A nurse is caring for a client who is postoperative following a mastectomy.
Which of the following actions should the nurse take to help the client cope with the body image change resulting from the surgery?
Encourage the client to help care for their surgical incision.
Suggest that the client decide about reconstruction as soon as possible.
Postpone referrals to support services until the client requests them.
Avoid talking to the client about the surgery.
The Correct Answer is A
Encourage the client to help care for their surgical incision. This can help the client accept the body image change and promote healing.
Choice B is wrong because suggesting that the client decide about reconstruction as soon as possible can pressure the client and interfere with their coping process.
Choice C is wrong because postponing referrals to support services until the client requests them can delay the client’s emotional recovery and increase their isolation.
Choice D is wrong because avoiding talking to the client about the surgery can indicate that the nurse is uncomfortable with the topic and discourage the client from expressing their feelings.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Medical diagnosis:
This provides context for the patient’s condition and guides the next nurse in understanding care priorities.
B. Number of visitors:
This is not essential clinical information for continuity of care.
C. Routine care:
Routine care (like scheduled hygiene or linen changes) is generally not included unless there was a deviation or issue.
D. Expected laboratory results:
Only actual or pending critical results should be reported. “Expected” values are not useful unless they have been received and are relevant.
Correct Answer is C
Explanation
The nurse should explain that the injection is administered in order to prevent vitamin K deficiency bleeding (VKDB) in the newborn. Vitamin K is needed for blood clotting, but newborn babies have very low levels of vitamin K in their bodies at birth because only small amounts of the vitamin pass through the placenta and breast milk. VKDB can cause life-threatening bleeding in various parts of the body, such as the brain, intestines, or skin. VKDB can be classified into early-onset, classic, or late- onset depending on the time of presentation after birth. The most effective way to prevent VKDB is to give a single intramuscular dose of 0.5 to 1 mg of vitamin K to all newborn infants within 6 hours of birth.
Choice A is wrong because sepsis is not caused by vitamin K deficiency, but by bacterial infection.
Choice B is wrong because tachypnea is not caused by vitamin K deficiency, but by respiratory distress or other conditions.
Choice D is wrong because jaundice is not caused by vitamin K deficiency, but by high levels of bilirubin in the blood.
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