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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Place the newborn on a flat surface and clap hands loudly.

This action will elicit the Moro reflex, also known as the startle reflex, which is a normal, involuntary reaction that newborns and infants have when they’re startled. In response to the sound, the baby will throw back his or her head, extend out his or her arms and legs, cry, then pull the arms and legs back in.

Choice A is wrong because placing the newborn on their abdomen and observing the movement of their extremities will not trigger the Moro reflex.

This position may elicit other reflexes such as the crawling reflex or the tonic neck reflex.

Choice B is wrong because stroking the newborn’s cheek toward their mouth will not trigger the Moro reflex. This action will elicit the rooting reflex, which helps the baby find the breast or bottle to start feeding.

Choice C is wrong because stroking upward on the lateral aspect of the newborn’s foot will not trigger the Moro reflex. This action will elicit the Babinski reflex, which causes the big toe to extend upward and the other toes to fan out.

A. The nurse is responsible for providing a written prescription for a client home care referral. B. The nurse should begin discharge planning upon the client’s admission. C. A home hazard appraisal includes an assessment of the client’s financial resources. D. A medication reconciliation is required 24 hours prior to the client’s discharge.

Correct Answer is B

Explanation

The nurse should begin discharge planning upon the client’s admission. This is because discharge planning is a key aspect of effective care that reduces the length of stay, emergency readmissions and pressure on hospital beds. Discharge planning involves considering what support might be required by the client in the community, referring the client to these services, and liaising with these services to manage the client’s discharge.

Choice A is wrong because the nurse is not responsible for providing a written prescription for a client home care referral. This is the role of the provider or another authorised prescriber.

Choice C is wrong because a home hazard appraisal does not include an assessment of the client’s financial resources. A home hazard appraisal is an evaluation of the safety and accessibility of the client’s home environment.

Choice D is wrong because a medication reconciliation is not required 24 hours prior to the client’s discharge. A medication reconciliation is a process of comparing the medications a client is taking with those prescribed for them to avoid errors or discrepancies. A medication reconciliation should be done at every transition of care, including admission, transfer and discharge.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is checking a newborn’s Moro reflex. Which of the following actions should the nurse take to elicit this reflex?

Correct Answer is D

Explanation

A nurse is reinforcing teaching with a newly licensed nurse about discharge planning. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

Correct Answer is B

Explanation

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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?