A nurse is caring for a client who is 2 days postoperative following a total bilateral mastectomy. The client is tearful and looks away when her surgical dressings are removed. The nurse should place the priority on which of the following actions?
Explanation & Rationale
A. Encouraging the client to write about her feelings in a journal each day.: While journaling can be therapeutic, it may not be the best immediate intervention. The client may first need support and validation of her feelings before engaging in such an activity. B. Demonstrating a nonjudgmental attitude toward the client when providing care for her surgical wounds.: This is important for maintaining therapeutic communication, but it does not address the emotional distress the client is currently experiencing. C. Identifying the client's perception of the changes in her physical appearance.: The client is likely struggling with body image changes following a bilateral mastectomy. The priority should be to assess the client’s emotional response to her altered appearance and to offer emotional support. This provides the foundation for helping the client process her feelings. D. Providing the client with information on community resources that will strengthen her coping skills.: While community resources can be helpful later on, the immediate priority is understanding the client’s emotional response to her surgery. Once the nurse has established the client's emotional needs, then providing resources may be more appropriate.