A nurse is caring for an adolescent with spina bifida who is paralyzed from the waist down. Which of the following client statements should alert the nurse to the need for further education?

Choice A rationale
While it’s important to assess the level of parental anxiety related to the diagnosis, it’s not the immediate priority. The child’s physical health needs to be stabilized first.
Choice B rationale
This is the correct answer. Auscultating the rate and characteristics of the child’s heart sounds is the immediate priority. Acute rheumatic fever can lead to serious cardiac complications, so it’s crucial to monitor the child’s heart function closely.
Choice C rationale
While assessing the severity of joint pain is important in managing the child’s comfort, it’s not the immediate priority. The child’s heart function needs to be assessed first.
Choice D rationale
While assessing the client’s erythematous rash is part of the overall assessment of a child with acute rheumatic fever, it’s not the immediate priority. The child’s heart function needs to be assessed first.

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.