A nurse is caring for a client following a bilateral mastectomy. The client is often tearful and avoids looking at her dressings. Which of the following actions should the nurse take first?
Refer the client to a breast cancer support group.
Identify the impact of the mastectomy on the client's body image.
Encourage the client to assist with her dressing changes.
Provide the client with a mirror to look at her mastectomy incisions.
The Correct Answer is B
The nurse should first identify the impact of the mastectomy on the client’s body image.
This is because the client’s behavior of avoiding looking at her dressings and being tearful suggests that she may be struggling with changes to her body image after the surgery.
By identifying and addressing this issue, the nurse can provide appropriate emotional support and interventions to help the client cope with these changes.
Choice A is not the first action the nurse should take because referring the client to a breast cancer support group may be helpful, but it is not addressing the immediate concern of the client’s emotional state.
Choice C is not the first action because encouraging the client to assist with her dressing changes may be premature if she is still struggling emotionally with her body image.
Choice D is not the first action because providing the client with a mirror to look at her mastectomy incisions may be overwhelming for her if she is not yet ready to confront her changed appearance.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This is important to prevent urine from flowing back into the bladder, which can cause infection 1.
Choice A is incorrect because the catheter should be secured to the outer side of the thigh, not taped to the lower abdomen 2.
Choice B is incorrect because attaching the drainage bag to the side rails of the bed can cause it to be above the level of the bladder.
Choice C is incorrect because it is important to empty the drainage bag regularly, not just when it is three-quarters full.
Correct Answer is B
Explanation
It is recommended that IVs are placed in the arm on the opposite side of your surgery, if possible.
Choice A is wrong because it involves placing the IV catheter on the same side as the mastectomy.
Choice C is wrong because it involves placing the IV catheter on the same side as the mastectomy.
Choice D is wrong because it involves placing the IV catheter on a vein that is not commonly used for IV therapy.
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