A nurse is providing discharge teaching about lymphedema prevention to a client who is 2 days postoperative following a modified radical mastectomy. Which of the following instructions should the nurse include?

Apply lotion to the incisional site twice daily.

Avoid measuring blood pressure on the affected arm.

Apply deodorant under the affected arm daily.

Avoid lifting objects greater than 5.4 kg (12 lb).

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Applying lotion to the incisional site may not be recommended as it could potentially irritate the incision or interfere with wound healing.

Choice B rationale:

Avoiding blood pressure measurements on the affected arm is important to prevent compromising lymphatic flow and potentially exacerbating lymphedema, a common complication after a modified radical mastectomy.

Choice C rationale:

Applying deodorant under the affected arm is discouraged, as it may contain chemicals that could irritate the surgical area.

Choice D rationale:

While lifting heavy objects is generally discouraged after surgery, the specific weight mentioned (5.4 kg or 12 lb) is not consistently supported as a limitation in post- mastectomy care.

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Correct Answer is A

Explanation

Choice A rationale:

Clients with obsessive-compulsive disorder (OCD) often benefit from maintaining control over their daily activities and schedules. Allowing the client autonomy in scheduling activities can help them manage their symptoms while feeling in control.

Choice B rationale:

Antipsychotic medications are not the first-line treatment for OCD, and their use would depend on the presence of other coexisting conditions.

Choice C rationale:

Providing ample time for rituals may inadvertently reinforce the compulsive behaviors associated with OCD. Cognitive-behavioral therapy (CBT) with exposure and response prevention is the recommended treatment for OCD.

Choice D rationale:

Implosion therapy, also known as flooding, exposes the client to anxiety-provoking stimuli in a controlled and safe environment. However, it is not typically the first-line treatment for OCD and requires careful implementation under the guidance of a mental health professional.

A. Is limited to clients who are in an acute care setting B. Provides financial assistance for clients in need C. Is available for clients who have a serious illness D. Is not appropriate for clients still receiving curative treatments

Correct Answer is C

Explanation

Choice A rationale:

Palliative care is not limited to acute care settings and can be provided in various healthcare settings.

Choice B rationale:

While palliative care aims to improve overall well-being, it does not provide financial assistance.

Choice C rationale:

Palliative care focuses on providing relief from symptoms and improving the quality of life for individuals with serious illnesses, regardless of whether they are receiving curative treatments.

Choice D rationale:

Palliative care can be provided alongside curative treatments to address symptoms and enhance quality of life.

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A nurse is providing discharge teaching about lymphedema prevention to a client who is 2 days postoperative following a modified radical mastectomy. Which of the following instructions should the nurse include?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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