at a health screening clinic a nurse is educating a young woman about breast self examination bse the nurse determines that the client demonstrates un

NCLEX-PN

Health Promotion and Maintenance NCLEX PN Questions

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. A nurse is supervising a student in preparing the physical environment for an interview with a client. Which action by the student is correct?

A. Setting the room temperature at a comfortable level
B. Placing a chair for the client across from the nurse's desk
C. Providing seating for the client so that the client faces a strong light
D. Setting up seating so that the client and nurse are not at eye level

Correct answer: A

Rationale: When preparing the physical environment for an interview with a client, it is crucial to ensure the client's comfort. Setting the room temperature at a comfortable level is essential for the client's well-being. Additionally, providing privacy, sufficient lighting, and removing distractions are crucial factors. It is recommended to maintain a distance of around 4 to 5 feet between the client and the nurse. Seating should be arranged so that the client and nurse are at eye level to facilitate effective communication and prevent barriers. Placing a chair across from the nurse's desk may create a physical barrier, positioning the client to face a strong light can be uncomfortable and distracting, and setting up seating so that the client and nurse are not at eye level may impede effective communication.

3. 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.

4. During a well-baby examination, the nurse measures the head circumference, and it is the same as the chest circumference. On the basis of this measurement, what action should the nurse take?

A. Document these measurements in the infant's health care record.
B. Tell the mother that the infant is growing faster than expected.
C. Suggest to the health care provider that a skull x-ray be performed.
D. Report the presence of hydrocephalus to the health care provider.

Correct answer: A

Rationale: The head circumference growth rate during the first year is approximately 0.4 inches (1 cm) per month. By 10 to 12 months of age, the infant's head and chest circumferences are equal. In this case, where the head circumference matches the chest circumference, it is a normal finding in infants around 10-12 months. Therefore, the most appropriate action is to document these measurements in the infant's health care record. Suspecting hydrocephalus or suggesting a skull x-ray would be premature and not indicated based on this measurement. Similarly, telling the mother that the infant is growing faster than expected is not accurate and could cause unnecessary concern.

5. Which condition is associated with inadequate intake of vitamin C?

A. rickets
B. marasmus
C. kwashiorkor
D. scurvy

Correct answer: D

Rationale: Scurvy is indeed associated with inadequate intake of vitamin C. Vitamin C deficiency leads to scurvy, which is characterized by weakness, anemia, gum disease, and skin hemorrhages. Choices A, B, and C are incorrect because rickets is caused by vitamin D deficiency, marasmus is due to severe malnutrition leading to wasting, and kwashiorkor is a form of severe protein-energy malnutrition.