A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is the best for the nurse to provide?
A) Check it
... [Show More] again in one month, and if it is still there schedule an appointment.
B) Most lumps are benign, but it is always best to come in for an examination.
C) Try not to worry too much about it, because usually, most lumps are benign.
D) If you are in your menstrual period it is not a good time to check for lumps.
(Ans- B) Most lumps are benign, but it is always best to come in for an examination.
(B) provides the best response because it addresses the client's anxiety most effectively and encourages prompt and immediate action for a potential problem. (A) postpones treatment if the lump is malignant, and does not relieve the client's anxiety. (C and D) provide false reassurance and do not help relieve anxiety.
The nurse should be correct in withholding a dose of digoxin in a client with congestive heart failure without specific instruction from the healthcare provider if the client's
A) serum digoxin level is 1.5.
B) blood pressure is 104/68.
C) serum potassium level is 3.
D) apical pulse is 68/min.
(Ans- C) serum potassium level is 3.
Hypokalemia (C) can precipitate digitalis toxicity in persons receiving digoxin which will increase the chance of dangerous dysrhythmias (normal potassium level is 3.5 to 5.5 mEq/L). The therapeutic range for digoxin is 0.8 to 2 ng/ml (toxic levels= >2 ng/ml); (A) is within this range. (B) would not warrant the nurse withholding the digoxin. The nurse should withhold the digoxin if the apical pulse is less than 60/min (D).
In assessing a client diagnosed with primary hyperaldosteronism, the nurse expects the laboratory test results to indicate a decreased serum level of which substance?
A) Sodium.
B) Antidiuretic hormone.
C) Potassium.
D) Glucose.
(Ans- C) Potassium.
Clients with primary aldosteronism exhibit a profound decline in the serum levels of potassium (C) (hypokalemia)--hypertension is the most prominent and universal sign. (A) is normal or elevated, depending on the amount of water reabsorbed with the sodium. (B) is decreased with diabetes insipidus. (D) is not affected by primary aldosteronism.
Based on the analysis of the client's atrial fibrillation, the nurse should prepare the client for which treatment protocol?
A) Diuretic therapy.
B) Pacemaker implantation.
C) Anticoagulation therapy.
D) Cardiac catheterization.
(Ans- C) Anticoagulation therapy.
The client is experiencing atrial fibrillation, and the nurse should prepare the client for anticoagulation therapy (C) which should be prescribed before rhythm control therapies to prevent cardioembolic events which result from blood pooling in the fibrillating atria. (A, B, and D) are not indicated.
Which information about mammograms is most important to provide a post-menopausal female client?
A) Breast self-examinations are not needed if annual mammograms are obtained.
B) Radiation exposure is minimized by shielding the abdomen with a lead-lined apron.
C) Yearly mammograms should be done regardless of previous normal x-rays.
D) Women at high risk should have annual routine and ultrasound mammograms.
(Ans- C) Yearly mammograms should be done regardless of previous normal x-rays. [Show Less]