A client returns to the surgical unit following a right modified radical mastectomy with dissection of axillary lymph nodes. An appropriate nursing intervention in the postoperative care for the client includes:

changing the surgical dressing when it becomes saturated with drainage.

encouraging the client to obtain permanent breast prosthesis as soon as she is discharged from the hospital.

placing a limb alert bracelet on the right wrist as warning against blood pressure or venipunctures.

teaching the client to use the prescribed patient-controlled analgesia (PCA) every 20 mintues for the best pain relief.

Answer and Explanation

The Correct Answer is C

A.   While it's important to monitor the surgical dressing, changing it too frequently can increase the risk of infection and disrupt healing. Instead, nurses typically assess the dressing regularly and only change it if it's overly saturated or if ordered by a physician. It’s essential to follow specific protocols regarding dressing changes.
B.   A While breast prostheses can be an important part of post-mastectomy care for some clients, it is usually recommended that clients wait until they have fully healed and received counseling regarding their options. Immediate encouragement may be premature, as physical and emotional adjustments take time after surgery.
C.   This is an appropriate intervention. After axillary lymph node dissection, there is a risk of lymphedema in the affected arm. Placing a limb alert bracelet serves as a reminder to healthcare providers to avoid taking blood pressure or performing venipunctures on the affected arm, thus helping prevent complications.
D.   While PCA can be an effective method for managing postoperative pain, the timing and dosage should be based on the specific prescription and the client's individual needs. It’s crucial to educate the client about the PCA device and its use, but the specific interval may vary based on the medication's parameters and the patient's condition.

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Correct Answer is C

Explanation

A. An ischemic stroke occurs when a blood vessel supplying blood to the brain is obstructed. Common symptoms include sudden numbness or weakness in the face, arm, or leg, confusion, difficulty speaking, and visual disturbances. However, "thunderclap" headache and neck stiffness are not typical symptoms of an ischemic stroke.
B. A TIA, often referred to as a "mini-stroke," produces similar symptoms to a stroke but lasts for a short duration (typically less than 24 hours) and does not cause permanent damage. Symptoms can include weakness, speech difficulties, and visual changes, but again, "thunderclap" headache and neck stiffness are not characteristic of a TIA.
C. A subarachnoid hemorrhage occurs when there is bleeding into the space between the brain and the tissues covering it, often due to a ruptured aneurysm. A "thunderclap" headache, described as an extremely sudden and severe headache, is a hallmark of this condition.
D. A cardioembolic stroke is a type of ischemic stroke that occurs when a blood clot forms in the heart and travels to the brain. Symptoms are similar to those of an ischemic stroke and do not typically include a "thunderclap" headache or neck stiffness.

A. Postmenopausal bleeding B. Green, malodorous vaginal discharge C. Extreme abdominal pain with intercourse D. Swelling on the posterior of the vulva

Correct Answer is A

Explanation

A. One of the most common and concerning symptoms of uterine (endometrial) cancer is abnormal vaginal bleeding, particularly postmenopausal bleeding. Any bleeding after menopause is considered abnormal and can be an indicator of uterine cancer, warranting further investigation.
B. While a malodorous vaginal discharge can occur due to infections or other gynecological issues, it is not a primary symptom of uterine cancer. Uterine cancer more commonly presents with bleeding rather than discharge.
C. While some women with advanced uterine cancer may experience pelvic pain or pain during intercourse (dyspareunia), this symptom is not as characteristic or early in the disease process. It is more associated with conditions like endometriosis or pelvic inflammatory disease.
D. This is not a typical manifestation of uterine cancer. While vulvar swelling may be seen in cases of vulvar cancer or infections, it is not a common symptom associated with uterine cancer specifically. Symptoms related to uterine cancer primarily focus on abnormal bleeding.

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A client returns to the surgical unit following a right modified radical mastectomy with dissection of axillary lymph nodes. An appropriate nursing intervention in the postoperative care for the client includes:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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A client returns to the surgical unit following a right modified radical mastectomy with dissection of axillary lymph nodes. An appropriate nursing intervention in the postoperative care for the client includes: