A nurse is providing discharge teaching to a client who is 1 day postoperative following a right modified radical mastectomy. Which of the following instructions should the nurse include in the teaching?
Wear a bra with wire support.
Use deodorant under the affected arm.
Begin ball squeezing exercises.
Avoid using the affected arm for eating.
The Correct Answer is D
A. Wear a bra with wire support: This is not recommended immediately after a modified radical mastectomy, as it can put pressure on the surgical site and cause discomfort or interfere with healing. Instead, the client should wear a soft, supportive bra without underwire to provide comfort and support.
B. Use deodorant under the affected arm: Applying deodorant under the affected arm is generally not recommended immediately after surgery, as the area may be sensitive and the skin may be healing. The client should avoid applying deodorant until the surgical site has healed and they have consulted with their healthcare provider.
C. Begin ball squeezing exercises: While exercises to improve range of motion and strength in the affected arm are important after a mastectomy, initiating them on the first day postoperative may be too early. The client should follow the specific instructions provided by their healthcare provider regarding when to begin exercises and which exercises are appropriate.
D. Avoid using the affected arm for eating: This is the most appropriate instruction for the client. After a modified radical mastectomy, the affected arm may be temporarily restricted in movement or may be sensitive. To avoid strain or discomfort, the client should avoid using the affected arm for activities such as eating until they receive further guidance from their healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "Did anything in particular make you feel this way?" - While exploring potential triggers for the client's feelings of uselessness is important, assessing for suicidal ideation takes precedence. However, this question can be asked after addressing the immediate safety concern.
B. "Do you ever think about harming yourself?" - This is the priority assessment question. Older adults experiencing feelings of uselessness and worthlessness may be at risk for suicidal ideation or self-harm. Asking about thoughts of self-harm allows the nurse to assess the client's safety and determine the need for immediate intervention.
C. "How long have you had these feelings of uselessness?" - While understanding the duration of the client's feelings is relevant, assessing for suicidal ideation is more critical in ensuring the client's safety.
D. "Would you tell me more about the changes you see in your body?" - Exploring the client's perception of physical changes is important for addressing body image concerns and promoting self-esteem. However, assessing for suicidal ideation takes precedence as it addresses the client's immediate safety.
Correct Answer is B
Explanation
Answer: B
Rationale:
A) Activate the fire alarm system:
While activating the fire alarm system is essential in alerting everyone to the fire, the immediate safety of the clients must be prioritized first. Ensuring clients are safe from potential harm should precede alerting others.
B) Evacuate clients from the area:
Evacuating clients from the area is the first priority as it directly ensures their safety. In the event of a fire, removing individuals from the source of danger is crucial to prevent injury or harm.
C) Obtain and use a fire extinguisher:
Using a fire extinguisher to put out the fire is important, but it should not be the first action. Ensuring clients are evacuated to safety must take precedence before attempting to control the fire.
D) Close the doors and windows on the unit:
Closing doors and windows can help contain the fire and smoke, but this should follow the evacuation of clients. The primary concern is to get clients to a safe area first before taking measures to contain the fire.
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