A nurse is caring for a client who has recently undergone a total bilateral mastectomy.

Which of the following statements by the client requires immediate action by the nurse?

"I don't understand why everyone is so worried about me."

"I don't know if I'll ever find someone who wants to marry me."

"When I look at myself in the mirror, I don't know if I can go on."

"I feel like the doctor pressured me into having the mastectomy."

Answer and Explanation

The Correct Answer is C

A: The client's statement reflects feelings of confusion but does not indicate immediate harm or danger to themselves. It requires therapeutic communication and support but not immediate action.
B: The client's statement expresses concern about their future relationships but does not indicate immediate harm or danger to themselves. It requires support and counseling but not immediate action.
C: Correct. The client's statement suggests significant emotional distress and a potential risk for self-harm or suicidal ideation. Immediate action is required to assess the client's safety and provide appropriate interventions, such as involving a mental health professional.
D: The client's statement indicates dissatisfaction or regret about the mastectomy decision but does not indicate immediate harm or danger to themselves. It requires supportive communication and addressing concerns but not immediate action.

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Correct Answer is A

Explanation

A.Keeping the crutch tips dry is essential to prevent slipping and falling, which can lead to further injury. Moisture on the tips can reduce friction, making the crutches unstable on surfaces.

B.When sitting down, the correct technique involves holding both crutches in one hand and using the other hand to lower yourself safely into the chair. Holding a crutch in each hand can make it difficult to balance and sit down safely.

C.Placing weight on the underarms can cause nerve damage and pain. The correct technique is to place weight on the hands and use the muscles of the arms and shoulders to support the body.

D. When going upstairs with a fractured leg, the proper technique is to lead with the uninjured leg, not the injured one. This ensures stability and reduces the risk of further injury to the fractured leg.

A. Ensure a client can use crutches before discharge. B. Check a client's ability to swallow following a stroke. C. Obtain a client's pain rating prior to physical therapy. D. Assist a client to get out of bed after a breathing treatment.

Correct Answer is D

Explanation

A: Incorrect. Ensuring a client can use crutches before discharge requires clinical judgment and skilled assessment, so it should not be delegated to assistive personnel.
B: Incorrect. Checking a client's ability to swallow following a stroke involves assessing the client's airway and potential risk of aspiration, which is a complex nursing task and should not be delegated to assistive personnel.
C: Incorrect. Obtaining a client's pain rating prior to physical therapy requires understanding the client's pain and its management, which should not be delegated to assistive personnel.
D: Correct. Assisting a client to get out of bed after a breathing treatment can be safely delegated to assistive personnel. It involves helping the client move, which is within the scope of their training.

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A nurse is caring for a client who has recently undergone a total bilateral mastectomy. Which of the following statements by the client requires immediate action by the nurse?

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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A nurse is caring for a client who has recently undergone a total bilateral mastectomy.

Which of the following statements by the client requires immediate action by the nurse?