A nurse is caring for a client who has breast cancer and is postoperative following a bilateral mastectomy. Which of the following statements indicates the client has an altered body image?

I prefer to wear loose clothing to hide my scars.

I am ready to join a support group for cancer survivors.

I feel confident about my recovery process.

I am planning to resume my exercise routine next week.

Answer and Explanation

The Correct Answer is A

Choice A reason: Preferring loose clothing to hide scars indicates an altered body image, as it reflects discomfort with physical changes post-mastectomy. This behavior suggests emotional distress about appearance, a common response to surgical body alterations, making it the correct indicator.
Choice B reason: Joining a support group shows proactive coping and acceptance, not necessarily an altered body image. It reflects social engagement and resilience, not distress about physical changes, making it incorrect for indicating body image concerns.
Choice C reason: Feeling confident about recovery suggests positive adjustment, not an altered body image. Confidence indicates emotional resilience rather than distress about physical appearance post-mastectomy, making this statement incorrect for this concern.
Choice D reason: Planning to resume exercise indicates focus on recovery and health, not body image distress. This proactive attitude reflects physical rehabilitation goals, not emotional concerns about appearance, making it incorrect for altered body image.

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Correct Answer is D

Explanation

Choice A reason: Contractions lasting 60 seconds every 5 minutes are normal for active labor, indicating effective uterine activity to progress delivery. This does not require immediate reporting, as it aligns with expected labor patterns and does not indicate fetal or maternal distress, making it a non-urgent finding.
Choice B reason: A fetal heart rate of 140 beats per minute is within the normal range (110-160 bpm) for a fetus in labor. This indicates fetal well-being and does not require reporting unless accompanied by abnormal patterns like decelerations, making this finding normal and not urgent.
Choice C reason: A maternal blood pressure of 120/80 mmHg is normal and does not indicate distress or complications like preeclampsia. It does not require reporting, as it reflects stable maternal hemodynamics during labor, making this finding non-urgent compared to fetal heart rate abnormalities.
Choice D reason: Late decelerations in the FHR indicate uteroplacental insufficiency, reducing fetal oxygenation and risking hypoxia. This requires immediate reporting to the provider for interventions like position changes or oxygen administration to prevent fetal distress, making it the critical finding necessitating urgent action.

A. Keeping the drainage bag above waist level. B. Disconnecting the catheter from the drainage bag to empty the bag. C. Emptying the drainage bag when it is three-quarters full. D. Using sterile gloves when emptying the drainage bag.

Correct Answer is C

Explanation

Choice A reason: Keeping the drainage bag above waist level promotes urine backflow, increasing infection risk. Bags must be below bladder level to ensure proper urine flow, so this action is incorrect and unsafe, requiring nurse intervention.
Choice B reason: Disconnecting the catheter to empty the bag breaks the closed system, increasing infection risk. The bag should be emptied via the drainage port, so this action is incorrect and requires correction by the nurse.
Choice C reason: Emptying the drainage bag when three-quarters full prevents overfilling, reducing backflow and infection risk. This aligns with proper catheter care protocols, ensuring safety for a fall-risk client, making it the correct technique.
Choice D reason: Using sterile gloves for emptying the drainage bag is unnecessary, as clean gloves suffice for this non-sterile procedure. Sterile gloves are for catheter insertion, so this action is incorrect and inefficient, requiring guidance.

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A nurse is caring for a client who has breast cancer and is postoperative following a bilateral mastectomy. Which of the following statements indicates the client has an altered body image?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?

Correct Answer is D

Explanation

A nurse is supervising an assistive personnel (AP) who is caring for a client who is at risk for falls. Which of the following actions taken by the AP indicates proper technique for urinary catheter care?

Correct Answer is C

Explanation

A nurse is assessing a client’s pulmonary artery wedge pressure (PAWP). The nurse should recognize that an elevated PAWP indicates which of the following complications?

A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following findings requires a referral for further care?

A charge nurse is mentoring a newly licensed nurse about ergonomic principles. Which of the following should the charge nurse include when teaching about ergonomic principles?

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