The nurse leading an educational session is describing self-examination of the breast. The nurse tells the womens group to raise their arms and inspect their breasts in a mirror. A member of the womens group asks the nurse why raising her arms is necessary. What is the nurses best response?

Correct Answer: A

Rationale: The correct answer is A: It helps to spread out the fat that makes up your breast. Raising the arms during breast self-examination stretches the breast tissue, making it easier to detect any lumps or abnormalities. This action also helps to distribute the breast tissue evenly, providing a clearer view of the entire breast. This method ensures a more thorough examination and increases the chances of detecting any changes in the breast tissue early on. Summary of incorrect choices: B: It allows you to simultaneously assess for pain - Although assessing for pain is important, raising the arms specifically helps with spreading out the breast tissue, not necessarily for assessing pain. C: It will help to observe for dimpling more closely - While observing for dimpling is important, raising the arms is primarily for spreading out the breast tissue, not for observing dimpling. D: This is what the American Cancer Society recommends - While recommendations from reputable sources are important, the rationale behind raising the arms during breast self-examination is not solely

Correct Answer: B

Rationale: The correct answer is B: Cholesteatoma. A red blemish behind the tympanic membrane is indicative of a cholesteatoma, which is a noncancerous cyst in the middle ear. This occurs due to the accumulation of skin cells and debris in the middle ear space. Other choices (A, C, D) are not associated with a red blemish on otoscopy. An acoustic tumor (A) typically presents as a slow-growing mass on the vestibulocochlear nerve. Facial nerve neuroma (C) involves the facial nerve and does not typically cause a red blemish. Glomus tympanicum (D) is a vascular tumor arising from the middle ear but does not usually present as a red blemish.

Correct Answer: A

Rationale: Step 1: The nurse is auditing and monitoring patients' health records, indicating a review process. Step 2: By reviewing patients' health records, the nurse is determining the degree to which standards of care are met. Step 3: This action aligns with auditing, which involves assessing if care meets established standards. Step 4: The other choices are incorrect because they do not directly involve auditing or monitoring for compliance with standards of care. Choice B talks about undocumented care, C about reimbursement, and D about treatment outcomes comparison.

Correct Answer: B

Rationale: The correct answer is B: Circumcision. Paraphimosis occurs when the foreskin is retracted behind the glans and cannot be returned to its original position. Once the inflammation and edema subside, circumcision is typically indicated to prevent recurrence. This procedure removes the foreskin, reducing the risk of future paraphimosis episodes. Needle aspiration of the corpus cavernosum (A) is not indicated for paraphimosis. Abstinence from sexual activity for 6 weeks (C) is not a standard treatment for paraphimosis. Administration of vardenafil (D) is used for erectile dysfunction and not indicated for paraphimosis.

Correct Answer: C

Rationale: The correct answer is C: Meaningful living during terminal illness is best supported in the home. This is because hospice care focuses on providing compassionate care and support in the comfort of the patient's own home, which can enhance quality of life and dignity. Being in a familiar and comfortable environment allows the patient to receive personalized care and emotional support from family members. Options A, B, and D are incorrect because hospice care emphasizes comfort and quality of life over technologic interventions, designated facilities, and prolonging physiologic dying. Ultimately, the goal of hospice care is to prioritize the patient's emotional and physical well-being during the end stages of life.

Correct Answer: A

Rationale: The correct answer is A: Leukopenia. Taxol and Paraplatin are known to cause bone marrow suppression, leading to decreased white blood cell counts. Leukopenia can increase the patient's risk of infection, so monitoring for signs of infection is crucial. Metabolic acidosis, hyperphosphatemia, and respiratory alkalosis are not typically associated with Taxol and Paraplatin chemotherapy.

Correct Answer: A

Rationale: Correct Answer: A Rationale: Abdominal cramping in a patient on enteral feedings could indicate feeding intolerance. The nurse's initial action should be to slow down the rate of the tube feeding to allow the patient's gastrointestinal tract to adjust gradually. This helps reduce the risk of further complications and allows for better tolerance. Slowing the rate is a safe and effective intervention that can help alleviate the abdominal cramping without causing additional stress on the patient's digestive system. Summary of Incorrect Choices: B: Instilling cold formula is not a recommended practice and can potentially cause harm or discomfort to the patient. C: Changing to a high-fat formula may exacerbate the abdominal cramping as it can be harder to digest for some patients. D: Consulting with the healthcare provider about prokinetic medication should come after trying less invasive interventions such as slowing the rate of tube feeding.

Correct Answer: B

Rationale: The correct answer is B: Protect the patient's airway. In anaphylaxis, airway compromise can lead to respiratory distress and even respiratory arrest. The priority is to ensure the patient has a patent airway to maintain oxygenation. This can be achieved through interventions such as positioning, oxygen therapy, and potentially intubation if needed. Monitoring the patient's level of consciousness (A) is important but secondary to ensuring airway patency. Providing psychosocial support (C) is not the immediate priority in anaphylaxis. Administering medications (D) is also important but only after ensuring the airway is protected.

Correct Answer: C

Rationale: The correct answer is C: Clear fluid from vagina. In threatened abortion, there is vaginal bleeding but the cervix is closed, indicating the possibility of the pregnancy continuing. If clear fluid is present, it suggests rupture of the amniotic sac, leading to inevitable abortion. Backache (A) and pelvic pressure (D) can be common symptoms in both threatened and inevitable abortion. A rise in hCG level (B) alone does not indicate a change from threatened to inevitable abortion.