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 A
Explanation
Choice A: "You seem scared to talk to your parents." This response is appropriate because it reflects the client's feelings and shows empathy and respect. It also opens the door for further communication and support from the nurse.
Choice B: "If you want me to, I can tell your parents for you." This response is not appropriate because it does not respect the client's autonomy and confidentiality. It also may make the client feel more anxious or helpless and may damage the trust between the client and the nurse.
Choice C: "Your parents will have to be told why you are being admitted." This response is not appropriate because it does not address the client's feelings or concerns. It also may sound harsh or threatening to the client, who may fear the consequences of telling her parents.
Choice D: "Give your parents a chance; they'll understand." This response is not appropriate because it does not acknowledge the client's feelings or concerns. It also may sound unrealistic or insensitive to the client, who may have valid reasons to doubt her parents' reaction or acceptance.
Correct Answer is B
Explanation
Choice A: Upper back pain is not the correct answer because it is not a common finding associated with uterine fibroids. Upper back pain is a feeling of discomfort or ache in the upper part of the back, between the shoulder blades, or below the neck. It can be caused by various factors such as muscle strain, poor posture, or spinal problems. It is not related to the presence or growth of benign tumors in the uterus.
Choice B: Chronic pelvic pain is the correct answer because it is a common finding associated with uterine fibroids. Chronic pelvic pain is a feeling of discomfort or ache in the lower abdomen or pelvis that lasts for more than six months. It can be caused by various factors such as endometriosis, ovarian cysts, or infection. It is also related to the presence or growth of benign tumors in the uterus, which can press on nerves, blood vessels, or organs and cause inflammation, bleeding, or scarring.
Choice C: Amenorrhea is not the correct answer because it is not a common finding associated with uterine fibroids. Amenorrhea is a condition that causes the absence of menstrual periods for more than three months in a woman who is not pregnant, breastfeeding, or menopausal. It can be caused by various factors such as hormonal imbalance, stress, or weight loss. It is not related to the presence or growth of benign tumors in the uterus, which can cause heavy or irregular menstrual bleeding instead.
Choice D: Diarrhea is not the correct answer because it is not a common finding associated with uterine fibroids. Diarrhea is a condition that causes loose, watery, or frequent stools. It can be caused by various factors such as infection, medication, or food intolerance. It is not related to the presence or growth of benign tumors in the uterus, which can cause constipation or bloating instead.
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