A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the following times?

Three to seven days after menses stops.

On the same day every month.

Prior to the beginning of menses.

On the second day of menstruation.

Answer and Explanation

The Correct Answer is A

a. Three to seven days after menses stops: Performing BSE a few days after menstruation allows the breasts to return to a more baseline state, reducing the influence of hormonal changes on

breast tissue.

b. On the same day every month: Hormonal changes during the menstrual cycle can affect breast tissue, and performing BSE on the same day every month may not provide consistent conditions for examination.

c. Prior to the beginning of menses: Hormonal changes before menstruation can lead to breast tenderness and changes, potentially affecting the accuracy of the examination.

d. On the second day of menstruation: Hormonal changes and potential breast tenderness during the early days of menstruation may not be the optimal time for BSE.

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Correct Answer is B

Explanation

a. C-reactive protein: This is a marker of inflammation and is not specific to renal function. It is more commonly used to assess inflammation in various conditions.

b. Serum creatinine: Elevated levels of serum creatinine are indicative of impaired renal

function. Creatinine is a waste product that is normally filtered by the kidneys. Increased levels suggest decreased renal filtration.

c. Antinuclear antibody: This test is used to diagnose autoimmune diseases like SLE but does not directly measure renal function.

d. Erythrocyte sedimentation rate: This is a nonspecific marker of inflammation and is not directly related to renal function.

A. Ineffective airway clearance related to thick, copious secretions B. Malnourishment related to NPO status and dysphagia C. High risk for infection related to surgical incisions D. Impaired verbal communication related to the tracheostomy

Correct Answer is A

Explanation

a. Ineffective airway clearance: This is the priority as it addresses the immediate threat to the client's respiratory status. Accumulation of thick, copious secretions can lead to airway

obstruction and respiratory distress.

b. Malnourishment: While important, addressing malnourishment is not an immediate

postoperative priority. The client may receive nutrition through alternative means until normal swallowing function is restored.

c. High risk for infection: Infection is a concern, but ensuring airway clearance takes precedence in the immediate postoperative period.

d. Impaired verbal communication: Verbal communication is important, but it is not as immediate a concern as ensuring the airway is clear to prevent respiratory compromise.

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A nurse is reinforcing teaching about breast self-examination (BSE) with a client who has a regular menstrual cycle. The nurse should instruct the client to perform BSE at which of the following times?

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