The nurse is caring for a patient who is one day post-mastectomy and notes that she is sobbing and gasping for breath. What should the nurse do first?
Notify the registered nurse.
Raise the head of the bed.
Sit with her and listen to her concerns.
Ask the patient what is wrong.
The Correct Answer is B
Choice A reason: Notifying the registered nurse is important but should come after initially assessing the patient's immediate needs.
Choice B reason: Raising the head of the bed may help with breathing but does not address the cause of the patient's distress.
Choice C reason: Sitting with her and listening to her concerns is supportive but should follow an initial assessment of why she is sobbing and gasping for breath.
Choice D reason: Asking the patient what is wrong is the first step in assessing the situation and providing appropriate care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Lying prone may be part of the care plan but is not specifically aimed at promoting ambulation.
Choice B reason: Coordination exercises are important but secondary to building the strength necessary for using mobility aids.
Choice C reason: Building upper body strength is essential for a patient who has had an above-the-knee amputation to be able to use assistive devices for ambulation effectively.
Choice D reason: Maintaining residual limb elevation is important for reducing swelling but does not directly promote ambulation.
Correct Answer is B
Explanation
Choice A reason: Extending the scheduled time could reinforce the client's resistance to discussing feelings until the end of the session, which is not therapeutic.
Choice B reason: Ending at the scheduled time maintains boundaries and structure, which are important in the therapeutic relationship, especially with clients who have personality disorders.
Choice C reason: Arranging for another nurse to continue the interview may disrupt the continuity of care and the therapeutic relationship.
Choice D reason: Setting an extra meeting time could be considered if the client's needs are urgent, but it is not the best option in this scenario as it may reinforce avoidance behaviors.
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