1.Which of these statements,if made by a female client who has discovered a lump in her breast,would indicate a risk factor associated with cancer of the breast?
A.“I had my first menstrual period when I was 16.”
B.“I got hit in the chest with a hard ball some time ago.”
C.“I breast-fed three children.”
D.“I had my first baby when I was 35 years old.”
2.A patient is scheduled for a below-the-knee (BK) amputation.After signing the consent form, the patient asks the nurse numerous questions about the procedure. Based on the patient’s lack of understanding of the procedure, which of these actions by the nurse is appropriate?
A.Assure the patient that the concerns about the surgery are valid.
B.Provide diversional activities to allay the patient’s fears about the surgery.
C.Have the primary care provider explain the surgery to the patient again.
D.Describe the details of the surgery to clarify the patient’s misconceptions.
3.The nurse finds a patient having a seizure. In addition to protect the patient, which of these actions should the nurse take?
A.Insert an oral airway into the patient.
B.Take the patient’s carotid pulse.
C.Restrain the patient’s extremities.
D.Observe the patient for progression of motor activity.
1.Key: D Client Need: Health Promotion and Maintenance
D.Women who had their first child after age 30 have a slightly higher breast cancer risk.
A.Early menstruation (before age 12) is a risk factor.
B. Trauma is not a risk factor for breast cancer.
C.Breast-feeding lowers the risk of breast cancer.
2.Key: C Client Need: Management of Care
C.Informed consent is required prior to a surgical procedure.If a patient still does not understand,the primary care provider should respond to the patient’s questions and concerns.
A.The patient’s concerns may be valid but the patient’s understanding of the procedure should be the main concern.
B.The patient’s lack of understanding should be addressed first.
D.Informing the patient about the surgery, the procedure, and the possible complications is the role of the primary care provider.
3.Key: D Client Need: Safety and Infection Control
D.The nurse should observe the progression and length of the seizure and note the information in the patient’s chart.
A.The nurse should not attempt oral airway insertion during a seizure –this may result in injury to the patient.
B.This is not a necessary action. The patient’s vital signs can be taken after the seizure subsides.
C.The patient should not be restrained during a seizure. This may cause injury to the patient.