The nurse is discussing Breast Self Examination (BSE) with a postmenopausal client. What instructions should the nurse give to the client about the correct time to perform BSE?

Daily, during the shower or bath

One week after the menstrual period

On the same day every month

Weekly, at the client's convenience

Answer and Explanation

The Correct Answer is C

A) Daily, during the shower or bath:
This is incorrect. Performing a breast self-examination (BSE) daily is not necessary. The goal of BSE is to check for any changes over time, not to examine the breasts every day. It's more effective to perform the exam regularly at a consistent time each month.

B) One week after the menstrual period:
This is incorrect. This instruction is relevant for pre-menopausal women, where the hormonal changes associated with the menstrual cycle can cause breast tissue to feel lumpy or swollen. The best time for them to perform a BSE is one week after the menstrual period ends when the breasts are least likely to be swollen or tender. However, for postmenopausal women, this is not necessary, as their hormonal levels are stable throughout the month.

C) On the same day every month:
This is the correct answer. For postmenopausal women, who no longer have menstrual cycles, the best time to perform a breast self-exam is on the same day every month. This ensures consistency and makes it easier for the client to notice any changes in the breast tissue over time. The day chosen should be one that is convenient and easy to remember, and it does not matter whether it is during the shower or bath, as long as the examination is done regularly.

D) Weekly, at the client's convenience:
This is incorrect. While performing a BSE weekly is not necessary, the key is consistency rather than frequency. Performing the exam monthly is sufficient, and it should be on a specific day each month, rather than at the client’s convenience on an irregular basis.

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Correct Answer is A

Explanation

A) The partner places the client's arm above the level of the client's heart:
This action indicates that further instruction is needed. For an accurate blood pressure reading, the arm should be at heart level (approximately at the level of the fourth intercostal space) when taking the measurement. If the arm is placed above the heart, it can result in a falsely low reading. If the arm is positioned below the heart, it can lead to a falsely high reading. The position of the arm is crucial for obtaining an accurate blood pressure measurement.

B) The partner centres the cuff bladder over the client's brachial artery:
This is the correct technique. The cuff bladder should be centered over the brachial artery for accurate readings. Proper cuff placement ensures the best possible measurement and avoids errors in reading due to misplacement.

C) The partner wraps the blood pressure cuff around the client's arm using firm pressure:
This is also correct. The cuff should be wrapped snugly around the upper arm with firm pressure to ensure that it fits properly. If the cuff is too loose or too tight, it may give inaccurate readings. However, it should never be excessively tight.

D) The partner checks the instrument gauge to ensure the reading starts at zero:
This is a correct action. Before using a blood pressure cuff, it is important to check that the gauge starts at zero when the cuff is deflated. This ensures the manometer is calibrated properly and provides accurate readings. If the gauge does not start at zero, it should be recalibrated or replaced.

A. When the client is obese B. When part of the lung is obstructed or collapsed C. When accessory muscles are used to facilitate respiratory effort D. When bulging of the intercostal spaces is present

Correct Answer is B

Explanation

A) When the client is obese:
While obesity can affect the overall ease of breathing due to increased fat tissue around the chest and abdomen, it is not a direct cause of unequal chest expansion. Obesity can limit the depth of breath and potentially make it harder for the chest to expand fully, but it would not typically cause asymmetry in the movement of the chest on one side. Unequal chest expansion is more likely to occur due to underlying respiratory or structural issues.

B) When part of the lung is obstructed or collapsed:
This is the most accurate reason for unequal chest expansion. If part of the lung is obstructed (such as with a mucous plug or foreign body) or collapsed (as in the case of pneumothorax or atelectasis), it prevents that area of the lung from fully expanding during inspiration. As a result, the affected side of the chest will expand less than the opposite side. This can be a critical finding and warrants immediate further investigation to determine the cause and ensure appropriate treatment.

C) When accessory muscles are used to facilitate respiratory effort:
While the use of accessory muscles (e.g., the sternocleidomastoid, scalene, and intercostal muscles) often occurs during labored breathing, it does not specifically result in unequal chest expansion. Accessory muscle use typically occurs in conditions like severe asthma, chronic obstructive pulmonary disease (COPD), or respiratory distress, where there is an increased effort to breathe, but it doesn't cause asymmetry in the chest's movement. Unequal chest expansion is usually related to a localized problem in the lung or pleura, not the general use of muscles.

D) When bulging of the intercostal spaces is present:
Bulging of the intercostal spaces may suggest increased pressure in the pleural space, such as in the case of a pleural effusion or severe respiratory distress. However, while bulging intercostal spaces can be a sign of a respiratory condition, it is not typically associated with unequal chest expansion. Instead, bulging could indicate that the lung or chest wall is under stress or that there is fluid accumulation, which would lead to other physical findings like decreased breath sounds or dullness to percussion, but it does not directly cause unequal expansion. Unequal expansion is more likely to occur when part of the lung is obstructed or collapsed

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The nurse is discussing Breast Self Examination (BSE) with a postmenopausal client. What instructions should the nurse give to the client about the correct time to perform BSE?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a client's partner about how to obtain a blood pressure reading. Which of the following actions by the partner should indicate that further instruction is needed?

Correct Answer is A

Explanation

A nurse is performing an assessment of an adult client and observes unequal chest expansion. The nurse should recognize that unequal chest expansion I occur for which reason?

Correct Answer is B

Explanation

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