A patient who is attending a family planning clinic is instructed in breast self-examination by a nurse.
Which statement by the patient would indicate that she understands the instructions?
“I will perform breast self-examination on the first day of my period.”.
“I will palpate my breasts to assure that any lumps that are present are present in both breasts.”.
“I will palpate my breasts using the padded sections of my fingers.”.
“I will look at my breasts while standing sideways in front of the mirror.”.
The Correct Answer is C
The correct answer is choice C. The patient should palpate her breasts using the padded sections of her fingers. This is the recommended technique for breast self-examination, as it allows the patient to feel any changes or lumps in the breast tissue.
Choice A is wrong because the patient should perform breast self-examination at the same time each month, preferably a few days after the menstrual period ends when the breasts are less likely to be swollen or tender.
Choice B is wrong because the patient should not assume that any lumps that are present in both breasts are normal. Some breast cancers can affect both breasts, and any new or unusual lumps should be reported to a doctor.
Choice D is wrong because the patient should look at her breasts while standing in front of the mirror with her arms at her sides, raised overhead, and pressed firmly on her hips. She should also look for any changes in the shape, size, color, or texture of her breasts and nipples.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The correct answer is choice D. Apply petrolatum to the patient’s perineum.This is because petrolatum can help soothe and protect the perineal area, which may be swollen, bruised, or have stitches after a vaginal delivery.Applying petrolatum can also prevent the pad from sticking to the wound and causing more pain.
Choice A is wrong because observing the patient for vaginal discharge of bright red blood is not a specific action for perineal care.Bright red blood may indicate postpartum hemorrhage, which requires immediate medical attention.
Choice B is wrong because assessing the patient’s vaginal tone is not a priority action for perineal care.Vaginal tone may be reduced after childbirth due to stretching of the pelvic floor muscles, but this can improve with time and exercises.
Choice C is wrong because massaging the patient’s perineum is not recommended for perineal care.Massaging the perineum may cause more trauma and discomfort to the area, especially if there are stitches or hemorrhoids.Massaging the fundus (the top of the uterus) may be done to help it contract and prevent bleeding, but this is different from massaging the perineum.
Correct Answer is A
Explanation
The correct answer is choice A. Maintaining the infants’ airways is the nurse’s priority when caring for a set of twins delivered by cesarean delivery.This is because twins are more likely to be born early and need special care after birth than single babies.They may have breathing difficulties or low oxygen levels and require oxygen therapy or ventilation.
The nurse should assess the infants’ respiratory status and intervene as needed.
Choice B is wrong because keeping the infants in a warm, draft-free environment is important but not as urgent as ensuring their airways are clear and they are breathing well.Premature twins may have trouble regulating their body temperature and need to be kept warm, but this can be done after their airways are secured.
Choice C is wrong because placing identification bands on the infants is a standard procedure but not a priority.
The nurse should make sure the infants are correctly identified and matched with their mother, but this can be done after their vital signs are stable.
Choice D is wrong because monitoring the infants’ vital signs is also important but not as urgent as maintaining their airways.
The nurse should check the infants’ heart rate, blood pressure, temperature and blood sugar levels regularly, but this can be done after their respiratory status is assessed and managed.
Normal ranges for vital signs in newborns are:
• Heart rate: 100 to 160 beats per minute
• Blood pressure: 50 to 75 mm Hg systolic and 30 to 45 mm Hg diastolic
• Temperature: 36.5 to 37.5°C (97.7 to 99.5°F)
• Blood sugar: 40 to 80 mg/dL
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