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 B
Explanation
A. Empty the urine drainage bag every 12 hours: While it's essential to empty the urine drainage bag regularly to prevent it from becoming too full, emptying it every 12 hours alone is not sufficient to prevent urinary tract infections (UTIs).
B. Drain the urine from the tubing before ambulation: Correct. Before the client ambulates or moves, the nurse should ensure that the urinary catheter's tubing is emptied. This prevents urine from flowing back into the bladder, reducing the risk of UTIs.
C. Use clean technique for urine specimen collection: While using clean technique during urine specimen collection is important for preventing contamination, it is not the primary action needed to prevent UTIs in a client with an indwelling urinary catheter.
D. Hang the urine drainage bag at the level of the bladder: While proper positioning of the drainage bag is essential for optimal urine flow and to prevent backflow, it alone is not sufficient to prevent UTIs.
Correct Answer is {"dropdown-group-1":"D","dropdown-group-2":"C"}
Explanation
Allergic reaction: The client is at risk of blood transfusion reaction as evidenced by an increase in respiratory rate to 22 and an increase in heart rate from 88 to 100.
Itching: itching is an immediate symptom of type 1 hypersensitivity reactions that are common with blood transfusion.
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