Med-Surg Reproduction - Progression Exam

The nurse employed in a woman's health care clinic would be most concerned about which client statement?

"My right breast is red and warm with little tiny indented areas on the surface of the skin." The nurse would be most concerned about the client who describes symptoms of inflammatory breast cancer. In this aggressive form of cancer, breast lymph channels are blocked by cancer cells, creating breast tissue that becomes red, warm, and has an orange peel (peau d'orange), pitting appearance on the skin surface. The nurse would be most concerned about this client and make an immediate referral to the health care provider for examination and evaluation. (Option 1) Clients usually describe lumps related to fibroadenoma, a benign breast disorder, as small, round, painless, mobile lumps with no breast tissue retraction or discharge. (Option 2) Further assessment is needed to determine if the client is at risk for developing mastitis. Mastitis may develop in lactating women when the nipples become dry and crack. The cracked nipples may provide a portal of entry for microorganisms, especially Staphylococcus. The client should be taught appropriate care of the breast during lactation. The client diagnosed with mastitis will experience warm, red, painful, and edematous breasts. (Option 4) Clients usually describe fibrocystic breast nodules as soft, movable nodules that change size at various times during the menstrual cycle. Fibrocystic breast changes are a common benign breast disorder. Educational objective: Inflammatory breast disease is an aggressive breast cancer with symptoms of red, warm, peau d'orange breast tissue. A breast mass may or may not be present.

The nurse caring for a group of clients on the gynecology unit recognizes that which are at increased risk for developing breast cancer? Select all that apply

24-year-old whose sister had breast cancer at age 38 32-year-old with genetic mutations in the BRCA1 and BRCA2 genes 56-year-old who is postmenopausal and has gained 50 lb (22.6 kg) in the last 5 years 65-year-old who took combined oral contraceptives for 15 years Breast cancer is the unregulated growth of abnormal breast tissue cells and the second most common cause of cancer deaths among women. When palpated, the breast lump is usually described as hard, irregularly shaped, non-mobile, and nontender. Mammography usually detects breast cancer. Non-modifiable breast cancer risk factors include: Female sex and age ≥50 (Options 4 and 5) First-degree relative (mother or sister) with history of breast cancer (Option 1) BRCA1 and BRCA2 genetic mutations (Option 2) Personal history of endometrial or ovarian cancer Menarche before age 12 or menopause after age 55 Modifiable breast cancer risk factors include: Hormone therapy with estrogen and/or progesterone (increased risk if taken after menopause) (Option 5) Postmenopausal weight gain and obesity as fat cells store estrogen (Option 4) History of smoking and alcohol consumption Dietary fat intake Sedentary lifestyle (Option 3) A client whose menstrual period began at age 17 would not be at increased risk for breast cancer. Clients who began menarche early (before age 12) or had late menopause (after age 55) are at increased risk for breast cancer. Educational objective: Breast cancer is the second leading cause of cancer deaths among women. Breast cancer non-modifiable risk factors include female sex, advanced age, first-degree relative with breast cancer, and BRCA1 or BRCA2 genetic mutations. Modifiable risk factors include behaviors such as smoking, alcohol consumption, sedentary lifestyle, dietary fat intake, and postmenopausal weight gain and hormone therapy.

The nurse is reviewing the history of several female clients. The nurse will recommend a Pap test to screen for cervical cancer for which individual?

26-year-old whose last Pap screening at age 23 was negative Pap testing allows early detection of cervical dysplasia (ie, abnormal cell growth) that may indicate cervical cancer. Human papillomavirus (HPV), one of the most common sexually transmitted infections, causes almost all cases of cervical cancer. Before age 30, most HPV infections are transient and may resolve spontaneously. Guidelines for Pap testing vary slightly by professional organization but are based on the knowledge that overtreating potentially transient HPV infections may cause more harm than good. Pap testing is generally started at age 21, regardless of sexual history. Women age 21-29 should be screened with a Pap test only every 3 years (Option 2). At age 30, HPV and Pap testing may be done together every 5 years. (Option 1) Teens do not need Pap test screenings, regardless of age at onset of sexual activity, as HPV infection rarely progresses to cancer in women age <21. However, testing for sexually transmitted infections (eg, gonorrhea, chlamydia, HIV) is appropriate. (Option 3) A woman whose uterus and cervix were removed for benign reasons (ie, unrelated to cervical cancer) does not need testing. (Option 4) The recommended age for discontinuing Pap testing ranges from 65-70. Women age ≥70 who have had regular cervical cancer testing with normal results may discontinue screening. Educational objective: Pap testing for cervical cancer allows early detection of cervical dysplasia and is initiated at age 21, regardless of sexual activity status. Women who have had their uterus and cervix removed for benign reasons may discontinue screening.

The nurse obtains the breast self-examination (BSE) history of a group of female clients. Which client needs further teaching on the best timing of monthly BSEs?

A 42-year-old with irregular periods who performs BSE when menstruation ends BSE may be performed monthly if a woman desires to monitor for changes in the breast tissue. BSE is not recommended as a substitute for routine screening (eg, clinical breast examination, mammography) and its benefit is unproven. However, the nurse can teach the correct procedure and the importance of reporting nipple discharge, a lump, or breast changes to the health care provider. The appropriate timing of BSE is determined by the client's menstrual cycle: Women with regular menstrual periods should perform BSE 5-7 days after menstruation (Option 2). Self-examination before menstruation is not recommended due to the risk of finding benign cystic lesions that usually resolve with menstruation. Women with irregular menses should perform BSE on the same day each month (Option 3). Women taking oral contraceptives should perform BSE when a new package is initiated (Option 1). Women who are postmenopausal should perform BSE on the same day each month (Option 4). Educational objective: Women with regular menstrual periods should perform BSE after menstruation. Those who are postmenopausal or have irregular menses should choose the same day of each month. Women taking oral contraceptives should perform BSE when a new package is initiated.

While reviewing prenatal records with a client and her partner, the nurse notes documentation in the medical record indicating that the client is a G2P0. However, the client denies a previous pregnancy. Which action by the nurse is appropriate?

Confirm the OB hx when the client is alone When reviewing obstetric history, the GTPAL notation system gives the health care provider information about a client's past pregnancies. This notation may be shortened to gravida (ie, number of previous pregnancies) and para (ie, number of births after 20 weeks). For example, a G2P0 indicates 1 prior pregnancy ending before 20 weeks and 1 current pregnancy. The nurse should be cautious of discussing obstetric history with a client in front of the partner or family and not assume that others have knowledge of the client's past pregnancies. If there is a discrepancy between what the client discloses in the interview and the medical record, the information should be clarified when the client is alone to maintain confidentiality (Option 3). (Option 1) The nurse should not change information in the medical record until the information is clarified appropriately with the client. (Option 2) Although the client's medical record indicates a previous pregnancy, it is not appropriate to ask if the pregnancy was an abortion or a miscarriage in front of the client's partner. (Option 4) Explaining the need for accurate information is not appropriate at this time and does not assist with clarifying the client's obstetric history in a private manner. Educational objective: The nurse should be cautious of discussing a client's obstetric history in front of the client's partner or family to avoid breaching confidentiality. Clarification or further questioning about the client's history should take place when the client is alone.

The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility?

Gonorrhea and chlamydia [57%] Gonorrhea and chlamydia can lead to pelvic inflammatory disease (PID) and infertility. They are referred to as "silent infections" because many affected women show no symptoms. Infections of the fallopian tubes and uterus can lead to permanent damage and infertility. The Centers for Disease Control and Prevention recommend annual chlamydia and gonorrhea screening for all sexually active females age <25 and older females with risk factors. Both chlamydia and gonorrhea are treatable. The use of latex condoms is recommended to reduce the risk of contracting chlamydia and gonorrhea. (Options 1 and 3) Herpes can lead to multiple, very painful genital vesicles/ulcers. HIV infection does not cause genital abnormalities. Human papillomavirus causes genital and anal warts. Syphilis usually causes a painless genital ulcer. The uterus and fallopian tubes (organs affected by PID) are typically not involved in any of these infections. (Option 4) Trichomoniasis and candidiasis (yeast infection) can lead to vaginitis (vaginal inflammation and discharge). They do not usually involve the uterus or fallopian tubes to cause infertility. Educational objective: Gonorrhea and chlamydia are the most common causes of pelvic inflammatory disease, which can lead to infertility. Therefore, annual gonorrhea and chlamydia screening is recommended for all sexually active females age <25 and older females with risk factors.

A nurse is teaching a client with a surgically repaired undescended testis about testicular self-examination (TSE). Which instructions should be included in the teaching? Select all that apply.

Perform the examination during a warm bath or shower Perform the examination monthly on the same day Report if there is a hard mass over the testis Use both hands to feel each testis separately Testicular cancer is the most common form of cancer in men age 15-35. When diagnosed early, it is highly curable. Clients at high risk for developing a tumor (eg, history of undescended testis) are encouraged to perform a monthly TSE. Client instructions for a TSE include: Perform TSE monthly on the same day (easy to remember) Perform TSE while taking a warm shower or bath as warm temperatures will relax the scrotal tissue and make the testis hang lower in the scrotum Use both hands to feel each testis separately Palpate each testicle gently, using the thumb and first 2 fingers Check that the testicle is normally egg-shaped and movable with a smooth surface The clinical findings that should be reported to the health care provider include: Painless, hardened lump on testes Scrotal swelling or heaviness Dull ache in pelvis or scrotum (Option 3) It is normal for one testicle to be slightly larger or hang lower than the other. Some people may also confuse epididymis (small coiled tube) as a small lump at the beginning. These do not need to be reported. Educational objective: Clients with a history of undescended testis or testicular tumor are encouraged to perform a monthly TSE. It is best done during a warm shower. The first indication of testicular cancer may be a painless, hardened lump on the testes or a feeling of scrotal heaviness.

The nurse is caring for an adolescent newly diagnosed with a chlamydial infection. After administering a one-time dose of azithromycin, the nurse understands that which of the following client statements indicate a correct understanding of client teaching? Select all that apply.

"A long-term consequence of an untreated chlamydial infection is infertility." "I can still spread the infection, even if I do not have any of the symptoms." "I should have screening yearly for chlamydia even if I do not have symptoms." "I will make sure my partner gets checked and treated to prevent reinfection." Chlamydia is the most common sexually transmitted infection and is diagnosed frequently among women, adolescents, and those with multiple sexual partners. Many clients are asymptomatic or have minor symptoms (eg, spotting after sex, dysuria, abnormal vaginal discharge) but can still transmit the infection (Option 3). Therefore, all sexually active women age <25 and any client age ≥25 at high risk (eg, new or several sexual partners) are screened annually for chlamydia and gonorrhea (Option 4). The client's sexual partners should also receive treatment to prevent transmission and reinfection (Option 5). If not treated appropriately, chlamydia can ascend the female genital tract, producing serious complications such as pelvic inflammatory disease and infertility (Option 1). Clients should also be instructed in general safe sex practices (eg, using condoms, avoiding multiple partners) to help prevent transmission of sexually transmitted infections. Clients should be taught to abstain from sexual intercourse for 7 days after initiation of drug therapy (eg, single dose of azithromycin, 7 days of doxycycline). This client received treatment today and therefore must wait 7 days before resuming intercourse (Option 2). Educational objective: Clients with a chlamydial infection may be asymptomatic or experience minor symptoms (eg, spotting after sex, dysuria, abnormal vaginal discharge). Clients should abstain from sexual intercourse for 7 days after antibiotic treatment is initiated and until all sexual partners have completed treatment to prevent transmission and serious complications. Sexually active clients age <25 or those age ≥25 at high risk should be screened annually.

Which statement is most important to emphasize when teaching a 40-year-old female client newly diagnosed with fibrocystic breast changes?

"Breast changes that are not related to your cycle should be reported to your provider." One of the most common benign breast disorders is fibrocystic breast changes. Fibrocystic changes correlate to estrogen/progesterone hormone fluctuations during the menstrual cycle. Clients may report cysts, nodules, or lumps that are more tender, swollen, and/or noticeable prior to menses. The condition typically resolves after menopause. The nurse instructs the client on breast self-awareness and emphasizes that any noncyclic breast changes (ie, not related to the menstrual cycle) may indicate malignancy (ie, cancer) and should be immediately reported to the health care provider (HCP) (Option 1). (Option 2) Clients should be instructed that cyclic pain and swelling may be reduced by decreasing caffeine and sodium intake; taking vitamins E, A, and B complex; wearing a support bra; utilizing cold compresses; and taking nonsteroidal anti-inflammatory drugs (eg, ibuprofen). (Option 3) Clients age >40 should receive yearly clinical breast examinations by an HCP and practice breast self-awareness. Emphasis is placed on the importance of reporting any suspicious breast changes. (Option 4) The client should be taught that fibrocystic breast changes are benign and do not increase the risk of breast cancer; however, reporting noncyclic changes is a higher priority. Educational objective: Fibrocystic breast changes are cyclic changes that occur as a result of heightened responses to estrogen and progesterone. Clients should be taught the need to report noncyclic changes to the health care provider, as well as symptom management, breast self-awareness, and the importance of regular clinical breast examinations.

A nurse is providing teaching about contraception. Which is appropriate contraceptive teaching?

"Emergency contraception is most effective when used within 3 days of unprotected intercourse." Emergency contraception (EC) prevents pregnancy after unprotected intercourse. EC pills (eg, levonorgestrel [Plan B]) should be taken within 5 days of intercourse; however, efficacy is reduced after 3 days (72 hours) (Option 4). The copper intrauterine device (IUD) may be inserted for up to 5 days after intercourse as another form of EC. (Option 1) Women in stable, monogamous relationships are good candidates for IUD placement. IUDs provide no protection against sexually transmitted infections (STIs) and increase the risk of pelvic inflammatory disease. (Option 2) Backup contraception is required for 7 days after starting oral contraceptives unless the pill pack is started on the first day of menses. In this case, backup barrier contraception may be used to prevent STIs but is not required to prevent pregnancy. (Option 3) Diaphragms are flexible latex/silicone devices inserted before intercourse to cover the cervix and prevent pregnancy. They do not provide protection against STIs such as HIV. Educational objective: Emergency contraception may be used for up to 5 days after intercourse to reduce the risk of pregnancy; they are most effective if used within 3 days (72 hours). Intrauterine devices and diaphragms do not provide protection against sexually transmitted infections. Backup contraception is required for 7 days after starting oral contraceptives, unless initiating on the first day of menses.

A client with diabetes mellitus is admitted to the surgical unit after a vaginal hysterectomy. The client received 6 units of regular insulin subcutaneously and metoprolol 50 mg by mouth in the post-anesthesia care unit. Which statement by the unlicensed assistive personnel would require immediate action by the nurse?

"I changed the client's perineal pad 3 times in the last 2 hours." The nurse should take immediate action when a client recovering from a vaginal hysterectomy saturates more than one perineal pad in an hour. The nurse should further assess the client and report these findings and excessive vaginal bleeding to the health care provider (HCP). (Option 2) The client should be encouraged to perform leg exercises while in bed to promote circulation and prevent deep vein thrombosis (DVT). (Option 3) The client's voiding of 500 mL of straw-colored urine is a normal finding. (Option 4) The client received metoprolol, a beta-adrenergic blocker, which slows the heart rate. If the heart rate is below 60 (or prescribed rate) prior to medication administration, the nurse should withhold further metoprolol and contact the HCP. The vital signs do not require immediate action by the nurse. Educational objective: A client recovering from a vaginal hysterectomy should be monitored for excessive vaginal bleeding, urinary retention, backache, decreased urinary output, and the development of signs and symptoms of complications such as DVT.

The nurse is teaching at a conference on cervical cancer prevention. One of the attendees asks about risk factors. The nurse teaches about which factors as risks for cervical cancer? Select all that apply.

Human papillomavirus infection Long-term corticosteroid therapy Multiple sexual partners Oral contraceptive use Sexual activity before age 18 Nearly all cases of cervical cancer result from cervical tissue changes caused by human papillomavirus (HPV) infection (Option 1). Most other risk factors for cervical cancer are related to features that increase the client's risk of contracting HPV (eg, early sexual activity, multiple sexual partners) or impair the immune system's ability to clear HPV infection (eg, immunosuppressive therapy, HIV infection) (Options 2, 3, and 5). The risk of cervical cancer doubles for women with sexual activity before age 18 or more than one sexual partner. Oral contraceptive and tobacco use also increase the risk (Option 4). It is thought that the metabolite of estradiol (oral contraceptives) may serve as a cofactor for HPV-induced cellular proliferation. Advanced cervical cancer may present as irregular, painless vaginal bleeding, but it is usually asymptomatic in the early stages. Regular Pap test screenings can detect cervical cancer in the early stages and precancerous tissue changes. HPV infection can be prevented with the HPV vaccine, which is recommended for female and male clients age 9-26. Educational objective: Nearly all cases of cervical cancer are related to human papillomavirus (HPV) infection, which can be prevented with the HPV vaccine. Other risk factors include sexual activity before age 18, multiple sexual partners, immunosuppression, history of sexually transmitted infections, oral contraceptive use, and tobacco use.

The nurse assesses a client who is 2 days postoperative breast reconstruction surgery. The client has 2 closed-suction Jackson Pratt bulb drains in place. There is approximately 10 mL of serosanguineous fluid in each one. One hour later, the nurse notices the bulbs are full of bright red drainage and measures a total output of 200 mL. What is the nurse's priority action?

Notify the HCP A closed-wound drainage system device (eg, Jackson-Pratt, Hemovac) consists of fenestrated drainage tubing connected to a flexible, vacuum (self-suction) reservoir unit. The distal end lies within the wound and can be sutured to the skin. It is usually inserted near the surgical site through a small puncture wound rather than in the surgical incision. The purpose of the drain is to prevent fluid buildup (eg, blood, serous fluid) in a closed space. Although it depends on the client and type of surgical procedure, about 80-120 mL of serosanguineous or sanguineous drainage per hour during the first 24 hours after surgery can be expected. The priority action is to notify the HCP due to the change in type and amount of drainage after the first 24 hours following surgery. Excessive bleeding and fluid collection into the closed space following breast reconstruction can greatly affect the integrity of the surgical incision, the tissue reconstruction, and wound healing (Option 1). (Option 2) Opening the bulb does not release excessive negative pressure. It would release all negative pressure, drainage would cease, and even more fluid would collect in the closed space, compromising the integrity of the incision even further. (Option 3) Recording the amount of wound drainage on the output record is an appropriate intervention. However, it is not the priority action. (Option 4) Although repositioning the client could affect the amount of drainage, it is not likely as drainage is maintained by negative pressure, not gravity. Educational objective: Although it depends on the type of surgical procedure performed, about 80-120 mL of serosanguineous or sanguineous drainage per hour for the first 24 hours following surgery can be expected. The nurse should notify the HCP if the drainage in the Jackson-Pratt closed-wound drainage device changes from serosanguineous to sanguineous and if the amount increases significantly after the first 24 hours following surgery.