A nurse is caring for a client who is 2 days postoperative following a total bilateralmastectomy. The client is tearful and looks away when her surgical dressings are removed. The nurse should place the priority on which of the following actions?

Demonstrating a nonjudgmental attitude toward the client when providing care for her surgical wounds

Providing the client with information on community resources that will strengthen her coping skills

Identifying the client's perception of the changes in her physical appearance

Encouraging the client to write about her feelings in a journal each day

Answer and Explanation

The Correct Answer is C

The correct answer is C. Identifying the client's perception of the changes in her physical appearance is essential for developing a plan of care that addresses her psychosocial needs and promotes her self-esteem and body image. The client may experience grief, anger, depression, anxiety, or guilt after losing her breasts, which can affect her quality of life and recovery. The nurse should explore how the client feels about herself and her sexuality, and provide emotional support and empathy. The other actions are also important, but they are not as a priority as understanding how the client views herself.

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Correct Answer is A

Explanation

The correct answer is A.

Grapes are a common choking hazard for toddlers because they are round, slippery, and can easily block the airway if swallowed whole or partially bitten. The nurse should include grapes as food to avoid or cut into small pieces before giving to toddlers.

A. "Why do you feel the staff is the FBI?" B. "What makes you think the staff is following you?" C. "This must be very frightening for you. Let's talk more about it." D. "The psychiatric staff is not FBI. They are here to help you."

Correct Answer is C

Explanation

The correct answer is C. Paranoid schizophrenia is a type of schizophrenia that involves delusions of persecution or conspiracy. The nurse should use therapeutic communication techniquesto empathize with the client's feelings and encourage them to express their thoughts without challenging or reinforcing their delusions. Therefore, stating that this must be very frightening for them and inviting them to talk more about it is an appropriate response that can help reduce anxiety and build trust. The other statements are not helpful or may be harmful. Asking why or what questions may imply doubt or disbelief in the client'sreality and provoke defensiveness or hostility. Contradicting or correcting the client's delusions may also increase their suspicion and resistance to treatment.

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A nurse is caring for a client who is 2 days postoperative following a total bilateralmastectomy. The client is tearful and looks away when her surgical dressings are removed. The nurse should place the priority on which of the following actions?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A community health nurse is assisting with the development of a pamphlet regarding choking hazards for toddlers. Which of the following foods should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for a client who has paranoid schizophrenia and believes that they are being followed by FBI agents who are pretending to be psychiatric staff. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has hyponatremia. Which of the following findings should the nurse expect?

A nurse is contributing to the plan of care for a client who had prolonged exposure to cold weather and has a core body temperature of 32.5°C (90.5° F). Which of the following data is the priority for the nurse to monitor?

A nurse is reinforcing discharge teaching with the family of an older adult client about safety precautions when administering a hypotonic enema to the client. Which of the following instructions should the nurse include in the teaching?

A nurse is caring for a client who has bulimia nervosa. Which of the following actions should the nurse take first?

A nurse is reinforcing discharge teaching with a client who has angina and a prescription for sublingual nitroglycerin tablets. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who follows a kosher diet. Which of the following menu items should the nurse include on the tray?

A nurse is collecting data from a client who has heart failure and is taking furosemide. Which of the following findings should indicate to the nurse that the medication is effective?

A nurse is reinforcing discharge teaching with the caregiver of a client who has dependent personality disorder. Which of the following instructions should the nurse include in theteaching?