A nurse is caring for a client who has a tracheostomy.

Which of the following actions should the nurse take?

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.

The correct answers are:

• c."I need to have a fire escape plan with my family."
• d."I will use the grab bars when getting in and out of the bathtub."

Rationale for each choice:

Choice c:

Having a fire escape plan is crucial for home safety. It ensures that all family members know what to do in the event of a fire, which can save valuable time and lives. Here's a detailed explanation of why a fire escape plan is essential:

1. Early Escape:A plan promotes quick evacuation,as everyone understands the escape routes and procedures.
2. Reduced Panic:Knowing what to do in a crisis minimizes panic and confusion,allowing for calmer and more efficient actions.
3. Accountability:The plan ensures that no one is left behind,especially children,older adults,or individuals with disabilities.
4. Firefighter Assistance:It provides vital information to firefighters,aiding their rescue efforts.
5. Regular Practice:Regularly practicing the plan familiarizes everyone with their roles and actions,ensuring smoother execution in a real fire.

Choice d:

Grab bars provide stability and support, reducing the risk of falls in bathrooms. Falls are a major safety hazard, especially for older adults, and can lead to serious injuries. Grab bars offer several benefits, including:

1. Entering and Exiting:They facilitate safe entry and exit from the bathtub or shower,especially on slippery surfaces.
2. Balance Support:They provide support when standing,reducing the likelihood of losing balance.
3. Transfer Assistance:They assist individuals with mobility impairments in safely transferring between the bathtub,shower,or toilet.
4. Confidence Boost:They offer a sense of security,allowing individuals to feel more confident and independent in the bathroom.

Rationale for incorrect choices:

Choice a:

Setting a hot water heater to 140 degrees Fahrenheit is unsafe. It can cause scalding burns within seconds, especially for children and older adults. The recommended temperature is 120 degrees Fahrenheit to balance safety and energy efficiency.

Choice b:

Taping over frayed electrical cords is a temporary and hazardous fix. It does not address the underlying issue of damaged wiring, which can lead to electrical shocks, fires, or electrocution. Frayed cords should be replaced immediately with new, undamaged ones.