A nurse is caring for a client who has breast cancer and is postoperative following a bilateral mastectomy. Which of the following statements indicates the client has an altered body image?

Rationale:

A. Provide a low-stimulation environment: The client has a severe headache, 3+ proteinuria, and elevated BP, indicating severe preeclampsia. A quiet, low-light environment reduces the risk of seizure by limiting neurologic stimulation.

B. Maintain bed rest: Bed rest in a side-lying position improves uteroplacental blood flow and helps lower blood pressure. It also decreases metabolic demand, which is critical in hypertensive pregnancies.

C. Give antihypertensive medication: The BP readings (162/112 and 166/110 mm Hg) require immediate antihypertensive therapy to prevent cerebral hemorrhage, eclampsia, or placental abruption.

D. Obtain a 24-hr urine specimen: A 24-hour urine collection for protein is the gold standard for quantifying proteinuria and confirming the diagnosis of preeclampsia. While a dipstick of 3+ is a strong indicator, the 24-hour collection provides a definitive measurement.

E. Perform a vaginal examination every 12 hr: There are no contractions or signs of labor, so regular vaginal exams are not indicated and increase the risk of infection in a preterm pregnancy.

F. Monitor intake and output hourly: Decreased renal perfusion is a complication of preeclampsia. Hourly monitoring detects oliguria early and helps assess for fluid overload or worsening renal function.

G. Administer betamethasone: At 31 weeks, betamethasone is indicated to enhance fetal lung maturity due to risk of preterm delivery from severe maternal complications.

Rationale:

A. Auscultation: This step is performed after inspection and before percussion or palpation to avoid altering bowel sounds. It allows the nurse to assess for the presence, frequency, and character of bowel sounds without stimulating them artificially.

B. Inspection: This is the first step in the abdominal assessment. It involves visually examining the abdomen for contour, symmetry, skin changes, pulsations, or visible masses without touching the patient, helping establish a baseline.

C. Palpation: Palpation is the final step in abdominal assessment to prevent interference with bowel sounds. It allows the nurse to detect tenderness, masses, or organ enlargement, but should only be done after auscultation and percussion.

D. Percussion: This is done after auscultation and provides information on underlying structures, such as gas, fluid, or masses. It helps differentiate between dullness, resonance, or tympany across abdominal quadrants.