The physician has just informed a patient that they have breast cancer and will require a mastectomy. The nurse finds that the patient is crying.
Which response by the nurse is most appropriate?

“This must be very difficult for you. I am here if you want to talk.”.

“Can you tell me why you are so upset?”

“I am sure everything will be alright. There is no need to cry.”.

“You will recover.”.

Answer and Explanation

The Correct Answer is A

Choice A rationale

When a patient is informed about a serious diagnosis like breast cancer and the need for a mastectomy, it is common for them to experience a range of emotions, including sadness, fear, and anxiety. As a nurse, providing emotional support and creating a safe space for the patient to express their feelings is crucial. Offering to be there for the patient if they want to talk acknowledges their emotional distress and provides comfort.

Choice B rationale

Asking the patient why they are upset may come across as insensitive or dismissive. The patient has just received a life-changing diagnosis, and their emotional reaction is completely normal and expected. It’s important to provide support and empathy rather than questioning their feelings.

Choice C rationale

Telling the patient that everything will be alright and there is no need to cry may seem comforting, but it can actually invalidate the patient’s feelings. It’s important to acknowledge the patient’s emotions and allow them to express their feelings without judgment.

Choice D rationale

Telling the patient that they will recover may be seen as providing false reassurance. While it’s important to maintain hope, it’s also crucial to be honest and realistic with the patient about their diagnosis and treatment.

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Correct Answer is C

Explanation

Choice A rationale

Administering the prescribed antibiotic early might not be the most immediate action. While antibiotics can help treat an infection, it’s crucial to first confirm the presence of an infection before starting antibiotic therapy.

Choice B rationale

Applying a sterile dressing to the area is important, but it’s not the priority nursing action. Dressings help protect the wound from further contamination, but they do not address the underlying issue of a potential infection.

Choice C rationale

Reporting the finding to the care provider is the priority nursing action. The symptoms described - a new foul odor coming from the incision, which is erythematous, tender, and warm to the touch - suggest a possible infection. Immediate reporting allows for prompt evaluation and treatment, which is crucial in preventing further complications.

Choice D rationale

Obtaining a culture of the incision might be necessary to identify the specific causative agent of the infection, but it’s not the priority action. It’s more important to first report the findings to the care provider.

A. Call the health care provider if you notice that your stools are dark. B. Change positions slowly to avoid dizziness. C. Do not take aspirin while you are taking clopidogrel. D. Take the clopidogrel with orange juice so it is more effective.

Correct Answer is A

Explanation

Clients taking clopidogrel should be advised to call their healthcare provider if they notice that their stools are dark. This could be a sign of gastrointestinal bleeding, a potential side effect of clopidogrel.

Choice B rationale

Changing positions slowly to avoid dizziness is not specifically related to clopidogrel use.

Choice C rationale

While it’s generally advised to avoid taking other blood thinners while on clopidogrel, aspirin is sometimes prescribed together with clopidogrel under the supervision of a healthcare provider.

Choice D rationale

There is no specific recommendation to take clopidogrel with orange juice for it to be more effective.

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The physician has just informed a patient that they have breast cancer and will require a mastectomy. The nurse finds that the patient is crying. Which response by the nurse is most appropriate?

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who had an above-the-knee amputation (AKA) five days ago. The nurse notices a new foul odor coming from the incision, which is erythematous, tender, and warm to the touch. What is the priority nursing action in this situation?

Correct Answer is C

Explanation

Choice A rationale

Choice B rationale

Choice C rationale

Choice D rationale

The client diagnosed with peripheral arterial disease (PAD) has a new prescription for clopidogrel. What information should the nurse include when teaching the client about this medication?

Correct Answer is A

Explanation

Choice B rationale

Choice C rationale

Choice D rationale

A Type 1 diabetic client’s blood glucose level is 50 mg/dL at 16:30. The client is alert; however, dinner will not be served until 17:15. What should be the nurse’s initial action?

The physician has just informed a patient that they have breast cancer and will require a mastectomy. The nurse finds that the patient is crying. Which response by the nurse is most appropriate?

Which clinical manifestation should the nurse anticipate as an expected finding for a client diagnosed with deep vein thrombosis (DVT)?

A patient recovering from aorto-femoral bypass surgery has developed edema, severe pain, paresthesia, and tightness of the operative limb. The nurse recognizes that what post-operative complication is most likely causing the patient’s symptoms?

A client asks a nurse, “What is a hemoglobin A1C test?” Which of the following is the most appropriate response?

A client is receiving trimethoprim-sulfamethoxazole. What information should the nurse include in the teaching about this medication?

The nurse is evaluating the patient’s response to antibiotic therapy. Which data would indicate that the medication has been effective?

Which prescribed medication for the client recovering from a traumatic amputation does the nurse correlate to the treatment of phantom limb pain?

The physician has just informed a patient that they have breast cancer and will require a mastectomy. The nurse finds that the patient is crying.
Which response by the nurse is most appropriate?