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."

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale:

Obtaining a urine specimen for analysis is an important step in the assessment of the client with renal calculi. However, it is not the most immediate intervention when the client is experiencing severe flank pain and hematuria. Pain management should take precedence.

Choice B rationale:

This is the correct answer. Severe flank pain in a client with renal calculi is indicative of renal colic, which is typically excruciating. Administering a prescribed opioid analgesic is the priority to relieve the client's pain and distress.

Choice C rationale:

Straining the urine for the presence of stones is an essential nursing intervention to identify and collect any passed stones. However, it is not the most immediate action when the client is in severe pain. Pain management is the priority.

Choice D rationale:

Preparing the client for a prescribed computed tomography (CT) scan is an important diagnostic step to assess the location and size of the renal calculi. However, it is not the most immediate intervention when the client is in severe pain and distress. Pain management should come first.

A. The client is the oldest of their siblings. B. The client's father lives in the client's home. C. The client's mother has asthma. D. The client has several siblings.

Correct Answer is D

Explanation

Choice A rationale:

The client being the oldest of their siblings is not a contributing factor related to the development of conduct disorder. Family dynamics such as birth order may have some influence on personality traits, but they are not a primary factor in the development of conduct disorder.

Choice B rationale:

The fact that the client's father lives in the client's home is a family dynamic, but it does not necessarily contribute to the development of conduct disorder. Other factors related to parenting style, communication, and family interactions play a more significant role in the development of conduct disorder.

Choice C rationale:

The client's mother having asthma is a medical condition and not a family dynamic that directly contributes to the development of conduct disorder. Conduct disorder is more closely associated with social, environmental, and psychological factors.

Choice D rationale:

The presence of several siblings in the family dynamic can contribute to the development of conduct disorder. Increased family size can lead to competition for attention and resources, which may affect the child's behavior and interactions. Sibling relationships and family dynamics are crucial in shaping a child's behavior and psychological well-being.

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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

A client with renal calculi is experiencing hematuria and reports severe flank pain. Which intervention should the nurse implement first?

Correct Answer is B

Explanation

A nurse is teaching a newly licensed nurse about contributing factors that can lead to the development of conduct disorder. Which of the following factors related to family dynamics should the nurse include in the teaching?

Correct Answer is D

Explanation

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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?