Nursing Elites

1. At a health screening clinic, a nurse is educating a young woman about breast self-examination (BSE). The nurse determines that the client demonstrates understanding when she makes which statement?

• A. BSE should be performed monthly after the menstrual period.
• B. BSE is performed after the menstrual period.
• C. Monthly BSE is a recommended method for early detection of breast cancer.
• D. Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down.

Correct answer: D

Rationale: The correct answer is 'Monthly BSE includes inspection before a mirror and palpation both in the shower and while lying down.' BSE should be performed monthly after the menstrual period, not every other month or on the day menstruation begins. Performing BSE on the seventh day of the menstrual cycle when the breasts are smallest and least congested is recommended. While BSE is a useful tool for early detection, it is not the only method. Regular physical examinations and mammograms are also important. The correct technique for BSE includes inspecting the breasts in front of a mirror, palpating in the shower for easier detection, and conducting palpation while lying down for thorough examination.

2. At what age are yearly mammograms recommended to start?

• A. Yearly mammograms are recommended starting at age 25.
• B. Yearly mammograms are recommended starting at age 40.
• C. Yearly mammograms are not necessary unless there is a family history of breast cancer.
• D. Yearly mammograms are recommended starting at age 20 and continuing until menopause begins.

Correct answer: B

Rationale: The correct answer is B. The American Cancer Society recommends yearly mammograms starting at age 40 and continuing for as long as a woman is in good health. Clinical breast examination should be done about every 3 years for women in their 20s and 30s and every year for women age 40 and older. Women should know how their breasts normally look and feel and report any breast change promptly to the healthcare provider. Breast self-examination should be done monthly starting when a woman is in her 20s. Choice A is incorrect as mammograms are not recommended to start at age 25. Choice C is incorrect as yearly mammograms are still recommended even without a family history of breast cancer. Choice D is incorrect as the recommended age for starting yearly mammograms is 40, not 20.

3. An adult client undergoes various diagnostic tests to determine the pumping ability of the heart. The nurse notes that the results of these tests indicate that the client's cardiac output is 5 L/min. The nurse makes which conclusion?

• A. The client has a low cardiac output.
• B. The client has a high cardiac output.
• C. The client has a normal cardiac output.
• D. The client will need a blood transfusion.

Correct answer: C

Rationale: A cardiac output of 5 L/min falls within the normal range for a resting adult, which typically ranges between 4 and 6 L/min. Cardiac output is calculated as the stroke volume (volume of blood in each systole) multiplied by the heart rate. Therefore, a cardiac output of 5 L/min is considered normal. Choices A and B are incorrect as they misinterpret the result as either low or high, which is not the case based on the provided information. Choice D is unrelated to the client's cardiac output and thus incorrect.

4. A nurse in the healthcare provider's office is checking the Babinski reflex in a 3-month-old infant. The nurse determines that the infant's response is normal if which finding is noted?

• A. The fingers curl tightly, and the toes curl forward.
• B. The toes flare, and the big toe is dorsiflexed.
• C. There is extension of the extremities on the side to which the head is turned, with flexion on the opposite side.
• D. The infant turns to the side that is touched.

Correct answer: B

Rationale: To elicit the Babinski reflex, the nurse strokes the lateral sole of the foot from the heel to across the base of the toes. In the expected response, the toes flare, and the big toe dorsiflexes. The Babinski reflex disappears at 12 months of age. Turning to the side that is touched is the expected response when the rooting reflex is elicited. Tight curling of the fingers and forward curling of the toes is the expected response when the grasp reflex (palmar and plantar) is elicited. Extension of the extremities on the side to which the head is turned with flexion on the opposite side is the expected response when the tonic neck reflex is elicited.

5. When preparing to assist the healthcare provider in examining a client's skin with the use of a Wood light, what action should the nurse perform?

• A. Darken the room
• B. Obtain informed consent from the client
• C. Obtain a scalpel and a slide for diagnostic evaluation
• D. Obtain medication to anesthetize the skin area before proceeding with the examination

Correct answer: A

Rationale: When using a Wood light during a skin examination, the room should be darkened to enhance the visibility of fluorescence. The Wood light emits long-wavelength ultraviolet light, highlighting certain skin conditions. Darkening the room aids in better visualization. Obtaining informed consent is a crucial aspect of healthcare but not directly related to using a Wood light. Obtaining a scalpel and a slide is unnecessary for a noninvasive Wood light examination. Anesthetizing the skin area is not required as the procedure is painless and noninvasive.

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