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 okay if you don't want to look or talk about the mastectomy. It will be available when you're ready."
"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."
"You will feel beter when you see that the incision is not as bad as you may think."
The Correct Answer is A
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"D"}
Explanation
Choice A rationale:
A pH level of 7.35 to 7.45 and HCO3- level of 22 to 26 mEq/L indicate a resolution of ketoacidosis. The normal pH range for the body is 7.35 to 7.45, and a return to this range indicates that the body’s acid-base balance has been restored. The bicarbonate (HCO3-) level is a measure of the metabolic component of the body’s acid-base balance, and the normal range is 22 to 26 mEq/L. A return to this range indicates that the metabolic acidosis caused by the ketoacidosis has been resolved.
Choice B rationale:
A pH level of 7.25 to 7.35 and HCO3- level of 18 to 22 mEq/L would indicate that the client is still in a state of mild acidosis, as the pH is below the normal range and the bicarbonate level is also slightly low, indicating a metabolic acidosis.
Choice C rationale:
A pH level of 7.15 to 7.25 and HCO3- level of 14 to 18 mEq/L would indicate a moderate acidosis. Both the pH and bicarbonate levels are significantly below their normal ranges, indicating a significant disruption in the body’s acid-base balance.
Choice D rationale:
A pH level of 7.05 to 7.15 and HCO3- level of 10 to 14 mEq/L would indicate severe acidosis, which would be life-threatening if not corrected. Both the pH and bicarbonate levels are far below their normal ranges, indicating a severe disruption in the body’s acid-base balance. In conclusion, choice A is correct because it represents values within the normal ranges for both pH and bicarbonate, indicating a resolution of ketoacidosis.
Correct Answer is A
Explanation
A - The injury may require medical attention, as the mother mentioned that the boy is in pain. Correct
This is the correct answer, as it reflects the nurse's assessment of the injury and the appropriate action to take. The nurse should consider the mother's report of pain as a valid indicator of the severity of the injury, and should not dismiss or minimize it.
The nurse should also observe the boy's arm and shoulder for any signs of fracture, dislocation, swelling, bruising, or deformity, and ask him to rate his pain on a scale of 0 to 10. The nurse should then decide whether to refer the boy to a physician or an emergency department for further evaluation and treatment.
B - The abrasions on the boy's leg and hand have healed.
This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The abrasions on the boy's leg and hand are not relevant to his current complaint of arm and shoulder pain, and do not indicate whether he needs medical attention or not. The nurse should focus on the boy's primary concern and not distract him with unrelated questions or comments.
C - The mother describes what she did after her child got injured.
This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The mother's description of what she did after her child got injured may provide some useful information, such as how long ago the injury occurred, what first aid measures were applied, and whether there was any improvement or worsening of symptoms. However, it does not directly answer the question of whether the injury requires medical attention or not. The nurse should listen to the mother's account, but also perform a physical examination and ask relevant questions to assess the injury.
D - The boy lacks coordination when answering the nurse's questions.
This is not the correct answer, as it does not reflect the nurse's assessment of the injury or the appropriate action to take. The boy's lack of coordination when answering the nurse's questions may indicate a possible head injury, concussion, or shock, which are serious complications that require immediate medical attention. However, it does not directly relate to his arm and shoulder pain, which is his main complaint.
The nurse should assess the boy's mental status and neurological function, but also evaluate his arm and shoulder for any signs of damage or inflammation.
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