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 A
Explanation
“Potassium 5.8 mEq/L” should be reported to the provider because it is higher than the normal range for potassium levels in the blood.
Normal potassium levels range from.6 to 5.2 millimoles per liter (mmol/L)1.
Choices B, C, and D are incorrect because sodium levels of 140 mEq/L, and magnesium levels of.9 mEq/L and calcium levels of 9.6 mg/dL are all within normal ranges and do not need to be reported to the provider.
Correct Answer is D
Explanation
When a client is restrained to each extremity, it is important for the nurse to assess the client’s peripheral pulses first to ensure that circulation is not compromised.
Choice A, Elimination needs, is important but not the first priority in this situation.
Choice B, Comfort level, is also important but not the first priority in this situation.
Choice C, Skin integrity, is important but not the first priority in this situation.
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