Nokea
A client expresses concern about facial appearance after surgery for excision of a melanoma on the side of the nose. What is the best response by the nurse?
- A. Have you shared your concerns with your health care provider (HCP)?
- B. If I were you, I would be more worried about whether the melanoma has spread.
- C. Scar tissue formation is part of the natural healing process. We will teach you how to care for your wound to minimize any complications.
- D. There is special make-up you can use to hide any facial scars left from the surgery.
Correct Answer: C
Rationale: This response addresses the client's concern about appearance by providing education on wound care to minimize scarring, promoting empowerment and trust. A deflects the concern without addressing it. B dismisses the client's feelings and focuses on an unrelated issue. D assumes scarring and offers a cosmetic solution prematurely, which may not address the client's emotional needs.
You may also like to solve these questions
The nurse is caring for a school-aged client recently diagnosed with attention deficit hyperactivity disorder. The nurse should recognize that the client is at risk for experiencing
- A. delayed physical development
- B. delusions
- C. low self-esteem
- D. Paranoia
Correct Answer: C
Rationale: Children with ADHD often face challenges with academic performance and social interactions, increasing the risk of low self-esteem. A is not typically associated with ADHD. B and D are more relevant to psychotic disorders, not ADHD.
The nurse is caring for a client who had a colostomy two days ago. Which comment the client makes indicates a readiness to learn about caring for the colostomy?
- A. How long will I have to have this thing on my body?'
- B. What is that bag for?'
- C. Did the doctor really do a colostomy?'
- D. Why did this have to happen to me?'
Correct Answer: B
Rationale: Asking about the bag's purpose shows curiosity and readiness to learn about colostomy care. Other comments reflect denial, frustration, or lack of engagement with care.
The nurse is planning a staff education program about intimate partner violence. Which of the following information should the nurse include? Select all that apply.
- A. Intimate partner violence is most common in high-income families.
- B. Intimate partner violence is rare in same-sex partnerships.
- C. The abusive partner often demonstrates jealousy and possessiveness.
- D. Victims may not leave due to financial concerns or fear of harm by the abuser.
- E. Violence against a female often intensifies during pregnancy.
Correct Answer: C,D,E
Rationale: Jealousy/possessiveness, barriers to leaving (financial/fear), and increased violence during pregnancy are accurate. Violence is not limited to high-income families and occurs in same-sex partnerships.
The nurse is caring for a client who has type 2 diabetes mellitus and an elevated hemoglobin A1c. Which statement by the nurse will best address this result?
- A. It is important for us to review the signs and symptoms of a hypoglycemic reaction.
- B. Let's review your diet, exercise, and medication regimen over the past 2-3 months.
- C. Please describe what you have eaten in the last 24-48 hours.
- D. You should fast for at least 8 hours prior to your morning blood work.
Correct Answer: B
Rationale: Elevated A1c reflects poor glycemic control over months, so reviewing diet, exercise, and medications is most relevant. Other options are less comprehensive.
The nurse is measuring the uterine fundal height of a client at 36 weeks gestation lying in a supine position. The client suddenly reports dizziness, and the nurse observes pallor and damp, cool skin. What should the nurse do first?
- A. Alert the supervising registered nurse
- B. Check the client's blood pressure and pulse
- C. Listen to the fetal heart rate
- D. Turn the client to a lateral position
Correct Answer: D
Rationale: Symptoms suggest supine hypotensive syndrome; turning the client to a lateral position relieves uterine pressure on the vena cava, improving blood flow.