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 D
Explanation
Use short phrases when talking to the client.
Some possible explanations for the other choices are:
Choice A is wrong because speaking in a louder than usual tone of voice during conversation can distort the sound and make it harder for the client to understand.
The nurse should speak in a normal tone and enunciate clearly.
Choice C is wrong because avoiding the use of hand gestures when talking to the client can limit nonverbal communication and reduce the client’s comprehension.
The nurse should use appropriate facial expressions
Correct Answer is C
Explanation
Collaborate with the client to develop a daily physical exercise routine. This intervention can help reduce aggression and impulsivity in schizophrenia by providing an outlet for frustration, enhancing self-esteem, and improving mood. Physical exercise can also improve physical health and reduce the risk of metabolic syndrome associated with antipsychotic medications.
Choice A is wrong because warning the client that the staff will use seclusion as a consequence if there are repeated reports of hallucination is punitive and threatening. This can increase the client’s anxiety, paranoia, and hostility, and may worsen the psychotic symptoms. Seclusion should only be used as a last resort when the client poses a serious danger to self or others, and not as a punishment or coercion.
Choice B is wrong because keeping the facility’s security personnel constantly visible to the client throughout treatment is intimidating and stigmatizing. This can also increase the client’s fear, distrust, and resentment, and may trigger aggressive behavior. Security personnel should only be involved when there is an imminent risk of violence, and not as a routine measure.
Choice D is wrong because agreeing that the hallucinations are real if the client exhibits aggressive behavior toward other clients is reinforcing the delusional belief and rewarding the aggression. This can also confuse the client and undermine the therapeutic relationship.
The nurse should acknowledge the client’s experience of hallucinations, but not endorse them as reality. The nurse should also set clear limits on aggressive behavior and use de-escalation techniques to calm the client.
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