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.
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Related Questions
Correct Answer is C
Explanation
The correct answer is C. Place a pillow under the child's head.
Rationale: The nurse should protect the child from injury by helping them to the floor and clearing away furniture or other items. The nurse should also place a pillow under the child's head to prevent head trauma and turn them onto their side to prevent aspiration of saliva or vomit. The nurse should not put anything in the child's mouth, as this could cause choking or damage to the teeth or tongue. The nurse should also not turn the child onto their back, as this could compromise their airway. The nurse should not restrain the child's upper extremities, as this could increase muscle spasms and cause injury.
Correct Answer is A
Explanation
The correct answer is A. Muscle cramps. Hyponatremia is a condition where sodium levels in the blood are lower than normal, which can cause water to move into body cells and make them swell. This can affect muscle cells and cause cramps, spasms or weakness. The other options are not typical signs of hyponatremia.
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