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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is B. Notify the charge nurse about the situation. Informed consent is when a healthcare provider explains a medical treatment to a patient before the patient agrees to it. The patient has the right to know their state of health, the diagnosis, and the treatments available, and to choose any alternative. The nurse is responsible for obtaining consent when initiating care, and reviewing consent before providing the care ordered by another health care professional. If the patient does not understand why the procedure is necessary, the nurse should notify the charge nurse or the physician who ordered the procedure, so that they can provide more information and answer any questions.
The nurse should not ask the client to sign the consent form anyway (A), as this would violate the patient's right to autonomy and self-determination.
The nurse should not remind the client about the specifics of the procedure (C) or explain to the client that the procedure will help treat his diagnosis (D), as these are not within the nurse's scope of practice and may be considered as giving medical advice.
Correct Answer is C
Explanation
Explanation: According to the Institute of Medicine, women who are obese before pregnancy (BMI of 30 or higher) should gain 11 to 20 pounds during pregnancy. Therefore, 16 lb is an acceptable weight gain for this client.
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