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 A
Explanation
Choice A reason:
Morphine is an opioid analgesic that can cause a decrease in gastrointestinal motility, leading to constipation and exacerbation of paralytic ileus, a condition where there is a cessation of peristalsis in the intestine. In the case of paralytic ileus, the intestinal contents cannot move, which can lead to bowel distention, pain, and further complications. Therefore, morphine is contraindicated in clients with paralytic ileus due to the risk of worsening the condition..
Choice B reason:
While morphine can suppress cough and provide some relief in respiratory conditions, it is not contraindicated in bronchitis pleurisy unless respiratory depression is present. However, caution is advised as morphine can cause respiratory depression and should be used carefully in patients with underlying respiratory disorders.
Choice C reason:
Morphine is often used in the management of acute myocardial infarction (MI) to relieve chest pain, reduce anxiety, and decrease the workload on the heart by lowering blood pressure and heart rate. It is not contraindicated in MI; in fact, it can be beneficial in managing the symptoms associated with MI.
Choice D reason:
Postoperative pain management following hip arthroplasty often includes opioids like morphine. Morphine is not contraindicated in this situation and can be used to control postoperative pain, provided that the patient's respiratory function is closely monitored
Correct Answer is C
Explanation
Choice A reason:
Clay-colored stools are typically associated with issues in the biliary system, such as bile duct obstruction, and not directly with aspirin use. Aspirin, especially when used in high doses, is more commonly associated with gastrointestinal side effects like bleeding, which would likely cause dark or bloody stools rather than clay-colored ones.
Choice B reason:
Nystagmus, which is a vision condition characterized by repetitive, uncontrolled eye movements, is not a recognized side effect of aspirin. While aspirin can have effects on various systems in the body, it does not typically affect the muscles or nerves controlling eye movements.
Choice C reason:
Tinnitus, or ringing in the ears, is a well-documented adverse effect of aspirin, particularly when taken in high doses or for a prolonged period. It is related to the effect of aspirin on the inner ear structures and is usually reversible once the medication is stopped or the dosage is reduced.
Choice D reason:
Respiratory depression is not a typical side effect of aspirin. Aspirin can cause respiratory alkalosis in cases of overdose due to hyperventilation, but it does not cause respiratory depression. If respiratory depression occurs, it would likely be due to a different cause and not the aspirin itself.
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