An unlicensed assistive personnel (UAP) reports that a client's right hand and fingers spasm when taking the blood pressure using the same arm.

After confirming the presence of the spasms, which action should the nurse take?

When a client refuses to look at their mastectomy incision and refuses to talk about it, the best response by the practical nurse (PN) is to respect the client's autonomy and validate their feelings. Option a) acknowledges the client's discomfort and provides reassurance that it is okay for them to decline looking or talking about the incision at the moment. It also offers support by letting the client know that the incision will be available for examination when they feel ready to do so.

Let's evaluate the other options:

b) "Would you like me to call another nurse to be here while I show you the wound?"
This response assumes that the client needs someone else present to address their refusal to look at the incision. While having another nurse present may be helpful for some clients, it is not the appropriate first response. Respecting the client's autonomy and providing support should be the initial approach.

c) "Part of recovery is accepting your new body image, and you will need to look at your incision."
This response may come across as directive and insensitive. It implies that the client must look at their incision as part of their recovery process, disregarding their feelings and personal choices. It is important to respect the client's autonomy and allow them to navigate their own healing journey at their own pace.

d) "You will feel beter when you see that the incision is not as bad as you may think."
This response invalidates the client's feelings and assumes that their concerns about the incision are unfounded. It is essential to respect the client's emotions and validate their experience rather than dismissing or minimizing their concerns.

In summary, when a client refuses to look at their mastectomy incision and refuses to talk about it, the best response by the practical nurse (PN) is to acknowledge the client's discomfort, respect their autonomy, and provide reassurance that it is okay for them to decline looking or talking about the incision at that moment. The client's readiness to address the incision should be honored, and support should be offered when they are ready.

The correct answer isChoice D.

Choice A rationale:

Hypertension is not a contraindication for administering clonidine. In fact, clonidine is often used to treat hypertension.It works by decreasing the levels of certain chemicals in your blood, allowing your blood vessels to relax and your heart to beat more slowly and easily.

Choice B rationale:

An apical heart rate of 72 beats/minute is within the normal range (60-100 beats/minute) and would not be a contraindication for administering clonidine.Clonidine can lower heart rate, so it’s important to monitor heart rate, but a normal heart rate does not preclude its use.

Choice C rationale:

Muscle weakness is not a specific contraindication for the use of clonidine. While muscle weakness can be a side effect of many medications, it is not typically associated with clonidine.However, if a patient was experiencing severe or unusual muscle weakness, it would be important for the healthcare provider to evaluate this symptom.

Choice D rationale:

A blood pressure of 90/76 mm Hg could be a contraindication for the use of clonidine. Clonidine is a medication that is used to lower blood pressure, and if a patient’s blood pressure is already low, further lowering it could lead to symptoms such as dizziness, fainting, or even shock.Therefore, it would be important to monitor the patient’s blood pressure closely while they are taking this medication.