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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["0.8 mL"]
Explanation
- To find out how many mL to administer for a medication dose, we need to use this formula: mL = (dose in mg) / (concentration in mg/mL)
- In this formula, the dose in mg is the amount of medication ordered by the provider, and concentration in mg/mL is the strength of medication available in the vial or syringe.
- We plug in the given values into this formula: mL = (30 mg) / (40 mg/mL)
- We simplify and solve this equation: mL = 0.75 mL
- We round off to the nearest tenth: mL = **0.8 mL**
- We add a leading zero if needed: mL = **0.8 mL**
- We do not add a trailing zero: mL = **0.8 mL**
Correct Answer is D
Explanation
Choice A reason: Increased vaginal discharge is a normal and expected outcome of using a pessary, as it helps to lubricate and cleanse the vagina.
Choice B reason: Urinary tract infection is not a common side effect of using a pessary, as it does not interfere with urination or introduce bacteria into the urinary tract.
Choice C reason: Vaginitis is not a common side effect of using a pessary, as it does not cause inflammation or infection of the vagina. However, the client should maintain good hygiene and use vaginal cream or gel as prescribed to prevent irritation.
Choice D reason: Vaginal ulceration is a serious and possible side effect of using a pessary, as it can cause pressure necrosis and erosion of the vaginal mucosa. The client should report any bleeding, pain, or foul-smelling discharge to the provider and have the pessary removed and replaced regularly.
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