The nurse is developing the discharge plan for a woman who has had a left-sided radical mastectomy. The nurse is including instructions for ways to minimize lymphedema. Which statement by the client indicates the need for additional instruction?

"I need to avoid driving to and from work every day."

"Any blood pressures need to be taken in my right arm."

"I need to wear gloves when doing any gardening."

"I should wear clothing with elasticized sleeves."

Answer and Explanation

The Correct Answer is D

A. "I need to avoid driving to and from work every day."

This statement indicates a misunderstanding of how to minimize lymphedema. Driving itself does not directly contribute to lymphedema. However, activities that involve prolonged or repetitive use of the affected arm, such as gripping the steering wheel while driving for long periods, may increase the risk of developing lymphedema. The nurse should clarify that while driving is generally acceptable, the client should take breaks and perform arm exercises during long drives to promote circulation.

B. "Any blood pressures need to be taken in my right arm."

This statement demonstrates correct understanding. Taking blood pressure measurements, administering injections, or obtaining blood samples from the unaffected arm helps prevent trauma or injury to the arm at risk for lymphedema. This practice helps avoid disrupting lymphatic flow and reduces the risk of developing lymphedema in the affected arm.

C. "I need to wear gloves when doing any gardening."

Wearing gloves during gardening is a recommended precaution to minimize the risk of injury and infection, especially if the client has undergone lymph node removal. This statement reflects appropriate understanding and adherence to preventive measures to protect the affected arm from cuts, scratches, and potential infection that could exacerbate lymphedema.

D. "I should wear clothing with elasticized sleeves."

This statement indicates a misunderstanding of how to minimize lymphedema. While elasticized sleeves or compression garments can help manage lymphedema by providing gentle compression and support to the affected arm, wearing tight or constrictive clothing, including elasticized sleeves, can potentially restrict lymphatic flow and exacerbate lymphedema. The nurse should clarify that loose-fitting clothing is preferable to allow unrestricted movement and circulation in the affected arm.

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Correct Answer is B

Explanation

A. Battering: This phase involves the actual violent and abusive behavior, where the perpetrator inflicts harm or abuse upon the victim. It is characterized by physical, emotional, or psychological abuse.

B. Honeymoon: The honeymoon phase follows the period of violence or abuse. During this phase, the perpetrator may apologize, show remorse, and express love and affection toward the victim. The perpetrator may also promise to change their behavior and make efforts to reconcile with the victim.

C. Tension-building: The tension-building phase is characterized by increasing tension, anger, and hostility in the relationship. Minor conflicts and stressors escalate, leading to a buildup of tension between the partners. This phase often precedes the occurrence of the violent or abusive episode.

D. Reconciliation: The reconciliation phase occurs after the violent or abusive episode, during which the perpetrator attempts to reconcile with the victim. This phase may involve apologies, promises to change, and expressions of regret. However, it is important to note that the reconciliation phase may be temporary and may cycle back into the tension-building phase, leading to another episode of violence.

A. recurrent pelvic infections B. heavy, irregular menses C. use of oral contraceptives for 5 years D. ovarian cyst 2 years ago

Correct Answer is A

Explanation

A. Recurrent pelvic infections:

Pelvic infections, particularly those affecting the fallopian tubes (such as pelvic inflammatory disease), can lead to scarring and damage to the fallopian tubes. Scar tissue can obstruct the normal passage of the fertilized egg, increasing the risk of ectopic pregnancy.

B. Heavy, irregular menses:

While irregular menstrual cycles can sometimes be associated with conditions like polycystic ovary syndrome (PCOS), heavy and irregular menses are not typically considered direct risk factors for ectopic pregnancy. However, underlying conditions contributing to irregular menstrual cycles, such as hormonal imbalances or conditions affecting the reproductive organs, could potentially increase the risk.

C. Use of oral contraceptives for 5 years:

Oral contraceptives (birth control pills) are known to significantly reduce the risk of ectopic pregnancy. They work by preventing ovulation and altering the uterine lining, making it less likely for a fertilized egg to implant outside the uterus. Therefore, long-term use of oral contraceptives would generally decrease the risk of ectopic pregnancy rather than increase it.

D. Ovarian cyst 2 years ago:

While ovarian cysts are common and usually benign, they typically do not directly contribute to the risk of ectopic pregnancy. However, certain types of ovarian cysts, such as those associated with conditions like polycystic ovary syndrome (PCOS) or endometriosis, may indirectly affect fertility and increase the risk of complications during pregnancy, including ectopic pregnancy.

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The nurse is developing the discharge plan for a woman who has had a left-sided radical mastectomy. The nurse is including instructions for ways to minimize lymphedema. Which statement by the client indicates the need for additional instruction?

Nursing Test Bank

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Correct Answer is B

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Correct Answer is A

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