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."
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A: Cantaloupe is relatively high in potassium and is not a suitable choice for a low-potassium diet.
B: Baked potatoes are high in potassium and should be avoided in a low-potassium diet.
C: Banana chips are also high in potassium and should not be included in a low-potassium diet.
D: Correct. Applesauce is a low-potassium food and is an appropriate choice for a client with chronic kidney disease following a low-potassium diet.
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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