The nurse is caring for a patient who is one day post-mastectomy and notes that she is sobbing and gasping for breath. What should the nurse do first?

Notify the registered nurse.

Raise the head of the bed.

Sit with her and listen to her concerns.

Ask the patient what is wrong.

Answer and Explanation

The Correct Answer is B

Choice A reason: Notifying the registered nurse is important but should come after initially assessing the patient's immediate needs.

Choice B reason: Raising the head of the bed may help with breathing but does not address the cause of the patient's distress.

Choice C reason: Sitting with her and listening to her concerns is supportive but should follow an initial assessment of why she is sobbing and gasping for breath.

Choice D reason: Asking the patient what is wrong is the first step in assessing the situation and providing appropriate care.

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Correct Answer is D

Explanation

Choice A reason: Bursting open of the wound is a description that could imply evisceration, but it is not as specific as choice D.

Choice B reason: Wound edges not approximating is a general description of a wound that is not healing properly, but does not specifically describe evisceration.

Choice C reason: Opening of the wound could refer to any situation where a wound has opened, not necessarily evisceration.

Choice D reason: Evisceration specifically refers to the viscera spilling out of the abdomen, usually through a surgical wound.

A. Auditory hallucinations B. Free-floating anxiety C. Flashbacks D. Delusions of grandeur

Correct Answer is C

Explanation

Choice A reason: Auditory hallucinations involve hearing voices or sounds that are not present, which does not match Audrey's experience of visual perceptions.

Choice B reason: Free-floating anxiety is a general feeling of unease that is not tied to a specific situation, whereas Audrey's anxiety is triggered by a specific scenario reminiscent of past trauma.

Choice C reason: Flashbacks are vivid, often distressing, memories of past traumatic events that feel as though they are happening in the present. Audrey's experience is indicative of flashbacks related to her military service.

Choice D reason: Delusions of grandeur involve beliefs of inflated worth, power, or identity, which is not described in Audrey's situation.

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The nurse is caring for a patient who is one day post-mastectomy and notes that she is sobbing and gasping for breath. What should the nurse do first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What is evisceration?

Correct Answer is D

Explanation

Audrey is a veteran who served in Afghanistan. She finds it very difficult to drive through a parking ramp because she perceives that "There are people hiding behind the pillars! They have guns! Be careful." Audrey is most likely experiencing which of the following?

Correct Answer is C

Explanation

A schizophrenic client is being assessed by the nurse. The client is demonstrating negative symptoms. Which symptoms should be considered negative? (select all that apply)

A resident returns to the long-term care center after a right total hip replacement. The nurse should reinforce teaching for maintaining which of the following postoperative leg positions?

A nurse is collecting data from a client who has obsessive-compulsive personality disorder. Which of the following findings should the nurse include?

Patients who display very bizarre behavior but who are still functional in society are most likely to have which of the following types of personality disorder?

A nurse in an acute care mental health facility is sitting with a client who has schizophrenia. The client whispers to the nurse, "I'm being kept in this prison against my will. Please try to get me out." Which of the following responses should the nurse make?

The nurse is providing care for a patient after an above-the-knee amputation due to diabetes complications. Which nursing care is essential for promoting ambulation?

In the Mental Health Status Examination, which of the following focuses on what the person is thinking?

The nurse is caring for a client on the third day following abdominal surgery and assesses the absence of bowel sounds, abdominal distention, and the client passing no flatus. These findings indicate the client is experiencing which of the following postoperative complications?