Choice B rationale
While using the palm of the hand to feel for lumps using a circular motion is a common method, it’s not the most effective. The pads of the three middle fingers should be used instead, as they are more sensitive to changes in the breast tissue.
Choice C rationale
This is the correct answer. Performing a breast self-exam in the shower with soapy hands is recommended because the soap helps your fingers glide smoothly over your skin, making it easier to feel for any lumps or changes.
Choice D rationale
While it’s true that women who have a menstrual cycle should perform a breast self-exam every month, the timing suggested here is not accurate. The best time to perform a breast self- exam is a few days after the menstrual period ends, when the breasts are less likely to be tender or swollen.

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Correct Answer is C

Explanation

Choice A rationale
Positioning the infant supine is not the most appropriate intervention for an infant diagnosed with spina bifida who is scheduled for a surgical closure of the myelomeningocele sac. This position could put pressure on the sac and potentially lead to rupture or infection.
Choice B rationale
While contact precautions can be important in certain situations to prevent the spread of infection, they are not the primary intervention for a child with spina bifida undergoing surgery. The main concern is protecting the myelomeningocele sac from damage and infection.
Choice C rationale
Ensuring a latex-free environment is crucial for a child with spina bifida. Many children with spina bifida have a latex allergy, and exposure to latex can cause an allergic reaction. This can range from skin redness and itching to more serious symptoms such as wheezing and difficulty breathing.
Choice D rationale
Restricting visitors to immediate family members is not specifically related to the care of an infant with spina bifida. While limiting visitors can help reduce the risk of infection, it is not the primary concern in this case.

A. Support the casted arm with a firm grasp. B. Place a heated fan at the bedside to facilitate drying. C. Tell the child, “This will make your arm feel better.”. D. Wrap the arm of the child’s doll or toy prior to the procedure.

Correct Answer is A

Explanation

Choice A rationale
Supporting the casted arm with a firm grasp is important to prevent unnecessary movement and potential discomfort or injury to the child. It also helps in ensuring the correct positioning of the cast.
Choice B rationale
Placing a heated fan at the bedside to facilitate drying is not recommended. Excessive heat can cause discomfort and potential burns to the child. The cast should be allowed to dry naturally.
Choice C rationale
Telling the child that the cast will make their arm feel better can be misleading. While the cast is necessary for healing, it may cause discomfort and itching. It’s important to explain to the child what the cast is for and what to expect.
Choice D rationale
Wrapping the arm of the child’s doll or toy prior to the procedure can help the child understand what is happening and make them feel more comfortable. However, this action alone is not sufficient in preparing to apply a cast to a preschooler’s arm.

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A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is formulating a care plan for an infant diagnosed with spina bifida who is scheduled for a surgical closure of the myelomeningocele sac. Which of the following interventions should be incorporated into the care plan?

Correct Answer is C

Explanation

A nurse is preparing to assist with applying a cast to a preschooler’s arm. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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