A breast biopsy indicates the presence of malignant cells, and the client is scheduled for a mastectomy. When preparing the client's preoperative plan of care, which area would the nurse most likely address as the priority?
Fluid balance
Body image
Urinary elimination
Activity
The Correct Answer is B
Choice A: Fluid balance is not the most likely priority because it is not directly affected by the mastectomy. Fluid balance is the state of equilibrium between the intake and output of fluids in the body. It can be influenced by various factors such as hydration, nutrition, medication, or illness. It can be monitored by measuring vital signs, weight, urine output, or laboratory values. Fluid balance is important for maintaining homeostasis and preventing dehydration or edema, but it is not a specific concern for a client undergoing a mastectomy.
Choice B: Body image is the most likely priority because it is directly affected by the mastectomy. Body image is the perception and attitude that one has toward one's own physical appearance and function. It can be influenced by various factors such as culture, media, self-esteem, or feedback from others. It can be assessed by observing verbal and nonverbal cues, asking open-ended questions, or using standardized tools. Body image is a major psychosocial issue for a client undergoing a mastectomy, as it can affect one's sense of identity, femininity, sexuality, or attractiveness. The nurse should address body image by providing information, support, and referral to appropriate resources.
Choice C: Urinary elimination is not the most likely priority because it is not directly affected by the mastectomy. Urinary elimination is the process of expelling urine from the bladder through the urethra. It can be influenced by various factors such as fluid intake, kidney function, medication, or infection. It can be assessed by measuring urine volume, color, odor, or specific gravity. Urinary elimination is important for maintaining fluid balance and preventing urinary tract infection or retention, but it is not a specific concern for a client undergoing a mastectomy.
Choice D: Activity is not the most likely priority because it is not directly affected by the mastectomy. Activity is the level of physical movement and exercise that one engages in on a daily basis. It can be influenced by various factors such as age, health status, motivation, or environment. It can be assessed by observing mobility, endurance, strength, or coordination. Activity is important for maintaining muscle tone, joint range of motion, circulation, or metabolism, but it is not a specific concern for a client undergoing a mastectomy.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: Vaginal pH of 3 is not the correct answer because it is not a finding of bacterial vaginosis. Vaginal pH is a measure of how acidic or alkaline the vaginal environment is. A normal vaginal pH ranges from 3.8 to 4.5, which helps prevent infections by maintaining a balance of healthy bacteria (lactobacilli). Bacterial vaginosis can cause an increase in vaginal pH above 4.5, which allows harmful bacteria (anaerobes) to grow and cause symptoms.
Choice B: Cervical bleeding on contact is not the correct answer because it is not a finding of bacterial vaginosis. Cervical bleeding on contact is a sign of inflammation or injury to the cervix, which is the lower part of the uterus that connects to the vagina. It can be caused by various factors such as infection, trauma, or cancer. Bacterial vaginosis does not affect the cervix directly, but it can increase the risk of other infections or complications that may cause cervical bleeding.
Choice C: Fishy odor of discharge is the correct answer because it is a finding of bacterial vaginosis. The fishy odor of discharge is a characteristic symptom of bacterial vaginosis that occurs due to the breakdown of organic compounds (amines) by the anaerobic bacteria. The odor is usually more noticeable after sexual intercourse or during menstruation.
Choice D: Yellowish-green discharge is not the correct answer because it is not a finding of bacterial vaginosis. Yellowish-green discharge is a sign of infection or inflammation of the vagina or cervix, such as trichomoniasis, gonorrhea, or chlamydia. These infections can cause symptoms such as itching, burning, or pain in the genital area. Bacterial vaginosis usually causes a thin, gray-white, or milky discharge that does not cause irritation or discomfort.
Correct Answer is C
Explanation
Choice A: White- or flesh-colored papillary growths in the genital area are not the correct answer because they are more likely a finding of another STI, such as HPV. HPV can cause genital warts that look like small bumps on or around the genitals. Genital herpes does not cause warts, but blisters or sores that may burst and crust over.
Choice B: Green penile discharge is not the correct answer because it is more likely a finding of another STI, such as gonorrhea. Gonorrhea can cause a thick, yellow-green discharge from the penis that may have a foul odor. Genital herpes does not cause discharge from the penis but may cause pain or burning during urination.
Choice C: Influenza-like symptoms are the correct answer because they are a possible finding of genital herpes. Genital herpes can cause systemic symptoms such as fever, headache, muscle aches, or swollen lymph nodes during an outbreak. These symptoms may resemble those of influenza (the flu) but are caused by HSV infection.
Choice D: Anuria is not the correct answer because it is not a finding of genital herpes. Anuria is a condition that causes a complete absence of urine output due to kidney failure or obstruction. Genital herpes does not affect the kidneys directly but may cause urinary retention if there is severe swelling or pain in the genital area.
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