A nurse is caring for a client who is one day postoperative following a left radical mastectomy. Which of the following behaviors should alert the nurse to the possibility that the client is having difficulty adjusting to the loss of her breast?
Refusing to look at the dressing or surgical incision
Asking questions about the information on her postoperative care pamphlet
Performing arm exercises once or twice a day
Asking for pain medication every 3 hours
The Correct Answer is A
Choice A: Refusing to look at the dressing or surgical incision is the correct answer because it is a behavior that may indicate difficulty adjusting to the loss of her breast. Refusing to look at the dressing or surgical incision may reflect denial, avoidance, or fear of facing the reality of the surgery and its consequences. It may also indicate low self-esteem, body image disturbance, or depression. The nurse should assess the client's emotional state and provide support and education.
Choice B: Asking questions about the information on her postoperative care pamphlet is not the correct answer because it is a behavior that may indicate a positive adjustment to the loss of her breast. Asking questions about the information on her postoperative care pamphlet may reflect acceptance, curiosity, or motivation to learn about her condition and treatment. It may also indicate high self-efficacy, coping skills, or optimism. The nurse should encourage the client's involvement and provide clear and accurate information.
Choice C: Performing arm exercises once or twice a day is not the correct answer because it is a behavior that may indicate a positive adjustment to the loss of her breast. Performing arm exercises once or twice a day may reflect compliance, responsibility, or self-care. It may also indicate physical recovery, functional ability, or quality of life. The nurse should reinforce the client's efforts and provide feedback and guidance.
Choice D: Asking for pain medication every 3 hours is not the correct answer because it is a behavior that may indicate a normal response to the loss of her breast. Asking for pain medication every 3 hours may reflect pain management, comfort, or relief. It may also indicate trust, communication, or satisfaction with care. The nurse should assess the client's pain level and provide adequate and timely pain relief.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A: Fecal incontinence is not the correct answer because it is not a disorder of pelvic organ prolapse. Fecal incontinence is a condition that causes the loss of bowel control, resulting in involuntary leakage of stool or gas. It can be caused by various factors such as nerve damage, muscle weakness, or diarrhea. It is not related to the displacement or descent of pelvic organs.
Choice B: Rectocele is the correct answer because it is a disorder of pelvic organ prolapse. Rectocele is a condition that occurs when the rectum bulges or sags into the vagina, creating a pouch or hernia. It can cause symptoms such as constipation, difficulty with bowel movements, or a feeling of pressure or fullness in the vagina. It is caused by the weakening or stretching of the pelvic floor muscles and connective tissue that support the rectum and vagina.
Choice C: Urinary incontinence is the correct answer because it is a disorder of pelvic organ prolapse. Urinary incontinence is a condition that causes the loss of bladder control, resulting in involuntary leakage of urine or urge to urinate. It can be caused by various factors such as stress, infection, or medication. It is also related to the displacement or descent of pelvic organs, such as the bladder or urethra, which can affect the function and closure of the urinary sphincter.
Choice D: Cystocele is the correct answer because it is a disorder of pelvic organ prolapse. Cystocele is a condition that occurs when the bladder protrudes or drops into the vagina, creating a pouch or hernia. It can cause symptoms such as urinary frequency, urgency, or retention, or a feeling of pressure or fullness in the vagina. It is caused by the weakening or stretching of the pelvic floor muscles and connective tissue that support the bladder and vagina.
Choice E: Enterocele is the correct answer because it is a disorder of pelvic organ prolapse. Enterocele is a condition that occurs when the small intestine bulges or descends into the vagina, creating a pouch or hernia. It can cause symptoms such as lower back pain, pelvic pressure, or difficulty with bowel movements. It is caused by the weakening or stretching of the pelvic floor muscles and connective tissue that support the small intestine and vagina.
Correct Answer is ["B","C","D","E"]
Explanation
Choice A: Rectal incontinence is not the correct answer because it is not a disorder related to pelvic organ prolapse. Rectal incontinence is a condition that causes loss of control over bowel movements, resulting in leakage of stool or gas. It can be caused by various factors, such as nerve damage, muscle weakness, or diarrhea.
Choice B: Rectocele is the correct answer because it is a disorder related to pelvic organ prolapse. Rectocele is a condition that occurs when the rectum bulges into the vagina due to weakening of the pelvic floor muscles and connective tissue. It can cause symptoms such as constipation, difficulty emptying the bowel, or a feeling of pressure or fullness in the vagina.
Choice C: Urinary incontinence is the correct answer because it is a disorder related to pelvic organ prolapse. Urinary incontinence is a condition that causes loss of control over urination, resulting in leakage of urine or urgency to urinate. It can be caused by various factors, such as stress, urge, overflow, or mixed types of incontinence.
Choice D: Cystocele is the correct answer because it is a disorder related to pelvic organ prolapse. Cystocele is a condition that occurs when the bladder bulges into the vagina due to weakening of the pelvic floor muscles and connective tissue. It can cause symptoms such as frequent urination, difficulty emptying the bladder, or a feeling of pressure or fullness in the vagina.
Choice E: Enterocele is the correct answer because it is a disorder related to pelvic organ prolapse. Enterocele is a condition that occurs when the small intestine bulges into the vagina due to weakening of the pelvic floor muscles and connective tissue. It can cause symptoms such as lower back pain, pelvic pressure, or difficulty having bowel movements.
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