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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
The correct answer is Choices A, C, and D.
Choice A rationale:
The statement, "I should avoid douching or using tampons for 24 hours after the Pap smear," demonstrates an understanding of post-procedure instructions. It reflects awareness of the need to avoid introducing foreign substances into the vagina immediately after the procedure, which could interfere with the accuracy of the results or increase the risk of infection. By abstaining from douching or tampon use, the client follows recommended guidelines for post-Pap smear care, promoting optimal healing and accuracy of results.
Choice B rationale:
The statement, "I can resume sexual activity as soon as I leave the clinic," is incorrect and does not reflect an understanding of post-Pap smear instructions. Resuming sexual activity immediately after the procedure is not recommended, as it may increase the risk of infection or discomfort. The client should be advised to abstain from sexual activity for a specified period, typically recommended by the healthcare provider, to allow for proper healing and to minimize the risk of complications.
Choice C rationale:
The statement, "It’s normal to experience some mild cramping or spotting after the procedure," demonstrates an understanding of common post-Pap smear symptoms. Mild cramping and spotting are normal reactions to the procedure and are not typically indicative of a problem. By acknowledging these potential side effects, the client shows awareness of what to expect after the Pap smear and is better prepared to manage any discomfort that may arise.
Choice D rationale:
The statement, "I should call the clinic if I experience heavy bleeding or foul-smelling discharge," reflects an understanding of the importance of monitoring for signs of complications post-procedure. Heavy bleeding or foul-smelling discharge may indicate an infection or other issues that require prompt medical attention. By instructing the client to contact the clinic in such situations, the nurse ensures that the client knows how to respond appropriately to potential complications, promoting their overall well-being and timely intervention if necessary.
Choice E rationale:
The statement, "I can expect the results of my Pap smear in about 2-3 days," is incorrect and does not reflect an understanding of the typical timeline for receiving Pap smear results. Pap smear results usually take longer, often a week or more, to be processed and interpreted by the laboratory. Providing accurate information about result expectations is essential for managing the client's post-procedure anxiety and ensuring realistic expectations regarding follow-up.
Correct Answer is C
Explanation
Choice A option:
Dietitian should not be consulted: The dietitian is an essential team member and will work closely with the client to ensure proper nutrition and dietary management. However, in the context of dysphagia, the speech-language pathologist's expertise is needed to determine safe swallowing strategies and food modifications.
Choice B option:
Physical therapist should not be consulted: The physical therapist focuses on maintaining and improving the client's physical function and mobility. While important in ALS management, the physical therapist's role is not directly related to the immediate issue of dysphagia.
Choice C option:
The speech-language pathologist is the correct answer because it specializes in assessing and treating communication and swallowing disorders. In this case, the speech-language pathologist is essential in evaluating the client's swallowing function, recommending appropriate dietary modifications (texture and consistency of foods), and implementing swallowing exercises or strategies to improve swallowing safety.
Choice D option:
Occupational therapist should not be consulted: The occupational therapist assists clients in regaining or maintaining independence in daily living activities. While the occupational therapist may address some aspects of mealtime activities and adaptive strategies, the speech-language pathologist is more specialized in evaluating and treating swallowing difficulties in clients with ALS.
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