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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

Determine the client's usual bowel pattern.

Choice A rationale:

Administering a prescribed PRN stool softener may be necessary if the client is experiencing constipation, but it is not the first action the PN should implement. Before administering any medication, the PN should gather more information to make an informed decision.

Choice B rationale:

Encouraging the client to ambulate more frequently can be beneficial for promoting bowel movements, but it is not the first action to implement. The PN should first assess the client's bowel pattern to determine if there is a deviation from their usual routine.

Choice C rationale:

Recommending increasing high fiber foods daily can also help with constipation, but it is not the first action to take. The PN should assess the client's current bowel pattern to better understand the situation.

Choice D rationale:

Determining the client's usual bowel pattern is the first action the PN should take. This assessment will help establish a baseline and identify any deviations that might indicate a potential issue, which can then guide further interventions.

A. Oatmeal is a good choice for breakfast. B. Eat red meat just until the anemia is resolved. C. Add lentils and black beans to soups. D. Increase green leafy vegetables in the diet.

Correct Answer is ["A","C","D"]

Explanation

The correct answers are:

A. Oatmeal is a good choice for breakfast.

C. Add lentils and black beans to soups.

D. Increase green leafy vegetables in the diet. Choice A rationale:

Oatmeal is a good choice for breakfast because it is a vegetarian option that is rich in iron. It contains non-heme iron, which is the type of iron found in plant-based foods. Non-heme iron may not be as easily absorbed as heme iron (found in animal products), but it can still contribute to increasing iron levels in the body, especially when combined with other sources of iron.

Choice B rationale:

Eat red meat just until the anemia is resolved is not a suitable instruction for a vegetarian client. Red meat is a source of heme iron, which is not part of a vegetarian diet. While heme iron is more easily absorbed by the body, there are other plant-based sources of iron that can be recommended to the client without compromising their dietary preferences.

Choice C rationale:

Lentils and black beans are excellent choices for a vegetarian client to increase iron intake. Both foods are rich in iron, and they also contain other nutrients that aid in iron absorption, such as vitamin C. Including lentils and black beans in soups can be a tasty and nutritious way to enhance iron intake.

Choice D rationale:

Increasing green leafy vegetables in the diet is another appropriate recommendation for a vegetarian client. Green leafy vegetables, such as spinach and kale, contain non-heme iron, as well as other essential vitamins and minerals that contribute to overall health. Combining them with vitamin C-rich foods can enhance iron absorption.

Choice E rationale:

Take two prenatal vitamins with iron daily is not necessary since the healthcare provider already prescribed one prenatal vitamin with iron daily. Taking additional supplements without medical advice can lead to an excessive intake of certain nutrients, which may have adverse effects on health.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When performing a focused gastrointestinal system assessment, the practical nurse (PN) asks a male client when his last bowel movement occurred. The client answers, "Three days ago.”. Which action should the PN implement first?

Correct Answer is D

Explanation

Correct Answer is ["A","C","D"]

Explanation

A male client who has just been told he has cancer asks the practical nurse (PN) to leave his room so he can be alone. Which action should the PN implement?

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A client is being treated for hepatic failure. On examination, the client has an elevated pulse rate and exhibited changes in mental status. Which intervention in the plan of care should the practical nurse (PN) implement?

The practical nurse (PN) is caring for a client who has darkened membranes of the mouth and a smoky breath. Which priority nursing problem should the PN include in the plan of care?

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The practical nurse (PN) is contributing to a care plan for an adult client with Lyme disease. Which client outcome is indicated for this client?

After administering pantoprazole to a client with gastroesophageal reflux disorder (GERD), which statement by the client indicates to the practical nurse (PN) that the medication is producing the desired effect?