An adolescent female client comes to the clinic troubled by breast tenderness before her menstrual periods. On examination, the nurse notes generalized lumpiness of both breasts with no discrete masses and no nipple discharge. Which action should the nurse take?
Suggest that the client schedule a mammogram after her next menstrual period.
Explain to the client that an ultrasound of the breast will likely be necessary.
Assure the client that her breasts are normal, and advise annual evaluations.
Request a return visit after her menstrual period for a breast exam re-check.
The Correct Answer is C
Answer: C. Assure the client that her breasts are normal, and advise annual evaluations.
Rationale:
A. Suggest that the client schedule a mammogram after her next menstrual period:
A mammogram is generally not indicated for adolescents unless there are specific concerns such as a family history of breast cancer or the presence of abnormal findings. Given the client's age and the findings of generalized lumpiness without discrete masses, a mammogram would not be the most appropriate action at this stage.
B. Explain to the client that an ultrasound of the breast will likely be necessary:
An ultrasound is typically used for further evaluation if discrete masses are found or if there are unusual characteristics in the breast tissue. In this case, the generalized lumpiness is likely related to normal physiological changes, making an ultrasound unnecessary at this time.
C. Assure the client that her breasts are normal, and advise annual evaluations:
The findings of generalized lumpiness and tenderness before menstruation are consistent with normal physiological changes associated with the menstrual cycle, often due to hormonal fluctuations. Providing reassurance and advising annual evaluations is appropriate, as it addresses the client's concerns and promotes confidence in her breast health without unnecessary interventions.
D. Request a return visit after her menstrual period for a breast exam re-check:
While a follow-up can be beneficial, it may not be necessary in this case since the findings are typical of normal breast tissue changes associated with the menstrual cycle. Reassuring the client and encouraging annual evaluations is a more effective approach than suggesting an unnecessary follow-up visit.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) White blood cell count (WBC): While an elevated WBC count can indicate infection or inflammation, it is not directly related to melena. Melena, which is black, tarry stool, is usually an indication of gastrointestinal bleeding, specifically from the upper GI tract.
B) Hematocrit: Hematocrit is a measure of the proportion of red blood cells in the blood. Monitoring hematocrit is essential in the context of melena because gastrointestinal bleeding can lead to a decrease in red blood cells, causing anemia. Therefore, tracking hematocrit levels helps assess the severity of blood loss and the client's overall oxygen-carrying capacity.
C) Glucose: Blood glucose levels are not directly related to melena. Monitoring glucose is crucial for managing diabetes and other metabolic disorders but does not provide information about bleeding or anemia.
D) Blood urea nitrogen (BUN): While BUN levels can increase with gastrointestinal bleeding due to the breakdown of blood proteins in the gut, it is not the primary test to monitor for the effects of bleeding. Hematocrit is more directly indicative of blood loss.
Correct Answer is C
Explanation
Answer: C. Assure the client that her breasts are normal, and advise annual evaluations.
Rationale:
A. Suggest that the client schedule a mammogram after her next menstrual period:
A mammogram is generally not indicated for adolescents unless there are specific concerns such as a family history of breast cancer or the presence of abnormal findings. Given the client's age and the findings of generalized lumpiness without discrete masses, a mammogram would not be the most appropriate action at this stage.
B. Explain to the client that an ultrasound of the breast will likely be necessary:
An ultrasound is typically used for further evaluation if discrete masses are found or if there are unusual characteristics in the breast tissue. In this case, the generalized lumpiness is likely related to normal physiological changes, making an ultrasound unnecessary at this time.
C. Assure the client that her breasts are normal, and advise annual evaluations:
The findings of generalized lumpiness and tenderness before menstruation are consistent with normal physiological changes associated with the menstrual cycle, often due to hormonal fluctuations. Providing reassurance and advising annual evaluations is appropriate, as it addresses the client's concerns and promotes confidence in her breast health without unnecessary interventions.
D. Request a return visit after her menstrual period for a breast exam re-check:
While a follow-up can be beneficial, it may not be necessary in this case since the findings are typical of normal breast tissue changes associated with the menstrual cycle. Reassuring the client and encouraging annual evaluations is a more effective approach than suggesting an unnecessary follow-up visit.
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