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 D

Explanation

Choice A: A 26-year-old client who has migraine headaches at the start of each menstrual cycle does not have a contraindication for receiving oral contraceptives. Oral contraceptives are pills that contain synthetic hormones (estrogen and progestin) that prevent ovulation and pregnancy. They can also help regulate menstrual cycles and reduce menstrual pain and bleeding. Some women with migraine headaches may benefit from oral contraceptives, especially if their migraines are related to hormonal fluctuations or menstruation. However, oral contraceptives may worsen migraines in some women, especially if they have aura (visual or sensory disturbances) or other risk factors for stroke. Therefore, oral contraceptives should be used with caution and under medical supervision in women with migraine headaches.

Choice B: A 28-year-old client who has a history of pelvic inflammatory disease does not have a contraindication for receiving oral contraceptives. Pelvic inflammatory disease (PID) is an infection of the female reproductive organs (uterus, fallopian tubes, ovaries) that can cause pain, fever, discharge, or infertility. It can be caused by various bacteria, often sexually transmitted ones such as gonorrhea or chlamydia. Oral contraceptives do not protect against STIs or PID, but they may reduce the risk of PID by thickening the cervical mucus and preventing bacteria from entering the uterus. Therefore, oral contraceptives can be used safely in women with a history of PID, but they should also use condoms or other barrier methods to prevent STIs.

Choice C: A 32-year-old client who has benign breast disease does not have a contraindication for receiving oral contraceptives. Benign breast disease (BBD) is a term that refers to various noncancerous conditions that affect the breast tissue, such as cysts, fibroadenomas, or mastitis. They can cause symptoms such as lumps, pain, or tenderness in the breasts. Oral contraceptives do not cause or increase the risk of BBD, but they may improve some symptoms of BBD by stabilizing the hormonal levels and reducing breast tissue sensitivity. Therefore, oral contraceptives can be used safely in women with BBD, but they should also have regular breast exams and mammograms to monitor their breast health.

Choice D: A 38-year-old client who reports smoking one pack of cigarettes every day has a contraindication for receiving oral contraceptives. Smoking is a habit that involves inhaling the smoke of tobacco or other substances that can cause various health problems, such as lung cancer, heart disease, or stroke. Oral contraceptives can increase the risk of these problems, especially in women who are older than 35 years or smoke more than 15 cigarettes per day. Smoking and oral contraceptives can interact and cause blood clots, high blood pressure, or reduced blood flow to the organs. Therefore, oral contraceptives should be avoided or discontinued in women who smoke, and alternative methods of contraception should be used.

A. "Don't worry, I will be with you during the exam." B. "What part of the exam makes you most nervous?" C. "All you need to do is relax." D. "A pelvic exam is required if you want birth control pills."

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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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 reviewing contraception options for four clients. The nurse should identify which of the following clients has a contraindication for receiving oral contraceptives.

Correct Answer is D

Explanation

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?

Correct Answer is B

Explanation

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