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 C
Explanation
A: While explaining the negative consequences of refusal is important, it may not change the client's decision, and respect for the client's autonomy must be upheld.
B: Discussing the treatment with the client's partner without the client's consent may breach patient confidentiality and privacy.
C: Correct. The nurse should document the client's refusal of the medical treatment in the client's medical record. This documentation is essential for legal and ethical purposes and to ensure that the refusal is adequately communicated to the healthcare team.
D: Trying to convince the client to undergo the treatment is not appropriate and may violate the principle of informed consent. The client has the right to refuse treatment after being adequately informed of the risks and benefits.
Correct Answer is D
Explanation
A: Cantaloupe is relatively high in potassium and is not a suitable choice for a low-potassium diet.
B: Baked potatoes are high in potassium and should be avoided in a low-potassium diet.
C: Banana chips are also high in potassium and should not be included in a low-potassium diet.
D: Correct. Applesauce is a low-potassium food and is an appropriate choice for a client with chronic kidney disease following a low-potassium diet.
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