A nurse palpates a small lump in a woman's breast. The most appropriate action by the nurse is to
a. ask the client if any relatives have had breast cancer.
b. document its characteristics and the position of the client.
c. refer the client for a same-day mammography.
d. tell the client to return next month for a repeat examination.
B
The nurse should note the lump's characteristics and the position of the client when palpated. The areola can be used as a reference point. History should precede physical examination. The client may or may not need mammography, depending on many factors, including if the lump has been noted and examined previously and is unchanged. Returning next month for follow-up, again, may or may not be appropriate.
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Nursing responsibilities when applying and monitoring restraints include: Standard Text: Select all that apply
1. Assess the restraint every 2–4 hours. 2. Apply a restraint such that it can be released quickly in case of an emergency. 3. Provide emotional support verbally and through touch. 4. Ensure that limb restraints are applied securely but not too tightly. 5. Record interventions at the end of the shift.
A client prescribed lithium (Eskalith) asks the nurse why they should continue to use salt. Which response should the nurse provide the client?
A. "You should use sea salt to avoid lithium (Eskalith) toxicity. B. "You must use table salt or your kidneys will retain lithium (Eskalith), and you will become toxic." C. "The amount of salt is not important; just increase your table salt if you notice signs of lithium (Eskalith) toxicity." D. "Salt is very important to avoid lithium (Eskalith) toxicity, but not as important as drinking 1 to 1.5 L of water per day."
A patient is given a prescription for oxycodone/acetaminophen (Vicodin), two tablets to be taken every 4 to 6 hours as needed for pain. What should the nurse include when teaching about this medication?
a. "You shouldn't take this more than every 4 hours, because oxycodone will cause respiratory depression." b. "Be careful not to take this more than every 4 hours, because Vicodin always relieves pain for at least 4 hours." c. "Oxycodone and acetaminophen interact to form a dangerous metabolite if they are taken less than 4 hours apart." d. "It is important to not to take this more often than prescribed, because acetaminophen can cause dangerous side effects if taken more frequently."
The nurse is making a home visit to a Korean family whose daughter gave birth 6 weeks earlier. She finds the daughter in bed with a severe headache
The daughter's father is holding her hand and is pressing different parts of the hand and lower arm. The mother explains that the father is trying to cure the headache by using pressure points. The nurse's best response would be to a. Tell the father to stop and give the daughter Tylenol. b. Ask the mother and/or father to explain the procedure. c. Explain to the father that what he is doing will not work. d. Let the father finish and then give the daughter Tylenol.