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).
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Rapid mood swings are not a defining characteristic of major depressive disorder.
Choice B rationale:
Hearing voices is a symptom more commonly associated with conditions like schizophrenia.
Choice C rationale:
Expressing mistrust of the nurse is not a specific symptom of major depressive disorder.
Choice D rationale:
A hallmark symptom of major depressive disorder is anhedonia, which is the diminished ability to experience pleasure or interest in previously enjoyed activities.
Correct Answer is C
Explanation
Choice A rationale:
Teaching about manifestations of anxiety might be important, but addressing the immediate needs of the anxious client takes precedence.
Choice B rationale:
Completing the assessment is important, but if the client is becoming increasingly anxious, immediate intervention is needed.
Choice C rationale:
Reassuring the client of their safety is a priority intervention for managing escalating anxiety. This can help to provide a sense of security and prevent the situation from worsening.
Choice D rationale:
Administering an anti-anxiety medication should not be the first step, especially without assessing the client's current condition and considering non-pharmacological interventions first.
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