A nurse is providing breast self-examination teaching to a client who is menopausal. Which of the following statements should the nurse identify as an indication that the teaching was effective? (Select all that apply.)
"I will make sure to feel for changes in my underarm area."
"It is important to press firmly when feeling my breasts to detect changes."
"I don't have to lie down to check my breasts. I can stand in the shower."
"If I feel a firm ridge in the lower curve of my breasts, I should report this immediately."
"Since I no longer have periods, I can perform an examination at any time of the month."
Correct Answer : A,B,C,E
The correct answer is: a, b, c, and e.
Choice A: “I will make sure to feel for changes in my underarm area.”
Reason: This statement is correct because the underarm area (axilla) contains lymph nodes that can be affected by breast cancer. Including the underarm area in a breast self-exam helps in detecting any unusual lumps or changes that could indicate a problem.
Choice B: “It is important to press firmly when feeling my breasts to detect changes.”
Reason: This statement is correct because using firm pressure during a breast self-exam helps to feel the deeper tissues of the breast, which is essential for detecting any abnormalities or lumps that might be present.
Choice C: “I don’t have to lie down to check my breasts. I can stand in the shower.”
Reason: This statement is correct because performing a breast self-exam in the shower is a common and effective method. The wet and slippery skin makes it easier to feel for any changes or lumps in the breast tissue.
Choice D: “If I feel a firm ridge in the lower curve of my breasts, I should report this immediately.”
Reason: This statement is incorrect because it is normal to feel a firm ridge in the lower curve of the breast. This ridge is part of the normal breast anatomy and does not necessarily indicate a problem.
Choice E: “Since I no longer have periods, I can perform an examination at any time of the month.”
Reason: This statement is correct because menopausal women do not have menstrual cycles to guide the timing of their breast self-exams. Therefore, they can choose any consistent day each month to perform the exam.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Applying a foot plate to the bed is not primarily intended to prevent pressure points from developing around the edges of the splint. A foot plate can help in maintaining proper alignment and preventing foot drop, but it does not address the issue of pressure points caused by the splint.
Choice B reason:
Repositioning the client is a key intervention to prevent pressure points. By changing the client's position regularly, the nurse can ensure that no single area is under prolonged pressure, which could lead to skin breakdown and pressure sores. This is particularly important in clients with limited mobility due to skeletal traction.
Choice C reason:
Removing the weights for a few minutes each hour is not a standard practice for preventing pressure points in balanced skeletal traction. The weights are integral to maintaining the necessary pull on the fractured femur, and their removal could disrupt the traction setup and potentially affect fracture healing.
Choice D reason:
Applying lotion to the skin under the edges of the splint is not recommended as it could soften the skin and make it more susceptible to injury. Instead, padding and proper positioning are used to protect the skin from the hard edges of the splint.
Correct Answer is D
Explanation
The correct answer is: d. Hypoglycemia
Choice A reason:
Hyperglycemia: This statement is wrong because hyperglycemia typically presents with symptoms like increased thirst, frequent urination, and fatigue, not sweating and anxiety.
Choice B reason:
Nephropathy: This statement is wrong because nephropathy, a kidney complication, does not cause acute symptoms like sweating and anxiety. It usually presents with proteinuria and progressive kidney dysfunction.
Choice C reason:
Ketoacidosis: This statement is wrong because diabetic ketoacidosis usually presents with symptoms like fruity breath, nausea, vomiting, and deep, rapid breathing (Kussmaul respirations), not sweating and anxiety.
Choice D reason:
Hypoglycemia: This statement is correct because hypoglycemia is characterized by symptoms such as sweating, anxiety, palpitations, and confusion due to the release of adrenaline in response to low blood glucose levels.
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