A home health nurse is assisting in the care of a client following a modified radical mastectomy. Which of the following statements by the client indicates effective coping?

"I would like to see what this looks like today."

"I'm going to close my eyes until you are done dressing my incision."

"I would just like to spend my day staring at the TV."

"I'm planning to stay at home until my breast reconstructive surgery."

Answer and Explanation

The Correct Answer is A

A. "I would like to see what this looks like today": This indicates effective coping as the client is engaging with their condition and facing the changes directly, which is an important step in emotional adjustment and recovery.
B. "I'm going to close my eyes until you are done dressing my incision": This suggests avoidance of the situation, which may indicate difficulty in coping with the reality of their condition.
C. "I would just like to spend my day staring at the TV": This may indicate withdrawal or avoidance, which is not an effective coping strategy.
D. "I'm planning to stay at home until my breast reconstructive surgery": While this may be part of the client's plan, it does not directly indicate effective coping with the current situation.

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Correct Answer is A

Explanation

A. Dyspnea: This is correct as dyspnea (difficulty breathing) can be a sign of fluid overload, particularly when excess fluid accumulates in the lungs.
B. Pruritus: This is more indicative of an allergic reaction rather than fluid overload.
C. Fever: This is often associated with transfusion reactions or infection, not specifically fluid overload.
D. Bradycardia: This is less commonly associated with fluid overload and more often seen in other conditions or complications.

A. Reposition the client in bed using the halo ring. B. Turn the client every 4 hr. C. Loosen the screws while cleansing the pin sites. D. Change the sheepskin lining under the device weekly.

Correct Answer is A

Explanation

A. When caring for a client with a halo vest after a cervical fracture, it's essential to maintain spinal alignment and prevent further injury. Repositioning the client using the halo ring ensures that the cervical spine remains immobilized during movement, thereby reducing the risk of additional damage. This method provides controlled movement while preserving the integrity of the spinal column.
B. This is incorrect. While frequent turning is necessary to prevent complications such as pressure injuries, turning every 2 hours (not 4) is the standard for immobile clients.
C. Loosen the screws while cleansing the pin sites: This is incorrect as loosening the screws can compromise the stability of the halo vest. Pin site care should be done carefully without altering the tension of the screws.
D. Change the sheepskin lining under the device weekly: This is not frequent enough for proper hygiene and skin care; the lining should be checked more regularly and changed as needed to maintain skin integrity and comfort.

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A home health nurse is assisting in the care of a client following a modified radical mastectomy. Which of the following statements by the client indicates effective coping?

Nursing Test Bank

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