A woman who had bilateral mastectomy three weeks ago admits to feeling helpless and depressed during a follow-up clinic visit. Which intervention should the nurse implement?

Determine if the client has suicidal intentions.

Ask the client how many times she has considered suicide.

Refer the client to the clinic's social worker.

Notify the client's significant other about her risk for suicide.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Determine if the client has suicidal intentions: Expressions of helplessness and depression following major body-altering surgery place the client at increased risk for suicidal ideation. The nurse’s priority is a direct, therapeutic assessment of suicide risk to ensure immediate safety. Early identification allows timely mental health intervention and protective measures.

B. Ask the client how many times she has considered suicide: Asking for frequency without first establishing whether suicidal thoughts are present is premature and overly intrusive. Assessment should begin with determining the presence or absence of suicidal ideation before exploring details. A stepwise, supportive approach is clinically appropriate.

C. Refer the client to the clinic's social worker: Referral to social work is appropriate after initial safety assessment has been completed. Without first assessing suicide risk, a critical and potentially urgent concern may be missed. Safety assessment takes precedence over supportive referrals.

D. Notify the client's significant other about her risk for suicide: Breaching confidentiality without first assessing risk or obtaining consent is inappropriate unless there is an immediate danger. Family notification is considered only after evaluation and in accordance with ethical and legal guidelines. The nurse must first assess the client directly.

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Correct Answer is B

Explanation

Rationale:
A. Support the client in an upright position until the belt is removed: Trying to keep a falling client upright increases the risk of both client and nurse injury. It is unsafe and does not control the fall effectively.

B. Ease the client to the floor while holding the gait belt securely: Lowering the client safely to the floor using the gait belt protects the client from injury and minimizes risk to the nurse. This is the standard safe procedure for fall prevention during ambulation.

C. Advise the client to grab hold of the gait belt for added support: During a sudden fall, the client may not have the strength, coordination, or reaction time to grab the belt effectively, so this is not a safe or reliable action.

D. Use the gait belt to slowly guide the client back to the room: Attempting to redirect or guide the client while they are falling does not prevent injury and may worsen the fall. Safe lowering to the floor is the priority.

A. Height and weight checks. B. Colorectal cancer screenings. C. Prostate exams for men. D. Tuberculosis screening. E. Contraception counseling.

Correct Answer is ["A","B","C"]

Explanation

Rationale:
A. Height and weight checks: Monitoring height and weight helps identify trends in body mass index (BMI), obesity, and related chronic disease risks such as diabetes, hypertension, and cardiovascular disease. Routine measurement is an essential component of health promotion in middle-aged adults.

B. Colorectal cancer screenings: Screening for colorectal cancer typically begins at age 45–50 for average-risk adults. Early detection through colonoscopy, stool tests, or other methods reduces morbidity and mortality, making it a key preventive health activity.

C. Prostate exams for men: Prostate cancer screening, including prostate-specific antigen (PSA) testing and digital rectal exams, is recommended for men starting around age 50, or earlier for those at higher risk. Regular screening promotes early detection and improved outcomes.

D. Tuberculosis screening: Routine TB screening is not indicated for all middle-aged adults unless they have specific risk factors, such as immunocompromised status, recent exposure, or travel to endemic areas. It is not a standard health promotion activity for the general population.

E. Contraception counseling: While important for reproductive-aged individuals, middle-aged adults are typically beyond peak fertility. Contraception counseling is not routinely prioritized in health promotion for this age group unless specific reproductive concerns exist.

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A woman who had bilateral mastectomy three weeks ago admits to feeling helpless and depressed during a follow-up clinic visit. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After applying a gait belt, the nurse assists a client with ambulation. While in the hallway, the client begins to fall. Which action should the nurse implement?

Correct Answer is B

Explanation

The nurse is teaching a health promotion class to middle-aged adults. Which routine health promotion activity(ies) should the nurse encourage? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

A woman who had bilateral mastectomy three weeks ago admits to feeling helpless and depressed during a follow-up clinic visit. Which intervention should the nurse implement?

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