A nurse is preparing to witness a client who is scheduled for a bilateral mastectomy sign the informed consent form. The client states, "I am glad they are not taking both breasts." Which of the following actions should the nurse take?

Check with the surgery department that the procedure is correct.

Notify the provider after the client signs the form.

Explain to the client that both breasts are to be removed.

Ask the provider to clarify the procedure with the client before she signs the form.

Answer and Explanation

The Correct Answer is D

A. Check with the surgery department that the procedure is correct. While important, it does not address the client's misunderstanding.
B. Notify the provider after the client signs the form. The client should not sign the form until they understand the procedure.
C. Explain to the client that both breasts are to be removed. The nurse should not provide surgical explanations beyond their scope.
D. Ask the provider to clarify the procedure with the client before she signs the form. The provider must ensure the client understands the procedure before consent is signed.

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Correct Answer is D

Explanation

A. Decrease in heart rate: Acute pain typically causes an increase in heart rate, not a decrease.
B. Increase in vagal nerve tone: An increase in vagal nerve tone can actually result in a decreased heart rate and is not a direct indicator of acute pain.
C. Decrease in respiratory rate: Acute pain usually causes an increase in respiratory rate, not a decrease.
D. Increase in muscle tone: This is correct. An increase in muscle tone can indicate acute pain as the body tenses in response to pain.

A. Encourage an Increased number of adults to abstain from alcohol use. B. Limit the intake of grain products for children older than 2 years. C. Increase calories from saturated fat intake for children older than 2 years. D. Advise adults to eat plant-based foods.

Correct Answer is D

Explanation

A. Encourage an increased number of adults to abstain from alcohol use. While reducing excessive alcohol consumption is a goal of Healthy People 2020, complete abstinence is not specifically a target unless it relates to specific health conditions or populations.
B. Limit the intake of grain products for children older than 2 years. Healthy People 2020 does not advocate for limiting grain products for children. Instead, it promotes a balanced diet that includes whole grains as part of healthy eating patterns.
C. Increase calories from saturated fat intake for children older than 2 years. Healthy People 2020 recommends reducing the intake of calories from saturated fats to promote heart health and prevent chronic diseases.
D. Advise adults to eat plant-based foods. This is correct. Healthy People 2020 encourages a diet rich in plant-based foods such as fruits, vegetables, and whole grains to improve health and reduce the risk of chronic diseases.

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A nurse is preparing to witness a client who is scheduled for a bilateral mastectomy sign the informed consent form. The client states, "I am glad they are not taking both breasts." Which of the following actions should the nurse take?

Nursing Test Bank

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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