A breast biopsy indicates the presence of malignant cells, and the client is scheduled for a mastectomy. When preparing the client's preoperative plan of care, which area would the nurse most likely address as the priority?

Fluid balance

Body image

Urinary elimination

Activity

Answer and Explanation

The Correct Answer is B

Choice A: Fluid balance is not the most likely priority because it is not directly affected by the mastectomy. Fluid balance is the state of equilibrium between the intake and output of fluids in the body. It can be influenced by various factors such as hydration, nutrition, medication, or illness. It can be monitored by measuring vital signs, weight, urine output, or laboratory values. Fluid balance is important for maintaining homeostasis and preventing dehydration or edema, but it is not a specific concern for a client undergoing a mastectomy.

Choice B: Body image is the most likely priority because it is directly affected by the mastectomy. Body image is the perception and attitude that one has toward one's own physical appearance and function. It can be influenced by various factors such as culture, media, self-esteem, or feedback from others. It can be assessed by observing verbal and nonverbal cues, asking open-ended questions, or using standardized tools. Body image is a major psychosocial issue for a client undergoing a mastectomy, as it can affect one's sense of identity, femininity, sexuality, or attractiveness. The nurse should address body image by providing information, support, and referral to appropriate resources.

Choice C: Urinary elimination is not the most likely priority because it is not directly affected by the mastectomy. Urinary elimination is the process of expelling urine from the bladder through the urethra. It can be influenced by various factors such as fluid intake, kidney function, medication, or infection. It can be assessed by measuring urine volume, color, odor, or specific gravity. Urinary elimination is important for maintaining fluid balance and preventing urinary tract infection or retention, but it is not a specific concern for a client undergoing a mastectomy.

Choice D: Activity is not the most likely priority because it is not directly affected by the mastectomy. Activity is the level of physical movement and exercise that one engages in on a daily basis. It can be influenced by various factors such as age, health status, motivation, or environment. It can be assessed by observing mobility, endurance, strength, or coordination. Activity is important for maintaining muscle tone, joint range of motion, circulation, or metabolism, but it is not a specific concern for a client undergoing a mastectomy.

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Correct Answer is A

Explanation

Choice A: "A provider can help you with that after a physical examination." This response is appropriate and respectful because it acknowledges the client's right to choose a contraceptive method that suits her needs and preferences. It also encourages the client to seek professional advice and care from a provider who can assess her health status, medical history, and risk factors, and offer her a range of options and information.

Choice B: "You are so young. Are you ready for the responsibilities of a sexual relationship?" This response is inappropriate and judgmental because it implies that the client is too immature or irresponsible to have a sexual relationship. It also discourages the client from seeking help or information from the nurse and may make her feel ashamed or guilty about her sexuality.

Choice C: "Because of your age, I think that a barrier method would be the best choice." This response is inappropriate and paternalistic because it assumes that the nurse knows what is best for the client without considering her individual situation or preferences. It also limits the client's options and may not address her specific needs or concerns.

Choice D: "Before I can help you, I need to know more about your sexual activity." This response is inappropriate and intrusive because it asks for personal and sensitive information that may not be relevant or necessary for choosing a contraceptive method. It also violates the client's privacy and may make her feel uncomfortable or embarrassed.

A. Sleep disturbances B. Syncope C. Unusual fatigue D. Extreme hunger E. Arm pain

Correct Answer is ["A","C","E"]

Explanation

Choice A: Sleep disturbances are the correct answer because they are a symptom of a heart attack observed in women. Sleep disturbances are problems that affect the quality or quantity of sleep, such as insomnia, nightmares, or snoring. They can indicate that the heart is not pumping enough blood and oxygen to meet the body's needs during sleep. About 48% of women who have had a heart attack report having sleep disturbances in the weeks before their event.

Choice B: Syncope is not the correct answer because it is not a symptom of a heart attack observed in women. Syncope is a condition that causes a temporary loss of consciousness due to a drop in blood pressure or blood flow to the brain. It can be caused by various factors such as dehydration, medication side effects, or cardiac arrhythmias. However, it is not a common sign of a heart attack in women and only about 12% of women who have had a heart attack report having syncope before their event.

Choice C: Unusual fatigue is the correct answer because it is a symptom of a heart attack observed in women. Unusual fatigue is a feeling of extreme tiredness or exhaustion that is not relieved by rest or sleep. It can indicate that the heart is not pumping enough blood and oxygen to meet the body's needs during daily activities. About 70% of women who have had a heart attack report having unusual fatigue in the weeks before their event.

Choice D: Extreme hunger is not the correct answer because it is not a symptom of a heart attack observed in women. Extreme hunger is a feeling of intense or excessive appetite or craving for food. It can be caused by various factors such as diabetes, thyroid disorder, or stress. However, it is not a sign of a heart attack in women, and only about 4% of women who have had a heart attack report having extreme hunger before their event.

Choice E: Arm pain is the correct answer because it is a symptom of a heart attack observed in women. Arm pain is a feeling of discomfort or ache in one or both arms, especially the left arm. It can indicate that the heart muscle is not receiving enough blood and oxygen due to a blocked coronary artery. About 42% of women who have had a heart attack report having arm pain before their event.

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A breast biopsy indicates the presence of malignant cells, and the client is scheduled for a mastectomy. When preparing the client's preoperative plan of care, which area would the nurse most likely address as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is leading a discussion about contraception with a group of 14-year-old clients. After the presentation, a client asks the nurse which method would be best for her to use. Which of the following responses should the nurse make?

Correct Answer is A

Explanation

A nurse is preparing a class discussion on the clinical manifestations of a heart attack observed in women. Which symptoms would the nurse include as key assessment data? Select all that apply.

Correct Answer is ["A","C","E"]

Explanation

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A nurse in a family planning clinic is caring for a 17-year-old female client who is requesting oral contraceptives. The client states that she is nervous because she has never had a pelvic examination. Which of the following responses should the nurse make?

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