A nurse is caring for a client who is 2 days postoperative following a total bilateralmastectomy. The client is tearful and looks away when her surgical dressings are removed. The nurse should place the priority on which of the following actions?
Demonstrating a nonjudgmental attitude toward the client when providing care for her surgical wounds
Providing the client with information on community resources that will strengthen her coping skills
Identifying the client's perception of the changes in her physical appearance
Encouraging the client to write about her feelings in a journal each day
The Correct Answer is C
The correct answer is C. Identifying the client's perception of the changes in her physical appearance is essential for developing a plan of care that addresses her psychosocial needs and promotes her self-esteem and body image. The client may experience grief, anger, depression, anxiety, or guilt after losing her breasts, which can affect her quality of life and recovery. The nurse should explore how the client feels about herself and her sexuality, and provide emotional support and empathy. The other actions are also important, but they are not as a priority as understanding how the client views herself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
"You should administer the medication at bedtime." This statement is incorrect option. Administering methylphenidate at bedtime is not appropriate because it is a stimulant medication, and taking it in the evening could interfere with the child's ability to fall asleep and disrupt their sleep pattern.
Choice Breason:
"Your child should avoid foods containing tyramine. “This statement is incorrect option. Tyramine is not a concern with methylphenidate. Tyramine is associated with certain antidepressant medications, such as MAO inhibitors. Methylphenidate is not a MAO inhibitor, so there is no need for the child to avoid tyramine-containing foods.
Choice Creason:
"You should administer the medication after breakfast." This is the correct option. Administering methylphenidate after breakfast is a common practice because it allows the child to benefit from the medication during school hours when improved attention and focus are needed the most.
Choice Dreason:
"Your child should avoid excess sodium intake." This statement is an incorrect option. Excess sodium intake is not directly related to methylphenidate use. However, it is generally a good idea for anyone, including children, to have a balanced and healthy diet, which may include monitoring sodium intake. But it is not specifically tied to the administration of methylphenidate.
Correct Answer is {"dropdown-group-1":"D"}
Explanation
The nurse should prepare to administer naloxone and oxygen 10 L/min via face mask. Naloxone is a medicine that can reverse the effects of opioid drugs like fentanyl, which may have caused respiratory depression in the client.
Oxygen can help improve the client's oxygen saturation, which has dropped below 90%.
The nurse should avoid giving acetaminophen, which is not indicated for this situation, or additional doses of propofol or fentanyl, which may worsen the client's condition.
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