A nurse is planning care for a client who has rheumatoid arthritis. Which of the following interventions should the nurse include in the plan?

Choice A rationale:

Beginning ball squeezing exercises is not advisable immediately after a modified radical mastectomy. The client's arm on the affected side needs time to heal, and strenuous exercises can strain the surgical site, increase pain, and potentially disrupt the healing process.

Choice B rationale:

Wearing a bra with wire support is not recommended, especially in the early postoperative period. Underwire bras can irritate the surgical site and interfere with the healing process. Patients are usually advised to wear soft, non-underwire bras or special post-surgical bras designed for comfort and support.

Choice C rationale:

Avoiding the use of the affected arm for eating is the correct instruction. Protecting the surgical site and preventing strain is essential for proper healing. Encouraging the client to use the opposite arm for activities like eating can minimize movement in the affected area, reducing the risk of complications.

Choice D rationale:

Using deodorant under the affected arm is not recommended immediately after surgery. The surgical site needs to be kept clean and dry to prevent infection and promote healing. Deodorants, especially those containing chemicals or fragrances, can irritate the skin and increase the risk of complications. Patients are usually advised to avoid applying any products to the surgical area until it is fully healed.

Choice A rationale:

Documenting the client's vital signs obtained by an assistive personnel is correct. Documenting vital signs is fundamental and immediate requirement when admitting a client to ensure their current health status is accurately captured and can be monitored effectively.

Choice B rationale:

Charting a summary of the data at the change of the shift is incorrect. While it's essential to provide an update at shift change, this option suggests summarizing the data, which might not include all necessary details. Comprehensive documentation is crucial for continuity of care and accurate communication among healthcare providers. Documenting specific vital signs, assessments, interventions, and the client's response to those interventions is necessary for effective patient care.

Choice C rationale:

Noting whether the client has a living will is incorrect. While it's essential to be aware of a client's advanced directives, this information is typically gathered during the admission process or during routine assessments. It is not the immediate action to be taken upon admission. Vital signs and other immediate clinical data take precedence during the initial documentation process.

Choice D rationale:

Beginning charting with an evaluation of the data is incorrect. It is important to document objective data, such as vital signs, observations, and assessments, before making any evaluations or interpretations. Objective data provide the basis for clinical decisions and interventions. Starting with evaluations might lead to biased documentation, potentially overlooking important clinical findings.