Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who is postoperative following a mastectomy.
Which of the following actions should the nurse take to help the client cope with the body image change resulting from the surgery?
A. Encourage the client to help care for their surgical incision.
Encourage the client to help care for their surgical incision. This can help the client accept the body image change and promote healing.
B. Suggest that the client decide about reconstruction as soon as possible.
Choice B is wrong because suggesting that the client decide about reconstruction as soon as possible can pressure the client and interfere with their coping process.
C. Postpone referrals to support services until the client requests them.
Choice C is wrong because postponing referrals to support services until the client requests them can delay the client’s emotional recovery and increase their isolation.
D. Avoid talking to the client about the surgery.
Choice D is wrong because avoiding talking to the client about the surgery can indicate that the nurse is uncomfortable with the topic and discourage the client from expressing their feelings.
This question is an excerpt from Nurse Dive's nursing test bank - ATI PN Capstone Proctored Comprehensive Assessment 2020 B. Take the full exam now
Full Explanation
Encourage the client to help care for their surgical incision. This can help the client accept the body image change and promote healing.
Choice B is wrong because suggesting that the client decide about reconstruction as soon as possible can pressure the client and interfere with their coping process.
Choice C is wrong because postponing referrals to support services until the client requests them can delay the client’s emotional recovery and increase their isolation.
Choice D is wrong because avoiding talking to the client about the surgery can indicate that the nurse is uncomfortable with the topic and discourage the client from expressing their feelings.
Similar Questions
A nurse on a medical-surgical unit is caring for a client who has hearing loss. Which of the following actions should the nurse take?
A. Speak in a louder than usual tone of voice during conversation.
Choice A is wrong because speaking in a louder than usual tone of voice during conversation can distort the sound and make it harder for the client to understand. The nurse should speak in a normal tone and enunciate clearly.
B. Mute the client’s television before beginning a conversation.
C. Avoid the use of hand gestures when talking to the client.
Choice C is wrong because avoiding the use of hand gestures when talking to the client can limit nonverbal communication and reduce the client’s comprehension. The nurse should use appropriate facial expressions
D. Use short phrases when talking to the client.
Full Explanation
Use short phrases when talking to the client.
Some possible explanations for the other choices are:
Choice A is wrong because speaking in a louder than usual tone of voice during conversation can distort the sound and make it harder for the client to understand.
The nurse should speak in a normal tone and enunciate clearly.
Choice C is wrong because avoiding the use of hand gestures when talking to the client can limit nonverbal communication and reduce the client’s comprehension.
The nurse should use appropriate facial expressions
A nurse is collecting data from a client prior to administration of verapamil. Which of the following findings indicates a need to withhold the medication?
A. Blood pressure 170/82 mm Hg.
Choice A is wrong because blood pressure 170/82 mm Hg is high and verapamil can help lower it. A normal blood pressure for adults is less than 120/80 mm Hg.
B. Respiratory rate 18/min.
Choice B is wrong because respiratory rate 18/min is normal and verapamil does not affect it. A normal respiratory rate for adults is between 12 and 20 breaths per minute.
C. Pulse rate 48/min.
Verapamil is a calcium channel blocker that can lower the heart rate and blood pressure. A normal pulse rate for adults is between 60 and 100 beats per minute. A pulse rate of 48/min is too low and indicates bradycardia, which can cause dizziness, fainting, or cardiac arrest. Verapamil should not be given to patients with bradycardia or heart block.
D. Potassium 4 mEq/L.
Choice D is wrong because potassium 4 mEq/L is normal and verapamil does not affect it. A normal potassium level for adults is between 3.5 and 5.0 mEq/L.
Full Explanation
Verapamil is a calcium channel blocker that can lower the heart rate and blood pressure. A normal pulse rate for adults is between 60 and 100 beats per minute. A pulse rate of 48/min is too low and indicates bradycardia, which can cause dizziness, fainting, or cardiac arrest. Verapamil should not be given to patients with bradycardia or heart block.
Choice A is wrong because blood pressure 170/82 mm Hg is high and verapamil can help lower it. A normal blood pressure for adults is less than 120/80 mm Hg.
Choice B is wrong because respiratory rate 18/min is normal and verapamil does not affect it. A normal respiratory rate for adults is between 12 and 20 breaths per minute.
Choice D is wrong because potassium 4 mEq/L is normal and verapamil does not affect it. A normal potassium level for adults is between 3.5 and 5.0 mEq/L.
A nurse is reinforcing teaching about self-care with an adolescent client who has infectious mononucleosis with splenomegaly.
Which of the following statements by the client indicates an understanding of the teaching?
A. “I will take an antibiotic for the next 10 days.”
Choice A is wrong because antibiotics are not effective for infectious mononucleosis, which is caused by a virus.
B. “I will not play soccer until my doctor tells me I can.”
“I will not play soccer until my doctor tells me I can.” This statement indicates that the client understands the risk of splenic rupture due to splenomegaly and the need to avoid contact sports until the spleen returns to normal size.
C. “I will need to get a varicella booster in 1 month.”
Choice C is wrong because varicella booster is not related to infectious mononucleosis and there is no evidence that the client needs it.
D. “I will expect the whites of my eyes to turn yellow.”
Choice D is wrong because jaundice (yellowing of the eyes and skin) is not a common manifestation of infectious mononucleosis and may indicate another condition such as hepatitis.
Full Explanation
“I will not play soccer until my doctor tells me I can.” This statement indicates that the client understands the risk of splenic rupture due to splenomegaly and the need to avoid contact sports until the spleen returns to normal size.
Choice A is wrong because antibiotics are not effective for infectious mononucleosis, which is caused by a virus.
Choice C is wrong because varicella booster is not related to infectious mononucleosis and there is no evidence that the client needs it.
Choice D is wrong because jaundice (yellowing of the eyes and skin) is not a common manifestation of infectious mononucleosis and may indicate another condition such as hepatitis.
Normal ranges for spleen size are 7 to 14 cm in length and 3 to 4 cm in thickness.