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. Jaundice:

Jaundice refers to the yellowing of the skin and whites of the eyes due to elevated levels of bilirubin in the blood. While jaundice can be a sign of liver dysfunction or obstruction of the bile ducts, it is not typically associated with a ruptured ectopic pregnancy. Therefore, assessing for jaundice would not be the priority in this situation.

B. Hemorrhage:

Hemorrhage, or excessive bleeding, is the priority assessment in a suspected case of a ruptured ectopic pregnancy. A ruptured ectopic pregnancy can lead to significant internal bleeding, which can quickly become life-threatening. Signs and symptoms of hemorrhage may include hypotension, tachycardia, abdominal pain, dizziness, fainting, and signs of shock. Prompt recognition and management of hemorrhage are crucial to stabilize the client's condition and prevent further complications.

C. Edema:

Edema refers to the abnormal accumulation of fluid in the body tissues, resulting in swelling. While edema can occur in various conditions, such as heart failure or kidney disease, it is not typically associated with a ruptured ectopic pregnancy. Assessing for edema would not be the priority in this situation.

D. Infection:

Infection can occur as a complication of a ruptured ectopic pregnancy, particularly if there is contamination of the abdominal cavity by blood and tissue from the ruptured fallopian tube. However, the immediate concern in a suspected case of a ruptured ectopic pregnancy is hemorrhage, as it poses an immediate threat to the client's life. While infection is a concern, it is secondary to hemorrhage in terms of priority assessment and management.

A. The batterer is contrite and attempts to apologize for the behavior. B. The victim accepts the anger as legitimately directed at him or her. C. The physical battery is abrupt and unpredictable. D. Verbal assaults begin to escalate toward the victim.

Correct Answer is D

Explanation

A. The batterer is contrite and attempts to apologize for the behavior. - This action is more characteristic of the "honeymoon" phase, which follows the tension-building phase and involves the abuser expressing remorse or making promises to change.

B. The victim accepts the anger as legitimately directed at him or her. - This is not specifically characteristic of the second phase but could potentially occur as a coping mechanism or as a result of manipulation and gaslighting tactics employed by the abuser.

C. The physical battery is abrupt and unpredictable. - This description aligns more closely with the acute battering incident, which occurs in the final phase of the cycle of violence, following the tension-building phase.

D. Verbal assaults begin to escalate toward the victim. - This option reflects the tension-building phase, where verbal abuse and other forms of intimidation may escalate in frequency and intensity as the tension between the abuser and victim increases.

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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

Naxlex Comprehensive Predictor Exams

A client is suspected of having a ruptured ectopic pregnancy. Which assessment would the nurse identify as the priority?

Correct Answer is B

Explanation

A nurse is listening to a client who is a victim of intimate partner violence. The client is describing how events would unfold with the partner. The nurse interprets the client's statements and identifies which action as characteristic of the second phase of the cycle of violence?

Correct Answer is D

Explanation

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