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. "I should avoid over-the-counter medications that contain alcohol.": Disulfiram causes an unpleasant reaction when alcohol is consumed, even in small amounts. Clients must avoid alcohol-containing products such as certain cough syrups, mouthwashes, and topical solutions to prevent serious adverse effects like flushing, nausea, and hypotension.

B. "I will need to get a monthly injection of this medication.": Disulfiram is an oral medication taken daily, not administered via monthly injection. The injectable form is associated with other medications used in substance use disorder treatment, such as naltrexone.

C. "My provider wants me to take this medication for 2 weeks before I try to quit drinking.": Disulfiram is intended for clients who have already stopped drinking. It is not used to initiate abstinence but to maintain it by discouraging alcohol use through aversive effects.

D. "I will plan to continue taking this medication for at least 5 years.": The duration of disulfiram therapy varies based on the client’s progress and treatment plan. Long-term use beyond 1–2 years is uncommon and typically guided by continued risk of relapse and provider judgment.

Rationale:

A. The client has a wound dressing saturated with sanguinous drainage after it was reinforced: Continued sanguineous drainage that saturates reinforced dressings just 2 hours post-op may indicate active bleeding or hemorrhage. This is an urgent finding that requires immediate provider notification for assessment and possible intervention.

B. The client reports a pain level of 2 on a 0 to 10 scale after administration of pain medication: A pain score of 2 reflects adequate pain control following intervention. This is an expected and desirable outcome and does not require provider notification.

C. The client has a urine output of 50 mL/hr after removal of the indwelling urinary catheter: A urine output of 50 mL/hr is within normal limits and suggests appropriate renal perfusion. No immediate action or provider notification is required based on this finding.

D. The client has an oxygen saturation level of 96% after oxygen 2 L/min via nasal cannula was applied: This oxygen saturation level indicates adequate oxygenation with supplemental oxygen and is within expected postoperative parameters.