The nurse is caring for a client who has just undergone a radical mastectomy and axillary node dissection. When providing client education regarding rehabilitation, which recommendation is appropriate?
Use a sling until healing is complete.
Avoid exercising the affected arm.
Keep cuticles cut neatly.
Continue to exercise the affected arm.
The Correct Answer is D
Choice A reason: Using a sling can lead to stiffness and lymphedema. It is not recommended unless specifically ordered for another condition.
Choice B reason: Avoiding exercise can result in decreased range of motion, contractures, and lymphedema. Gentle, progressive exercises are encouraged.
Choice C reason: Cutting cuticles increases the risk of infection, especially in clients at risk for lymphedema. Nail care should be done cautiously.
Choice D reason: Continuing to exercise the affected arm promotes circulation, prevents stiffness, and reduces the risk of lymphedema. It is a key component of post-mastectomy rehabilitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Staphylococcus species are not the most common cause of pyelonephritis. The predominant pathogen is Escherichia coli, which ascends from the lower urinary tract to infect the renal parenchyma. Staphylococcus may be involved in rare cases, such as hematogenous spread, but it is not typical.
Choice B reason: Pyelonephritis usually presents with noticeable symptoms such as fever, flank pain, nausea, vomiting, and urinary symptoms like dysuria and urgency. Asymptomatic cases are uncommon and typically occur in immunocompromised individuals or those with altered pain perception.
Choice C reason: Pyelonephritis is an infection of the upper urinary tract, specifically the kidneys. The lower urinary tract includes the bladder and urethra. Confusing the anatomical location misrepresents the severity and management of the condition.
Choice D reason: Pyelonephritis can lead to kidney damage if not promptly and adequately treated. Recurrent infections or delayed therapy may result in scarring, impaired renal function, and in severe cases, chronic kidney disease or sepsis.
Correct Answer is A
Explanation
Choice A reason: Iron deficiency anemia is characterized by fatigue, low serum iron and ferritin, and pica—cravings for non-nutritive substances like ice or dirt. These findings align directly with the client’s symptoms.
Choice B reason: Pernicious anemia is caused by vitamin B12 deficiency and presents with neurological symptoms and macrocytic anemia, not pica or low ferritin.
Choice C reason: Hemolytic anemia involves destruction of red blood cells and typically presents with jaundice, dark urine, and elevated bilirubin—not low iron or pica.
Choice D reason: Sickle cell disease is a genetic disorder with vaso-occlusive crises and hemolysis, but it does not present with low iron or cravings for non-food items.
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