HESI Case Studies Breast Cancer – Flashcards
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what is the best response by the nurse?
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"select whatever day you can best remember to perform BSE consistently each month."
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what instructions should the nurse provide?
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"when you are lying down, your arm should be positioned over your head."
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how should the nurse respond?
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"the combination of yearly CBE and monthly BSE is the best approach for early detection."
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what intervention should the nurse implement first?
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teach barb that even women with no identified risk factors are at risk
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how should the nurse respond?
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"you may experience some discomfort, but only for a few minutes."
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what is the best response by the nurse?
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"its hard to believe that this is happening, isn't it?"
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how should the nurse respond?
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"are you saying that you do not want to have surgery?"
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which nursing diagnosis should be reflected in Sandra's plan of care?
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anticipatory grieving
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what is the best response by the nurse?
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"to ensure your safety, I need to notify the surgeon of the snack you ate."
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which ethical principle has the greatest weight in the nurse's decision to inform Sandra's surgeon about the snack?
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nonmaleficence
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the nurse confirms that Sandra has signed the informed consent for surgery, but learns that Sandra does not understand the procedure for breast reconstruction that is to be performed.
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notify the surgeon that further explanation of the procedure is necessary.
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which nursing actions have the highest priority in the initial postoperative period? (select all that apply)
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-observe the Jackson-Pratt drainage device -administer a PRN dose of prescribed analgesic -monitor vital signs and pulse oximetry
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after Sandra is awake and stable, she is moved from PACU to the regular post-op unit. The nurse observes Sandra perfoming wrist flexion and extension exercises 4 hours after surgery. what action should the nurse take?
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encourage Sandra to continue performing these exercises
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the nurse enters Sandra's room and observes that a graduate nurse (GN) is assessing Sandra's dressing while the UAP takes postoperative vital signs. the UAP is preparing to take Sandra's BP on her operative side because there is an IV in the other arm. what action should the nurse implement first?
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advise the UAP to immediately stop and obtain a larger cuff so the BP can be taken in the leg
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what should the nurse emphasize in the discussion?
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both the GN and the UAP are at fault for the incorrect action of the UAP
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what action should the nurse take first?
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ask Sandra to clarify how she learned this information so that a plan for further teaching can be developed.
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what complication is most often associated with tamoxifen?
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blood clots
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how should the nurse respond?
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"the medication decreases estrogen levels, which is what also causes the symptoms of menopause."
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what adverse effects most often associated with antineoplastic chemotherapy used to treat breast neoplasms should be included in this discussion? (select all that apply)
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-diarrhea -alopecia
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what intervention is appropriate for the nurse to implement?
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label the two lumens as non-functional, and use one of the remaining lumens.
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which assessment finding would cause the nurse to suspect that an immunosuppressed client has an infection?
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oral temperature of 99.5F
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which nursing diagnosis has the highest priority when the nurse is planning care for Sandra?
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altered tissue perfusion
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which nursing care measure(s) will be most beneficial in the management of Sandra's highest priority problem? (select all that apply)
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-apply SCD -elevate the affected arm
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when is the best time to obtain the vancomycin serum trough level?
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fifteen minutes prior to administration of the next dose of the drug
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it is time for Sandra's vancomycin. the vancomycin IV 1g is in a 250mL bag of 0.9% normal saline to be delivered in 1 hour. the IV tubing set is 15 drops/mL. how many drops per minute would the nurse set on the IV pump?
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63 (250 x 15/60 minutes = 62.5 rounded is 63 drops/minutes)
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what is the most probable cause of this finding?
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candida superinfection
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which client's history indicates the person at highest risk for breast cancer?
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a 65-year-old woman, who is a retired teacher and who never married or had children.
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the development of breast cancer by which family member indicates Sandra's increased risk?
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younger sister
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which symptom of breast cancer does this describe?
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unusual skin texture
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which description of a breast lump is most typical of breast cancer?
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hard, irregular, and does not move freely
