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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A: White- or flesh-colored papillary growths in the genital area are not the correct answer because they are more likely a finding of another STI, such as HPV. HPV can cause genital warts that look like small bumps on or around the genitals. Genital herpes does not cause warts, but blisters or sores that may burst and crust over.
Choice B: Green penile discharge is not the correct answer because it is more likely a finding of another STI, such as gonorrhea. Gonorrhea can cause a thick, yellow-green discharge from the penis that may have a foul odor. Genital herpes does not cause discharge from the penis but may cause pain or burning during urination.
Choice C: Influenza-like symptoms are the correct answer because they are a possible finding of genital herpes. Genital herpes can cause systemic symptoms such as fever, headache, muscle aches, or swollen lymph nodes during an outbreak. These symptoms may resemble those of influenza (the flu) but are caused by HSV infection.
Choice D: Anuria is not the correct answer because it is not a finding of genital herpes. Anuria is a condition that causes a complete absence of urine output due to kidney failure or obstruction. Genital herpes does not affect the kidneys directly but may cause urinary retention if there is severe swelling or pain in the genital area.
Correct Answer is B
Explanation
Choice A: "Don't worry, I will be with you during the exam." This response is not appropriate because it does not address the client's feelings or concerns. It also may sound dismissive or patronizing to the client, who may have valid reasons to be nervous.
Choice B: "What part of the exam makes you most nervous?" This response is appropriate because it shows empathy and interest in the client's perspective. It also invites the client to express her fears or questions and allows the nurse to provide information and reassurance.
Choice C: "All you need to do is relax." This response is not appropriate because it does not acknowledge the client's feelings or concerns. It also may sound unrealistic or insensitive to the client, who may find it hard to relax in a stressful situation.
Choice D: "A pelvic exam is required if you want birth control pills." This response is not appropriate because it does not address the client's feelings or concerns. It also may sound coercive or threatening to the client, who may feel pressured or intimidated by the requirement.
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