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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: A nasal cannula provides a low to moderate concentration of oxygen and is not suitable for a client experiencing severe difficulty breathing.
B: A simple face mask provides a higher concentration of oxygen than a nasal cannula but may not deliver a high enough concentration for a client experiencing severe respiratory distress.
C: A Venturi mask can provide a precise and adjustable concentration of oxygen but may not deliver the highest concentration needed in this scenario.
D: A nonrebreather mask can deliver the highest concentration of oxygen (up to 100%) and is the most appropriate choice for a client experiencing severe difficulty breathing.
Correct Answer is B
Explanation
A. Alarm clock that shakes the bed: While a vibrating alarm clock can be helpful for waking a person with hearing loss, it may not be a priority modification for safety in the home environment.
B. Flashing smoke alarm: Correct. A flashing smoke alarm is a priority modification because it addresses the safety concern of alerting the client in the event of a fire or smoke in the home. The flashing light serves as an effective visual cue to notify the client about the danger.
C. Lowpitched buzzer doorbell: A lowpitched buzzer doorbell can be beneficial for individuals with hearing loss, but it is not as critical as having a flashing smoke alarm for immediate safety.
D. Telephone with an amplified receiver: An amplified telephone receiver can improve communication for clients with hearing loss but is not as essential for immediate safety as a flashing smoke alarm.
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