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A maternity client is in need of surgery. Which healthcare member is legally responsible for obtaining informed consent for an invasive procedure?
- A. The social worker
- B. The nurse
- C. The physician
- D. The unit secretary
- G. C
Correct Answer: The physician is legally responsible for obtaining informed consent, explaining the procedure's purpose, risks, and alternatives. Nurses may assist, but social workers and unit secretaries have no role in this process.
Rationale:
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A maternity client is in need of surgery. Which healthcare member is legally responsible for obtaining informed consent for an invasive procedure?
- A. The social worker
- B. The nurse
- C. The physician
- D. The unit secretary
- G. C
Correct Answer: The physician is legally responsible for obtaining informed consent, explaining the procedure's purpose, risks, and alternatives. Nurses may assist, but social workers and unit secretaries have no role in this process.
Rationale:
A nurse is caring for a client who is one day postoperative following a left radical mastectomy. Which of the following behaviors should alert the nurse to the possibility that the client is having difficulty adjusting to the loss of her breast?
- A. Refusing to look at the dressing or surgical incision
- B. Asking questions about the information on her postoperative care pamphlet
- C. Performing arm exercises once or twice a day
- D. Asking for pain medication every 3 hours
- G. A
Correct Answer: Refusing to look at the incision may indicate denial or body image issues. Asking questions, exercising, and requesting pain relief suggest positive coping.
Rationale:
A woman who has undergone a right-sided modified-radical mastectomy returns from surgery. Which nursing intervention would be most appropriate for the nurse to include in the client's plan of care at this time?
- A. Encourage her to turn, cough, and deep breathe at frequent intervals.
- B. Ask the client how she feels about having her breast removed.
- C. Attach a sign above her bed to have BP, IV lines, and lab work on her right arm.
- D. Position her right arm below heart level.
- G. A
Correct Answer: Turning, coughing, and deep breathing prevent respiratory complications post-surgery. Asking about feelings is premature, using the right arm risks lymphedema, and elevating the arm aids drainage.
Rationale:
After teaching a group of adolescent girls about female reproductive development, the nurse determines that teaching was successful when the girls state that menarche is defined as a woman's first:
- A. Sexual experience
- B. Menstrual period
- C. Signs of breast development
- G. B
Correct Answer: Menarche is the first menstrual period, marking the onset of fertility. Sexual experience and breast development are unrelated to this definition.
Rationale:
A nurse is preparing a client for radiation treatment who is postoperative following a mastectomy. The nurse should inform the client to expect which of the following adverse effects from the treatment?
- A. Diarrhea
- B. Anorexia
- C. Fatigue
- D. Alopecia
- G. C
Correct Answer: Fatigue is a common side effect of radiation due to damage to healthy cells. Diarrhea and anorexia are more associated with gastrointestinal or systemic treatments, and alopecia is typical with chemotherapy.
Rationale: