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:
Complete AV block with rates slower than 40/min Complete atrioventricular (AV) block, especially with rates slower than 40 beats per minute (bradycardia), is an indication for the placement of a permanent pacemaker. Complete AV block means there is a complete block in the electrical conduction between the atria and ventricles, resulting in a significant slowing or absence of impulses reaching the ventricles. This can lead to dangerously low heart rates and inadequate cardiac output.
Choice B reason:
Vasovagal bradycardia without syncope - Vasovagal bradycardia is often a temporary response to certain triggers (like pain or emotional stress) and does not typically require a permanent pacemaker.
Choice C reason:
Sinus tachycardia with rates faster than 80/min - Sinus tachycardia is a normal response to various factors, such as exercise, fever, or anxiety. It's not an indication for a permanent pacemaker.
Choice D reason:
Asymptomatic second-degree AV block - Asymptomatic second-degree AV block can be monitored and managed without a pacemaker, especially if the patient is not experiencing any symptoms or hemodynamic compromise. However, the type and severity of the second-degree AV block should be assessed by a healthcare provider to determine the appropriate course of action
Correct Answer is B
Explanation
"I will tell your provider that you do not want to take this medication." - This response does not address the client's concerns and might lead to a confrontational approach.
Choice B Reason:
"Your provider wouldn't prescribe this medication if it weren't necessary." Response B is the most appropriate and therapeutic response in this situation. It acknowledges the client's concerns while also emphasizing the importance of following the provider's prescription. By reassuring the client that the provider's decision to prescribe the medication is based on their assessment and medical judgment, the nurse promotes trust and encourages the client to comply with the treatment plan.
Choice C Reason:
"Most clients feel better after taking the antibiotic." - While true, this response doesn't directly address the client's specific concern and might not alleviate their doubts.
Choice D Reason:
"If you don't take this medication, you will feel worse." - This response might come across as overly negative and could potentially lead to resistance or defensiveness from the client. It's important to approach the situation with empathy and respect for the client's perspective.
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