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:
The instruction to urinate a small amount into the toilet before collecting the sample is correct because it helps clear the urethra of organisms that could contaminate the specimen. This initial void helps to flush out bacteria that are present at the opening of the urethra.
Choice B Reason:
This choice is incorrect because urine samples should be kept at body temperature and sent to the lab as soon as possible. Cooling the urine can lead to precipitation of solutes and may affect the results of certain tests.
Choice C Reason:
This statement is incorrect. The proper technique for cleansing prior to urine collection is to wipe from front to back, not back to front. Wiping from back to front can contaminate the urine with bacteria from the anal area.
Choice D Reason:
It is advisable not to collect a urine sample during menstruation unless absolutely necessary because menstrual blood can contaminate the urine specimen, leading to inaccurate test results.
Correct Answer is A
Explanation
Choice A reason:
The inability to abduct the arm at the shoulder is a classic sign of a rotator cuff injury. The rotator cuff is responsible for stabilizing the shoulder joint and aiding in various movements, including abduction. When there is a tear or significant weakness in the rotator cuff muscles, especially the supraspinatus muscle, the patient may be unable to lift the arm away from the body or may experience pain while doing so.
Choice B reason:
A negative drop arm test would actually indicate that there is no rotator cuff injury. The drop arm test is performed by asking the patient to fully abduct the arm to 90 degrees and then slowly lower it. If the patient can control the motion and lower the arm smoothly, the test is negative. A positive drop arm test, where the patient cannot control the descent of the arm, would suggest a rotator cuff tear.
Choice C reason:
While an alteration in the contour of the joint may indicate some form of shoulder pathology, it is not specific to a rotator cuff injury. Changes in the contour could be due to various conditions, including dislocation, arthritis, or other musculoskeletal disorders.
Choice D reason:
A positive Tinel's sign is used to diagnose nerve compression or nerve damage, not rotator cuff injuries. It is performed by tapping over the course of a nerve to elicit a tingling sensation or pain in the distribution of the nerve. This sign is commonly associated with conditions like carpal tunnel syndrome.
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