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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
This statement indicates that the client understands the importance of gradually adjusting to wearing a hearing aid.
It can take time for the brain to adapt to new sounds and volume levels, so it’s important to increase usage gradually.
Choice A is wrong because turning the hearing aid up as high as it will go can cause discomfort and may not improve hearing.
Choice B is wrong because hearing aids typically last several years with proper care and maintenance.
Choice C is wrong because it’s important to remove the battery from the hearing aid when not in use to preserve battery life.
Correct Answer is D
Explanation
The first two actions the nurse should take are to obtain a sputum culture and a chest X-ray.
These tests can help diagnose the cause of the client’s symptoms and guide treatment.
Choice A is wrong because administering antibiotics and bronchodilators should only be done after a diagnosis has been made.
Choice B is wrong because airborne precautions and isolation may not be necessary depending on the cause of the client’s symptoms.
Choice C is wrong because cough suppressants and antihistamines may not be appropriate treatments depending on the cause of the client’s symptoms.
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