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?

I prefer to wear loose clothing to hide my scars.

I am ready to join a support group for cancer survivors.

I feel confident about my recovery process.

I am planning to resume my exercise routine next week.

Answer and Explanation

The Correct Answer is A

Choice A reason: Preferring loose clothing to hide scars indicates an altered body image, as it reflects discomfort with physical changes post-mastectomy. This behavior suggests emotional distress about appearance, a common response to surgical body alterations, making it the correct indicator.
Choice B reason: Joining a support group shows proactive coping and acceptance, not necessarily an altered body image. It reflects social engagement and resilience, not distress about physical changes, making it incorrect for indicating body image concerns.
Choice C reason: Feeling confident about recovery suggests positive adjustment, not an altered body image. Confidence indicates emotional resilience rather than distress about physical appearance post-mastectomy, making this statement incorrect for this concern.
Choice D reason: Planning to resume exercise indicates focus on recovery and health, not body image distress. This proactive attitude reflects physical rehabilitation goals, not emotional concerns about appearance, making it incorrect for altered body image.

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Correct Answer is B

Explanation

Choice A rationale: Donut-shaped cushions are contraindicated because they create a ring of high pressure that restricts blood flow to the central area. This can worsen tissue ischemia and accelerate skin breakdown.

Choice B rationale: Clients with paraplegia sitting in a chair should be repositioned every 15 minutes to relieve pressure. Frequent shifts are necessary because sitting exerts higher pressure on the ischial tuberosities than lying down.

Choice C rationale: Moisture-barrier creams are used to protect skin from incontinence or wound drainage. Nonblanchable erythema indicates a stage 1 pressure injury, which requires pressure relief rather than a topical moisture barrier.

Choice D rationale: While in bed, the standard of care is to turn and reposition the client at least every 2 hours. A 3-hour interval is too long and increases the risk of further tissue damage.

A. A client who is taking warfarin and has started working in a parking garage 3 months ago. B. A client who is taking bumetanide and reports an increase in urinary frequency. C. A client who received a Mantoux test 48 hr ago and has an induration. D. A client who is 1 day postoperative following a total knee replacement.

Correct Answer is C

Explanation

Choice A reason: Starting work in a parking garage while on warfarin does not inherently indicate a need for referral unless specific risks (e.g., injury prone to bleeding) are present. Without additional concerns, this situation is routine, making it incorrect for requiring further care.
Choice B reason: Increased urinary frequency with bumetanide, a diuretic, is an expected side effect, not requiring referral unless severe or accompanied by electrolyte imbalances. This is a normal response, so it does not warrant further care, making it incorrect.
Choice C reason: An induration 48 hours after a Mantoux test suggests a positive tuberculosis result, requiring referral for chest X-ray and further evaluation. This finding indicates potential latent or active TB, a significant health concern, making it the correct choice for referral.
Choice D reason: Being 1 day postoperative after knee replacement is expected, with routine monitoring for complications like infection or thrombosis. Without specific issues, this does not require referral beyond standard postoperative care, making it incorrect.

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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?

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Naxlex Comprehensive Predictor Exams

A nurse working on a surgical unit is developing a care plan for a client who has paraplegia. The client has an area of nonblanchable erythema over his ischium. Which of the following interventions should the nurse include in the care plan?

Correct Answer is B

Explanation

A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following findings requires a referral for further care?

Correct Answer is C

Explanation

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