A nurse is caring for a client who has recently undergone a total bilateral mastectomy.
Which of the following statements by the client requires immediate action by the nurse?
"I don't understand why everyone is so worried about me."
"I don't know if I'll ever find someone who wants to marry me."
"When I look at myself in the mirror, I don't know if I can go on."
"I feel like the doctor pressured me into having the mastectomy."
The Correct Answer is C
A: The client's statement reflects feelings of confusion but does not indicate immediate harm or danger to themselves. It requires therapeutic communication and support but not immediate action.
B: The client's statement expresses concern about their future relationships but does not indicate immediate harm or danger to themselves. It requires support and counseling but not immediate action.
C: Correct. The client's statement suggests significant emotional distress and a potential risk for self-harm or suicidal ideation. Immediate action is required to assess the client's safety and provide appropriate interventions, such as involving a mental health professional.
D: The client's statement indicates dissatisfaction or regret about the mastectomy decision but does not indicate immediate harm or danger to themselves. It requires supportive communication and addressing concerns but not immediate action.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Keep the conversation moving by asking about the client's family: While engaging the client in conversation is important, this statement does not specifically address the client's difficulty in talking about their illness.
B. Let the client know that as their nurse, they are available and willing to listen: Correct. This response demonstrates the nurse's willingness to provide emotional support and active listening. Encouraging the client to express their feelings and concerns about their illness is essential in promoting therapeutic communication.
C. Ask if the client understands what to expect in the advanced stages of the illness: While discussing the client's understanding of their illness is essential, it does not directly address their difficulty in talking to others about it.
D. Ask the client's visitors not to say anything about the advanced disease: This response may hinder communication and restrict the client's opportunity to talk about their feelings and concerns with supportive visitors.
Correct Answer is A
Explanation
A. "Tell me what the afterlife means to you." Correct. This response demonstrates active listening and encourages the client to share their beliefs and feelings about the afterlife, providing the client with an opportunity for spiritual expression and understanding.
B. "You should discuss the afterlife with your priest." While discussing spiritual matters with a religious leader can be valuable, this response does not directly address the client's request for
the nurse to discuss the afterlife with them.
C. "Keep praying. A miracle could happen." This response may not fully address the client's need to discuss their beliefs about the afterlife. It focuses on hope but does not actively engage in the client's spiritual conversation.
D. "Maybe your condition will lead you closer to God." While offering comfort, this response may not meet the client's request to discuss the afterlife directly.
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