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 because before providing the client with information about insulin self-administration and other resources, it is important to first determine whether the client can afford the insulin administration supplies.
This will help to ensure that the client has access to the necessary supplies for managing their diabetes mellitus.
Choice A is wrong because making a copy of the medication reconciliation form for the client is not the first action that should be taken.
While it is important to provide the client with a copy of their medication reconciliation form, this should be done after determining whether the client can afford the insulin administration supplies.
Choice B is wrong because obtaining printed information about insulin self-administration is not the first action that should be taken.
While it is important to provide the client with information about insulin self-administration, this should be done after determining whether the client can afford the insulin administration supplies.
Choice C is wrong because providing the client with the contact number for a diabetes education specialist is not the first action that should be taken.
While it is important to provide the client with resources for diabetes education, this should be done after determining whether the client can afford insulin administration supplies.
Correct Answer is B
Explanation
Prepare the client for a central venous line.
Parenteral nutrition (PN) with 20% dextrose and fat emulsions is a hypertonic solution that requires infusion through a central venous line to prevent damage to peripheral veins.
Choice A is wrong because the PN infusion bag should be changed every 24 hours, not every 48 hours.
Choice Cis wrong because blood glucose should be monitored more frequently than once daily when initiating PN therapy.
Choice Dis wrong because PN and fat emulsions can be administered together in a total nutrient admixture (TNA)1.
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