A nurse is assessing a female client and suspects that the client may have endometrial polyps based on which clinical manifestation?

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.

Choice A: Limit the intake of fluid. This action is not correct and should not be taught to the client. Limiting the intake of fluid can cause dehydration, urinary tract infection, or kidney stones. The client should drink enough fluid to keep her urine clear and odorless.

Choice B: Void every hour while awake. This action is not correct and should not be taught to the client. Voiding every hour while awake can cause bladder irritation, infection, or overdistension. The client should void when she feels the urge or at least every 3 to 4 hours.

Choice C: Perform Kegel exercises daily. This action is correct and should be taught to the client. Kegel exercises are exercises that strengthen the pelvic floor muscles that support the bladder and urethra. They can help improve bladder control and prevent urinary incontinence. The client should perform Kegel exercises daily by contracting and relaxing the muscles around the vagina and anus as if she is trying to stop urinating or passing gas.

Choice D: Take a laxative every night. This action is not correct and should not be taught to the client. Taking a laxative every night can cause diarrhea, dehydration, electrolyte imbalance, or dependence. The client should avoid constipation by eating a high-fiber diet, drinking plenty of fluids, and exercising regularly.