A 72-year-old retired saleswoman comes to your office, complaining of a bloody discharge from her left breast for 3 months. She denies any trauma to her breast. Her past medical history includes high blood pressure and abdominal surgery for colon cancer. Her aunt died of ovarian cancer and her father died of colon cancer. Her mother died of a stroke. The patient denies tobacco, alcohol, or drug use. She is a widow and has three healthy children. On examination her breasts are symmetric, with no skin changes. You are able to express bloody discharge from her left nipple. You feel no discrete masses, but her left axilla has a hard, 1-cm fixed node. The remainder of her heart, lung, abdominal, and pelvic examinations are unremarkable. What cause of nipple discharge is the most likely in her circumstance?

Correct Answer: B

Rationale: In this case, the most likely cause of the bloody discharge from the left breast in a 72-year-old woman with a history of breast cancer in her family and a palpable axillary node is breast cancer (Option B). This choice is supported by the patient's age, family history, presence of a palpable axillary node, and the symptom of bloody discharge, which are all red flags for malignancy. Option A, benign breast abnormality, is less likely given the presence of a fixed axillary node and the duration and nature of the discharge. Galactorrhea (Option C) is characterized by milky discharge and is not associated with bloody discharge or axillary node findings. Educationally, this scenario underscores the importance of considering a comprehensive history, including family history, along with physical examination findings to guide diagnostic decision-making in patients presenting with breast concerns. It also highlights the significance of recognizing red flags that warrant further investigation for malignancy, such as in this case.

Correct Answer: C

Rationale: In a health assessment, mental status evaluation is crucial for understanding a patient's overall well-being. Option C, observing the patient and inferring health or dysfunction, is the correct activity for assessing mental status during an examination. This is because observing the patient's behavior, speech, and overall demeanor can provide valuable insights into their mental functioning, emotional state, and cognitive abilities. It allows the nurse to assess for signs of alertness, orientation, memory, mood, and thought processes, which are essential components of mental status evaluation. Examining the patient's electroencephalogram (Option A) is not typically used to assess mental status during a routine examination. An EEG is a test that measures electrical activity in the brain and is primarily used to diagnose conditions like seizures or sleep disorders. Observing the patient as they perform an IQ test (Option B) is more focused on assessing cognitive abilities rather than overall mental status. While IQ tests provide information about a person's intellectual functioning, they do not capture the full spectrum of mental status evaluation, including emotional and behavioral aspects. Examining the patient's response to a specific set of questions (Option D) is a component of assessing mental status, particularly cognitive functions like attention, memory, and comprehension. However, relying solely on a set of questions may not provide a comprehensive understanding of the patient's mental status as it may miss non-verbal cues and behavioral indicators that are crucial in mental health assessment. In an educational context, understanding the correct method for assessing mental status is essential for nurses and healthcare professionals to provide holistic care. By honing observational skills and learning how to interpret behavioral cues, nurses can gather valuable information about a patient's mental well-being, leading to more accurate assessments and tailored interventions.

Correct Answer: C

Rationale: In this scenario, the correct answer is C - "Take this pill? The pill is red. I see red. Red velvet is soft, soft as a baby's bottom." This response demonstrates flight of ideas, which is a rapid shifting in thoughts that are loosely connected or unrelated. The patient jumps from one idea to another without a logical progression. Option A is incorrect because although there is some repetition, it does not show the same level of disconnected thoughts as seen in flight of ideas. Option B is a random list of words and does not demonstrate a rapid shift in thoughts. Option D shows repetitive behavior but lacks the same level of tangential and loosely connected thoughts seen in flight of ideas. Educationally, understanding flight of ideas is crucial in mental health assessment as it can be a symptom of conditions like mania or schizophrenia. It is important for healthcare professionals to recognize these signs to provide appropriate care and intervention for patients experiencing these symptoms. Learning to identify and differentiate between various thought patterns is a key component of mental health assessment skills for nurses and other healthcare providers.

Correct Answer: A

Rationale: The correct response, option A, "You're afraid you might lose your breast?" is the most therapeutic because it demonstrates active listening and empathy towards the patient's emotional state. By reflecting the patient's feelings back to her, the nurse shows understanding and opens up a supportive dialogue, allowing the patient to express her fears and concerns. Option B, "No, I'm not sure what you are talking about," is dismissive and invalidating of the patient's emotions, which can worsen the patient's distress. This response lacks empathy and fails to address the patient's immediate emotional needs. Option C, "I'll wait here until you get yourself under control, and then we can talk," is insensitive and implies impatience. It disregards the patient's current emotional state and fails to offer immediate support or comfort. Option D, "I can see that you are very upset. Perhaps we should discuss this later," is also not as therapeutic as option A. It postpones the conversation and does not actively engage with the patient's feelings in the moment, missing an opportunity to provide immediate emotional support and connection. In an educational context, this scenario highlights the importance of therapeutic communication skills in nursing practice. Active listening, empathy, and validation of patient emotions are crucial in establishing trust and rapport with patients, especially in sensitive situations like delivering a cancer diagnosis. Nurses must prioritize patient-centered care and emotional support to effectively meet the holistic needs of patients.

Correct Answer: C

Rationale: The best way to begin assessing a 2-year-old child is by allowing the child to keep a toy or blanket for comfort, which is option C. This approach is rooted in child development principles and pediatric nursing best practices. Children at this age can be fearful or anxious in unfamiliar environments, so providing them with a familiar object like a toy or blanket can help establish trust and create a sense of security during the assessment. This can help the child feel more comfortable and cooperative, leading to a more accurate assessment of their vital signs. Option A, asking the parent to place the child on the exam table, may cause distress to the child by separating them from the parent and can lead to resistance during the assessment. Option B, having the child remove all clothing before the exam, may be overwhelming and invasive for a young child, potentially leading to increased anxiety and resistance. Option D, directly interacting with the child and ignoring the parent, is not recommended as young children often rely on their parents for security and comfort, especially in unfamiliar situations. In pediatric nursing, it is essential to involve parents in the care of their children and to prioritize the child's emotional well-being during assessments. In conclusion, allowing the child to keep a toy or blanket for comfort is the most appropriate way to begin assessing a 2-year-old child as it promotes a sense of security, comfort, and cooperation, ultimately facilitating a successful health assessment.