CH4 - correct answer
54. A 20-year-old woman tells the nurse that she performs breast self-examination (BSE) on a regular basis. The nurse evaluates
... [Show More] the woman's understanding of BSE and ability to perform the technique correctly. Which actions by the woman indicate that she needs further instruction regarding BSE? (Circle all that apply.)
A. Performs BSE every month on the first day of her menstrual cycle.
B. Observes the size of her breasts, direction of her nipples, and appearance of her skin, including the presence of dimpling, when looking at her breasts in the mirror.
C. Lies down on a bed and puts a pillow under the shoulder of the breast she is going to palpate. Then she places the arm on that side under her head.
D. Uses the tips of two fingers to palpate her breast.
E. Palpates her breast, using an overlapping circular pattern around her entire breast.
F. Palpates her breasts again, including up into her axillae, while taki - correct answer Choices A and D are correct; a woman should perform BSE every month at the end of menstruation when the breasts are the least tender; she should use the finger- pads of her three middle fingers for palpation.
55. When palpating the small breasts of a young, slender woman the nurse should:
A. Wear clean gloves
B. Lift the hands when moving from one segment of the breast to another
C. Use both hands
D. Follow a systematic, overlapping pattern - correct answer Choice D is correct; clean gloves are required only if open lesions are present and when compressing the nipple if discharge is anticipated; fingers should not be lifted; two hands are used for women with large, pendulous breasts.
56. A nurse instructed a female client regarding vulvar self-examination (VSE). Which statement made by the client indicates that further instruction is needed?
A. "I will perform this examination at least once a month, especially if I change sexual partners or am sexually active."
B. "I will become familiar with how my genitalia look and feel so that I will be able to detect changes."
C. "I will use the examination to determine when I should get medications at the pharmacy for infections."
D. "I will wash my hands thoroughly before and after I examine myself." - correct answer 56. Choice C is correct; self-examination should not be used for self-diagnosis but rather to detect early changes, which would call for the guidance of a health care provider.
57. A women's health nurse practitioner is going to perform a pelvic examination on a female client. Which nursing action would be least effective in enhancing the client's comfort and relaxation during the examination?
A. Encourage the client to ask questions and express feelings and concerns before and after the examination.
B. Ask the client questions as the examination is performed.
C. Allow the client to keep her shoes and socks on when placing her feet in the stirrups.
D. Instruct the client to place her hands over her diaphragm and take deep, slow breaths. - correct answer 57. Choice B is correct; do not ask questions during the examination because it may distract the client, inter- fering with relaxation measures she may be using; offer explanations only as needed during the exami- nation.
58. When assessing women it is important for a nurse to keep in mind the possibility that they are victims of violence. The nurse should:
A. Use an abuse assessment screen during the assessment of every woman
B. Recognize that abuse rarely occurs during pregnancy
C. Assess a woman's legs and back as the most commonly injured areas
D. Notify the woman's partner immediately if abuse is suspected - correct answer 58. Choice A is correct; all women should be screened because abuse can happen to any woman; abuse can begin or escalate during pregnancy; the most com- monly injured sites are head, neck, chest, abdomen, breasts, and upper extremities. If abuse is suspected, the nurse needs to assess further to encourage disclo- sure [Show Less]