A nurse is preparing a client for discharge after a mastectomy. The nurse teaches the client how to perform arm exercises to prevent lymphedema and promote mobility. Which of the following statements by the client indicates an understanding of the teaching?
"I will start with gentle shoulder shrugs and circles.”
"I will lift my arm above my head several times a day.”
"I will use my affected arm for normal activities as much as possible.”
"I will wear a compression sleeve on my affected arm.”
The Correct Answer is C
Choice A reason:
This is incorrect because gentle shoulder shrugs and circles are not enough to prevent lymphedema and promote mobility. The client needs to perform more active and progressive exercises that involve the full range of motion of the shoulder joint.
Choice B reason:
This is incorrect because lifting the arm above the head several times a day is too aggressive and may cause swelling and pain. The client should gradually increase the elevation of the arm over several weeks, starting with 90 degrees and then progressing to 120 degrees.
Choice C reason:
This is correct because using the affected arm for normal activities as much as possible helps to restore function and prevent stiffness. The client should avoid heavy lifting, tight clothing, blood pressure measurements, and injections on the affected arm, but otherwise should use it for daily tasks such as combing hair, dressing, and eating.
Choice D reason:
This is incorrect because wearing a compression sleeve on the affected arm is not recommended for routine use after a mastectomy. Compression sleeves are only indicated for clients who have developed lymphedema and need to reduce the swelling. They may also be used for air travel or strenuous exercise, but only with a physician's prescription.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Notify the provider of the findings.
Choice A reason:
The client has signs of a possible infection, such as low-grade fever, foul-smelling vaginal discharge and lower abdominal tenderness. These are complications of hysterectomy that require immediate attention from the provider. The provider may order further tests, such as a wound culture or blood tests, and prescribe antibiotics or other treatments. Therefore, notifying the provider is the first action the nurse should take.
Choice B reason:
Obtaining a wound culture from the surgical site may be necessary to identify the type of infection and the appropriate antibiotic therapy. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and follow their orders.
Choice C reason:
Administering an antibiotic as ordered may help treat the infection and reduce the risk of further complications. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and obtain a wound culture if ordered to determine the best antibiotic for the client.
Choice D reason:
Increasing the frequency of perineal care may help prevent or reduce infection by keeping the area clean and dry. However, this is not the first action the nurse should take. The nurse should first notify the provider of the findings and administer an antibiotic as ordered to treat the infection.
Correct Answer is ["D"]
Explanation
The correct answer is choiced. “I will resume my normal activities as soon as I feel better.”
Choice A rationale:Using a pillow between the legs when sleeping is recommended to prevent dislocation of the new hip joint. This helps maintain proper alignment and reduces stress on the hip.
Choice B rationale:Avoiding crossing the legs or bending forward is crucial to prevent dislocation and ensure proper healing of the hip joint. These movements can place undue stress on the new hip.
Choice C rationale:Reporting any signs of infection or bleeding to the doctor is essential for early detection and treatment of complications. This is a standard part of post-operative care.
Choice D rationale:Resuming normal activities as soon as one feels better is not recommended. Patients should follow a gradual rehabilitation plan and the specific instructions of their healthcare provider to avoid complications and ensure proper healing.
Choice E rationale:Taking anticoagulant medication as prescribed is important to prevent blood clots, which are a common risk after hip replacement surgery. This helps ensure the patient’s safety during recovery.
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