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 C

Explanation

A. Discontinued medications do not provide actionable information for the receiving facility, as they are no longer relevant to the client's ongoing care. Including this information may lead to confusion about the current treatment plan.
B. Resolved health conditions are not a priority to communicate because they do not require further monitoring or intervention. Focus should be placed on active health concerns and ongoing care needs.
C. The frequency of vital sign collection is critical information for the receiving facility to maintain continuity of care and ensure appropriate monitoring of the client's condition. This detail helps guide the long-term care staff in managing the client’s ongoing health needs effectively.
D. Completed nursing interventions are not typically included in the transfer report as they have already been addressed and do not impact future care. The focus should remain on ongoing and future interventions required for the client.

A. Heart rate 62/min B. Urine output of 200 mL per 8 hr C. Pulse oximetry 95% on room air D. BP 112/76 mm Hg

Correct Answer is B

Explanation

A. Heart rate 62/min: A heart rate of 62 beats per minute is within the normal range for many adults and may not require immediate reporting unless it is a significant change from the client's baseline.
B. Urine output of 200 mL per 8 hr: Correct. A urine output of 200 mL in 8 hours is considered low and may indicate inadequate kidney perfusion or function. It should be reported to the provider as it could be a sign of renal impairment or dehydration.
C. Pulse oximetry 95% on room air: A pulse oximetry reading of 95% on room air is within the normal range for oxygen saturation in most healthy individuals. It does not require immediate reporting unless the client has a specific condition or baseline that warrants concern.
D. BP 112/76 mm Hg: Blood pressure of 112/76 mm Hg is within the normal range for many adults and may not require immediate reporting unless there are specific concerns related to the client's medical history or condition.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

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?