During the breast examination of a perimenopausal woman, the NP detects a bloody spontaneous discharge from the right nipple. This indicates further evaluation:

Correct Answer: C

Rationale: The correct answer is C: An intraductal papilloma. Bloody spontaneous discharge from the nipple in a perimenopausal woman is concerning for an intraductal papilloma, which is a benign growth in the milk ducts. Further evaluation with imaging studies and possibly a biopsy is necessary to rule out malignancy. Choice A: Fibroadenoma is a common benign breast tumor but does not typically present with bloody discharge. Choice B: Polycystic breast disease is not associated with bloody discharge and is characterized by multiple fluid-filled cysts in the breast tissue. Choice D: Pituitary prolactinoma is a benign tumor of the pituitary gland that can cause elevated prolactin levels leading to nipple discharge, but it is not typically bloody and would not present with spontaneous discharge from the nipple.

Correct Answer: D

Rationale: The correct answer is D: Changes in behavior. This is the most common presenting sign of substance abuse in adolescents because substance use often leads to noticeable changes in behavior, such as irritability, mood swings, aggression, and withdrawal from family and friends. These behavioral changes are typically the first noticeable signs of substance abuse. A: Poor school performance may be a consequence of substance abuse, but it is not necessarily the most common presenting sign. B: Change in sleep habits can be a sign of substance abuse, but changes in behavior are more prominent and common. C: Increased blood pressure is a physical symptom of substance abuse, but changes in behavior are usually more readily apparent and commonly observed in adolescents with substance abuse issues.

Correct Answer: B

Rationale: The correct answer is B: Gastroesophageal reflux. Heartburn and regurgitation are classic symptoms of GERD, where stomach acid flows back into the esophagus. This causes a burning sensation in the chest and sour taste in the mouth. Hiatal hernia (A) can contribute to GERD but is not directly associated with these symptoms. Peptic ulcer disease (C) typically presents with stomach pain, not heartburn. Esophageal cancer (D) may present with difficulty swallowing and weight loss, not just heartburn and regurgitation. Therefore, choice B is the most appropriate answer.

Correct Answer: A

Rationale: Rationale for correct answer (A): Amoxicillin does not significantly interact with warfarin. It is an antibiotic that works through a different mechanism than warfarin and is not known to affect its anticoagulant activity. Summary of incorrect choices: B (Trimethoprim/sulfamethoxazole): This drug combination can enhance the effects of warfarin, increasing the risk of bleeding. C (Ciprofloxacin): Ciprofloxacin can increase warfarin's effects, leading to a higher risk of bleeding. D (Clarithromycin): Clarithromycin can interact with warfarin, potentially increasing the risk of bleeding.

Correct Answer: D

Rationale: The correct answer is D: A deviated septum. Unilateral rhinitis typically refers to inflammation in one nostril. A deviated septum is a physical obstruction in the nasal passage that affects both nostrils, not just one. Choices A, B, and C can all cause unilateral rhinitis as they specifically affect one side of the nasal passage. A foreign body in the nasal canal, a nasal polyp, and drug-induced rhinitis can all lead to inflammation and symptoms in one nostril.