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A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching?

A.

"I should expect less than 25 mL of secretions per day in the drainage devices."

B.

"I will perform strength-building arm exercises using a 15-pound weight."

C.

"I will keep my left arm flexed at the elbow as much as possible."

D.

"I will have to wait 2 months before additional saline can be added to my breast expander."

Answer and Explanation

The Correct Answer is A

A. Less than 25 mL of secretions per day in the drainage devices is an expected finding after surgery. The nurse should instruct the client to monitor the drainage and report if the output exceeds this amount, as it could indicate a complication.  

B. Performing strength-building arm exercises using a 15-pound weight is not recommended immediately after surgery. The client should start with gentle range-of-motion exercises and gradually increase the intensity, but heavy weightlifting should be avoided in the early recovery period.  

C. Keeping the left arm flexed at the elbow for prolonged periods is not recommended. The client should be encouraged to perform exercises to prevent stiffness and improve mobility in the affected arm, but excessive flexion can lead to contractures.  

D. The client may begin the process of saline expansion in the breast expander soon after surgery, typically within a few weeks. Waiting 2 months may be too long, as expansion is often started earlier to avoid complications such as capsular contracture.  
 


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Related Questions

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"C"},"D":{"answers":"C"},"E":{"answers":"B"},"F":{"answers":"A"}}

Explanation

Rationale

Interpretation of Findings:

  • Productive cough:
    • Unrelated to diagnosis
      A productive cough is not directly related to cirrhosis. It may indicate a respiratory issue, but it does not directly reflect the progression or improvement of the client's liver condition.
  • Spontaneous bruising:
    • Indication of potential worsening condition
      Spontaneous bruising suggests a decline in clotting function, which is common in advanced cirrhosis due to impaired liver synthesis of clotting factors.
  • Hematemesis:
    • Indication of potential worsening condition
      Hematemesis indicates gastrointestinal bleeding, which could result from esophageal varices or other complications of portal hypertension, a severe complication of cirrhosis.
  • Ascites:
    • Indication of potential worsening condition
      Ascites reflects worsening fluid retention and portal hypertension, indicating the progression of cirrhosis.
  • Increased albumin level:
    • Indication of potential improvement
      An increased albumin level suggests improved liver synthetic function or nutritional status, which is a positive sign in a client with cirrhosis.
  • Elevated iron:
    • Unrelated to diagnosis
      Elevated iron levels are associated with the client's history of hemochromatosis but are not directly indicative of the progression or improvement of cirrhosis in this context.

Correct Answer is D

Explanation

A. The PPD test is typically evaluated 48 to 72 hours after administration, so returning in another 48 hours is not necessary at this point.

B. The frequency of PPD testing depends on the individual's risk factors and exposure to tuberculosis (TB), not necessarily on an annual basis.

C. The test does not need to be repeated at this time. A 12 mm induration is a positive result for individuals with certain risk factors, and further evaluation is needed rather than repeating the test.

D. A 12 mm induration is considered a positive result for the PPD test in individuals with moderate risk factors for TB. The nurse should instruct the client to follow up with their provider for further evaluation, which may include a chest X-ray or other diagnostic tests.

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