At the first dressing change, the practical nurse (PN) tells the client that her mastectomy incision is healing well, but the client refuses to look at the incision and refuses to talk about it. Which response by the PN to the client's silence is best?
It's OK if you don't want to look or talk about the mastectomy. I will be available when you're ready.
You will feel better when you see that the incision is not as bad as you may think.
Would you like me to call another nurse to be here while I show you the wound?.
Part of recovery is accepting your new body image, and you will need to look at your incision.
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Circumoral cyanosis is a bluish discoloration around the mouth that indicates inadequate oxygenation. It is an abnormal finding in a full-term newborn and requires immediate assessment and intervention by the PN.
The other options are not correct because:
- A positive Babinski's reflex is a normal finding in newborns that indicates intact neurological function. It is elicited by stroking the sole of the foot and observing the fanning of the toes.
- A negative Ortolani's sign is a normal finding in newborns that indicates no hip dislocation or dysplasia. It is elicited by abducting the hips and feeling for any clicking or clunking sensation.
- A large sacral "stork bite" is a common benign birthmark that appears as a reddish patch on the lower back or nape of the neck. It usually fades within the first year of life and does not require any treatment.
Correct Answer is D
Explanation
This comment shows empathy, respect, and support for the client, without being intrusive or judgmental. The PN acknowledges the client's feelings and offers companionship, which can help reduce isolation and loneliness.
The other options are not correct because:
A. This comment may be perceived as coercive or dismissive of the client's feelings, as it tries to persuade the client to do something he does not want to do or enjoy.
B. This comment may be perceived as accusatory or interrogatory, as it questions the client's decision or motive for staying in his room.
C. This comment may be perceived as minimizing or invalidating the client's feelings, as it implies that the client should not be sad or that his family is doing enough for him.
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