A nurse is providing discharge teaching to a client following a modified left radical mastectomy with a breast expander. Which of the following statements by the client indicates an understanding of the teaching?
“will keep my left arm flexed at the elbow as much as possible"
“will have to wait 2 months before additional saline can be added to my breast expander"
“should expect less than 25 ml of secretions per day in the drainage devices."
“will perform strength-building arm exercises using a 15-pound weight."
The Correct Answer is C
Choice A reason:
"will keep my left arm flexed at the elbow as much as possible": This statement is incorrect because after a mastectomy, it's important to promote full range of motion in the affected arm to prevent complications like contractures and lymphedema.
Choice B reason:
“will have to wait 2 months before additional saline can be added to my breast expander" Typically, the process of adding saline to a breast expander begins much sooner, often within a few weeks after surgery, depending on the individual’s healing progress and the surgeon’s protocol.
Choice C reason:
"should expect less than 25 ml of secretions per day in the drainage devices":After a mastectomy, drainage devices are often placed to prevent fluid accumulation. The client should be aware that once the drainage decreases to less than 25 ml per day, it may be an indication that the drain can be removed. This shows an understanding of what to monitor postoperatively.
Choice D reason:
"will perform strength-building arm exercises using a 15-pound weight": This statement is not appropriate, especially shortly after surgery. Gradual and gentle strength-building exercises are recommended, and using a 15-pound weight could be too strenuous and potentially harmful.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason:
Disequilibrium with movement is correct. The vestibulocochlear nerve (cranial nerve VIII) is responsible for both hearing (cochlear component) and balance (vestibular component). Impaired function of this nerve can result in problems with equilibrium and balance, leading to symptoms such as disequilibrium or vertigo (a sensation of spinning or whirling), especially with movement.
Choice B Reason:
Deviation of the tongue from midline is incorrect. This is related to cranial nerve XII (hypoglossal nerve) and its role in tongue movement and control.
Choice C Reason:
Loss of peripheral vision is incorrect. This is related to cranial nerve II (optic nerve) and its role in vision.
Choice D Reason:
Inability to smell is incorrect. This is related to cranial nerve I (olfactory nerve) and its role in the sense of smell.
Correct Answer is C
Explanation
Choice A reason:
Recommending staying at a local shelter might not be appropriate unless the client's health is in immediate danger due to the low temperature. It's better to explore other options first.
Choice B reason:
Contacting the client's family members about their financial status might not be necessary or respectful of the client's privacy without their consent.
Choice C reason:
Contact the local Department of Health and Human Services for the client. Contacting the local Department of Health and Human Services can help ensure that appropriate resources and assistance are provided to the client. They may have programs or services available to assist individuals who are struggling to afford heating during the winter. This action addresses the immediate concern of the client's health and the living environment.
Choice D reason:
Providing information about the dangers of hypothermia is important, but the client's current situation of living in a cold environment should be addressed first. The nurse can provide this information along with appropriate resources to help the client.
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