A home health nurse is assisting in the care of a client following a modified radical mastectomy. Which of the following statements by the client indicates effective coping?

"I would like to see what this looks like today."

"I'm going to close my eyes until you are done dressing my incision."

"I would just like to spend my day staring at the TV."

"I'm planning to stay at home until my breast reconstructive surgery."

Answer and Explanation

The Correct Answer is A

A. "I would like to see what this looks like today": This indicates effective coping as the client is engaging with their condition and facing the changes directly, which is an important step in emotional adjustment and recovery.
B. "I'm going to close my eyes until you are done dressing my incision": This suggests avoidance of the situation, which may indicate difficulty in coping with the reality of their condition.
C. "I would just like to spend my day staring at the TV": This may indicate withdrawal or avoidance, which is not an effective coping strategy.
D. "I'm planning to stay at home until my breast reconstructive surgery": While this may be part of the client's plan, it does not directly indicate effective coping with the current situation.

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Correct Answer is B

Explanation

A. Orthopnea: This is more commonly associated with left-sided heart failure, where fluid accumulation in the lungs causes difficulty breathing when lying flat.
B. Lower-extremity edema: This is correct as right-sided heart failure often leads to fluid retention in the body, resulting in swelling of the lower extremities.
C. Clammy skin: This is not a typical finding specific to right-sided heart failure and may be seen in other conditions or complications.
D. Pink, frothy sputum: This is characteristic of left-sided heart failure and pulmonary edema, not right-sided heart failure.

A. The skin around the client's stoma is bulging. B. The client has had no fecal output from the stoma. C. The stoma protrudes 2 cm (0.8 in) above client's abdominal wall. D. The client's stoma is moist and beefy red.

Correct Answer is B

Explanation

A. The skin around the client's stoma is bulging: While bulging skin can be concerning, it is often a normal postoperative finding as the stoma settles into its new position. However, further evaluation may be needed if other symptoms are present.
B. The client has had no fecal output from the stoma: This is correct as the absence of fecal output 24 hours postoperatively could indicate a potential issue such as a blockage or anastomotic failure, which requires prompt evaluation by the provider.
C. The stoma protrudes 2 cm (0.8 in) above client's abdominal wall: This is generally considered normal. The stoma should protrude slightly to ensure it is not retracted and is functioning properly.
D. The client's stoma is moist and beefy red: This is a normal finding. A healthy stoma should be moist and beefy red, indicating good blood flow and viability.

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A home health nurse is assisting in the care of a client following a modified radical mastectomy. Which of the following statements by the client indicates effective coping?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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