A nurse is reinforcing teaching with a client about how to perform a breast self exam (BSE). The nurse should identify which of the following findings as an indication of breast cancer?
Lumps that are mobile and tender upon palpation prior to a menstrual period.
Multiple round masses that are tender and found in both breasts
Bilaterally darkened areolas
A nontender hard lump that is palpated in one breast
The Correct Answer is D
Choice A reason: This is a normal finding, not an indication of breast cancer. Lumps that are mobile and tender upon palpation prior to a menstrual period are usually benign and related to hormonal changes.
Choice B reason: This is a normal finding, not an indication of breast cancer. Multiple round masses that are tender and found in both breasts are usually benign and related to fibrocystic breast changes.
Choice C reason: This is a normal finding, not an indication of breast cancer. Bilaterally darkened areolas are usually benign and related to genetic factors, pregnancy, or aging.
Choice D reason: This is an abnormal finding, and an indication of breast cancer. A nontender hard lump that is palpated in one breast is usually malignant and related to abnormal cell growth.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: This is an incorrect action, because elevating the residual limb on a soft pillow can cause contractures and impair the blood flow to the stump. The residual limb should be elevated only for the first 24 hr after surgery, and then positioned flat on the bed.
Choice B reason: This is the correct action, because assisting the client to a prone position every 4 hr can prevent hip flexion contractures and promote the range of motion of the hip joint. The client should lie prone for 20 to 30 minutes at a time, with the residual limb extended.
Choice C reason: This is an incorrect action, because reapplying a bandage to the residual limb every 12 hr can increase the risk of infection and delay the healing of the wound. The bandage should be changed only when it is soiled or loose, and under sterile technique.
Choice D reason: This is an incorrect action, because applying dressings to the site in a proximal-to-distal direction can cause edema and impair the circulation to
Correct Answer is C
Explanation
Choice A reason: This is an incorrect action, because covering the insertion site with a hydrocolloid dressing can prevent air from escaping and cause a subcutaneous emphysema, which is a complication of chest tube removal. The insertion site should be covered with a sterile gauze dressing and taped on three sides.
Choice B reason: This is an important action, but not the first one. The nurse should provide pain medication before removal, not immediately after, to reduce the discomfort and anxiety of the client.
Choice C reason: This is the correct action, because auscultating the lungs after removal can help assess the respiratory status and detect any signs of pneumothorax, such as diminished or absent breath sounds.
Choice D reason: This is an incorrect action, because delegating removal of the chest tube to an AP is beyond the scope of practice and can cause harm to the client. The removal of the chest tube should be performed by the nurse or the provider.
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