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 D
Explanation
Choice A rationale:
Tetracycline antibiotics can form insoluble complexes with calcium, reducing their absorption when taken together. Therefore, advising the client to continue taking calcium supplements with food while on tetracycline therapy is not recommended as it may decrease the effectiveness of the antibiotic.
Choice B rationale:
The nurse should advise the client to avoid taking calcium supplements while on tetracycline therapy. Calcium-containing products (such as supplements, dairy products, and antacids) should be taken at least 2 hours before or after tetracycline administration to minimize the interference with drug absorption.
Choice C rationale:
Taking calcium supplements with tetracycline, even with plenty of water, can still lead to reduced drug absorption due to the formation of insoluble complexes. Therefore, this advice is not appropriate.
Choice D rationale:
The nurse should recommend that the client take calcium supplements at least 2 hours before or after tetracycline. This approach ensures that the client receives the full therapeutic benefit of the antibiotic while still meeting their calcium needs separately.
Correct Answer is D
Explanation
Choice A rationale:
This statement is incorrect. Suicidal ideation is not a diagnosis in itself but rather a symptom or thought process associated with various mental health conditions.
Choice B rationale:
This statement is incorrect. Suicidal ideation can occur in individuals of all age groups, not just in older adults. It is not limited to any specific age demographic.
Choice C rationale:
This statement is incorrect. Suicidal ideation does not always involve a detailed plan for self-harm. It can range from fleeting thoughts of self-harm to more detailed plans, but the severity can vary widely.
Choice D rationale:
This statement is accurate. Suicidal ideation can be a symptom of various underlying mental health conditions, including depression, anxiety disorders, bipolar disorder, and others. It involves thoughts of self-harm or suicide, which may or may not be accompanied by specific plans.
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