An older adult female asks the practical nurse (PN) if she should get a Herpes zoster (shingles) vaccination because she gets cold sores on her mouth when she is sick or stressed. Which response should the PN provide?

The correct answer is choice A: "It's OK if you don't want to look or talk about the mastectomy. I will be available when you're ready.”.

Choice A rationale:

This response shows empathy and understanding, acknowledging the client's feelings and respecting her decision not to look at or discuss the incision. It allows the client to take control of her own emotions and healing process, while also reassuring her that the nurse will be available whenever she feels ready to talk or see the incision.

Choice B rationale:

Telling the client that she will feel better when she sees the incision minimizes her feelings and may be seen as dismissive. It does not address her emotions or concerns and can be counterproductive to building trust and rapport.

Choice C rationale:

Suggesting to call another nurse to be present while showing the wound might make the client feel uncomfortable or pressured. It is essential to establish a therapeutic nurse-client relationship, and forcing the issue could increase the client's distress.

Choice D rationale:

Telling the client that part of recovery is accepting her new body image and needing to look at her incision is insensitive and inappropriate. It is not the nurse's role to dictate how the client should feel about her body or her healing process. Such a response could potentially harm the nurse-client relationship and hinder the client's emotional healing.

The correct answer is choice C. Suction the oral and nasal passages.

Choice A rationale:

Turning the infant onto the right side may not be the most appropriate intervention for cyanosis caused by regurgitation. Cyanosis signifies a lack of oxygen, and simply changing the infant's position might not address the underlying issue.

Choice B rationale:

Giving oxygen by positive pressure is not the immediate intervention needed for regurgitation-induced cyanosis. While administering oxygen is important, the first step should involve clearing the airway to ensure proper oxygenation.

Choice C rationale:

Suctioning the oral and nasal passages is crucial in this situation as the cyanosis is likely due to the infant's airway being obstructed by regurgitated material. Clearing the airway can restore normal breathing and oxygenation.

Choice D rationale:

Stimulating the infant to cry is not the appropriate action when cyanosis is present. Cyanosis indicates a serious problem with oxygenation, and crying may worsen the situation by further compromising the infant's breathing.