A nurse is caring for a client who is to undergo a bilateral prophylactic mastectomy. The client states that her family opposes her decision. Which of the following responses should the nurse make?

Did you tell your provider that your family doesn't agree with your decision?

Your family disagrees with your decision?

You are making the same decision I would make.

You should get your family to agree with your decision before signing the consent.

Answer and Explanation

The Correct Answer is B

Choice A reason: Asking if the client informed her provider about family disagreement shifts focus from addressing her emotional needs to a procedural question. It does not facilitate therapeutic communication or explore the client’s feelings about her family’s opposition. This response fails to support the client’s autonomy or address the psychological impact of her decision, making it less effective in this context.
Choice B reason: Restating the client’s concern about family disagreement uses reflective listening, a therapeutic technique that validates her feelings and encourages further discussion. This approach fosters trust, helps the client process her emotions, and supports her autonomy in deciding on the mastectomy, aligning with patient-centered care principles for addressing sensitive decisions.
Choice C reason: Stating that the nurse would make the same decision introduces personal bias, which is inappropriate in therapeutic communication. It shifts focus from the client’s needs to the nurse’s perspective, potentially undermining the client’s autonomy. This response does not address the family’s opposition or support the client’s decision-making process, making it ineffective.
Choice D reason: Suggesting the client needs family agreement before signing consent undermines her autonomy as a competent adult. Informed consent requires only the client’s understanding and agreement, not family approval. This response dismisses the client’s decision-making capacity and fails to address her emotional concerns about family opposition, making it inappropriate.

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Correct Answer is B

Explanation

Choice A reason: Removing a thermometer for use on another client risks cross-contamination, as C. difficile spores are highly transmissible. Dedicated equipment is required to prevent spread, so this action is incorrect and violates infection control protocols.
Choice B reason: Wearing a gown during care prevents C. difficile spore transmission via contact, a key precaution for this infection. This aligns with CDC contact isolation guidelines, protecting staff and other patients, making it the correct action.
Choice C reason: Washing hands with alcohol-based cleaner is ineffective against C. difficile spores, which require soap and water to physically remove them. This action is incorrect and inadequate for infection control in this scenario.
Choice D reason: Wearing an N95 respirator is unnecessary, as C. difficile is not airborne. Contact precautions (gown, gloves) suffice, so this action is incorrect and overprotective, wasting resources without addressing the transmission mode.

A. Heart rate 60/min B. Skin warm and dry C. Respiratory rate 30/min D. Tenting skin turgor

Correct Answer is C

Explanation

Choice A reason: A heart rate of 60/min is within normal range and does not indicate fluid overload, which may present with tachycardia due to increased cardiac workload. This finding is more consistent with normal physiology or hypovolemia, making it incorrect for identifying fluid overload.
Choice B reason: Skin warm and dry suggests normal hydration or dehydration, not fluid overload, which typically causes edema or moist skin. Dry skin indicates fluid deficit, not excess, making this finding irrelevant and incorrect for assessing fluid overload in this client.
Choice C reason: A respiratory rate of 30/min indicates tachypnea, a sign of fluid overload due to pulmonary edema from excess IV fluids. Fluid in the lungs impairs gas exchange, increasing breathing effort, aligning with clinical manifestations of overload, making this the correct finding.
Choice D reason: Tenting skin turgor indicates dehydration, not fluid overload, as it reflects reduced skin elasticity from fluid loss. Fluid overload causes edema, not tenting, making this finding opposite to the expected presentation and incorrect for this scenario.

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A nurse is caring for a client who is to undergo a bilateral prophylactic mastectomy. The client states that her family opposes her decision. Which of the following responses should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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