A nurse is preparing to discharge an older adult patient who had a mastectomy several months ago. The client tells the nurse that she has not had much desire for sexual relations since her surgery, stating, "my body is so different now." Which of the following is an appropriate response by the nurse?

"It is still too soon to expect to feel normal. Give it a few more years."

"Really, you look just fine to me. There's no need to feel undesirable."

"Consider an afternoon at the spa. A facial will make you feel more attractive."

"I'm interested in finding out more about how your body feels to you."

Answer and Explanation

The Correct Answer is D

Choice A reason: Telling the client it is too soon to expect to feel normal and to give it a few more years dismisses her feelings and provides an unrealistic timeline. It is not supportive or empathetic.

Choice B reason: Saying "Really, you look just fine to me. There's no need to feel undesirable" invalidates the client's feelings and does not address her concerns about her body image and sexual desire.

Choice C reason: Suggesting an afternoon at the spa and a facial to make her feel more attractive trivializes the client's emotional and physical experience post-surgery. It does not provide meaningful support or address the underlying issues.

Choice D reason: Expressing interest in how the client's body feels to her validates her feelings and opens up a dialogue for her to share her concerns. This approach is empathetic and allows the nurse to provide better support and address any issues the client might have.

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Correct Answer is D

Explanation

Choice A reason: Bright light sensitivity is a common side effect following cataract surgery and can be managed with appropriate measures such as wearing sunglasses. It does not necessarily indicate a complication requiring immediate reporting.

Choice B reason: Difficulty seeing with a patch on one eye and fear of falling are valid concerns, but they do not necessarily indicate an immediate complication that requires urgent reporting to the healthcare provider.

Choice C reason: Eye itching is common after cataract surgery, and the client should be advised not to rub the eye to prevent infection or damage. This comment does not indicate a severe complication that needs immediate reporting.

Choice D reason: Severe eye pain that the client cannot stand is a potential sign of a serious complication, such as increased intraocular pressure, infection, or other postoperative issues. This requires immediate attention from the healthcare provider to prevent further complications and ensure the client's safety.

A. Are you taking any medications? B. Have you had a recent infection? C. Have you traveled overseas? D. Do you have a history of chronic alcohol abuse?

Correct Answer is B

Explanation

Choice A reason: While knowing if the client is taking any medications is important, it does not directly relate to diagnosing Guillain-Barré syndrome.

Choice B reason: Guillain-Barré syndrome often follows a recent infection, such as a respiratory or gastrointestinal infection. The immune response to the infection can trigger an autoimmune reaction that damages the peripheral nerves, leading to the symptoms of GBS. Therefore, asking about recent infections helps establish a potential cause for the syndrome.

Choice C reason: Travel history can be relevant for certain infectious diseases, but it is not a primary question for diagnosing GBS.

Choice D reason: A history of chronic alcohol abuse is more relevant to other neurological conditions, such as peripheral neuropathy, but not specifically to Guillain-Barré syndrome.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client following cataract surgery. Which comment from the client should the nurse report to the client's health care provider IMMEDIATELY?

Correct Answer is D

Explanation

A nurse is assessing a client who has a suspected diagnosis of Guillain-Barré syndrome (GBS). Which of the following questions should the nurse ask the client?

Correct Answer is B

Explanation

The nurse is assessing a client's eyes and notes that when the client looks at a near object, the pupil constricts, but when the client looks at an object in the distance, the pupil dilates. The nurse should identify this finding as which condition?

A nurse evaluates a client who presents to the provider's office to assess multiple nevi. Which finding should the nurse highlight to the provider as a possible sign of malignancy?

A nurse is monitoring a client post-hypophysectomy. Which assessment finding is most important to report to the health care provider?

A client seen in the clinic with shortness of breath and fatigue is being evaluated for a possible diagnosis of heart failure. Which laboratory result will be the most useful to monitor?

The nurse identifies the client exhibiting supraventricular tachycardia and calls the provider. Several orders are given. For which of the following orders would the nurse request further clarification? (Select all that apply)

In reviewing a 50-year-old client's medical record, which clinical manifestation should the nurse plan to assess for?

The nurse is preparing the client assignments for the day to a licensed practical nurse (LPN) and an unlicensed assistive personnel (UAP). Which client should the nurse assign to the LPN? (Select all that apply)

The nurse is assessing a client diagnosed with Addison's disease for signs of hyperkalemia. What should the nurse observe with this electrolyte imbalance?