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
Choice A reason:
Tingling in the fingers and toes is a sign of paresthesia, which is a common symptom of hypocalcemia. Hypocalcemia occurs when the blood calcium level is too low, which can happen after a thyroidectomy if the parathyroid glands are damaged or removed. The parathyroid glands produce parathyroid hormone, which regulates calcium balance in the body. Without enough parathyroid hormone, calcium levels drop and cause neuromuscular irritability and numbness or tingling sensations.
Choice B reason:
Difficulty swallowing and speaking is not a specific sign of hypocalcemia, but rather a possible complication of a thyroidectomy due to injury to the recurrent laryngeal nerve. This nerve innervates the muscles of the larynx, which control voice production and swallowing. Damage to this nerve can cause hoarseness, weak voice, or vocal cord paralysis.
Choice C reason:
Dry mouth and increased thirst are not signs of hypocalcemia, but rather signs of dehydration. Dehydration can occur for various reasons, such as fluid loss, inadequate fluid intake, or increased fluid needs. Dehydration can affect the electrolyte balance in the body, but it does not directly cause hypocalcemia.
Choice D reason:
Muscle weakness and fatigue are not specific signs of hypocalcemia, but rather general signs of malaise. Malaise can occur for various reasons, such as infection, inflammation, stress, or chronic illness. Malaise can affect the physical and mental well-being of a person, but it does not directly cause hypocalcemia.
Correct Answer is B
Explanation
Choice A reason:
This is not the best response because it does not address the patient's pain experience or offer any empathy. It also implies that medication is the only option for pain relief, which may not be true.
Choice B reason:
This is the best response because it acknowledges the patient's pain and asks them to elaborate on how it affects their daily activities. This can help the nurse assess the impact of pain on the patient's quality of life and plan appropriate interventions.
Choice C reason:
This is not the best response because it focuses on the duration and triggers of pain, which are more relevant for chronic pain than acute pain. It also does not show empathy or validate the patient's pain rating.
Choice D reason:
This is not the best response because it only expresses sympathy but does not ask the patient any questions or offer any solutions. It may also sound patronizing or dismissive to some patients.
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