The nurse is providing care for a patient who had a mastectomy for breast cancer 2 days ago. What should the nurse include in the daily care?
Empty the drain device every shift.
Minimize use of the affected arm.
Measure the circumference of both arms.
Place the affected arm below the level of the heart.
The Correct Answer is A
Choice A reason: Emptying the drain device every shift is important to prevent infection and accumulation of fluid, which can impede healing.
Choice B reason: Minimizing use of the affected arm is not recommended; rather, gentle exercises to promote circulation and prevent lymphedema are usually encouraged.
Choice C reason: Measuring the circumference of both arms can be part of monitoring for lymphedema, but it is not the priority in immediate post-mastectomy care.
Choice D reason: Placing the affected arm below the level of the heart is not recommended as it can increase swelling; elevation is usually advised.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: It is not recommended for clients to take morning vitamins before surgery due to the risk of aspiration and interference with anesthesia.
Choice B reason: Clients are typically instructed to remove all jewelry, including tongue studs, to prevent complications during surgery.
Choice C reason: Clients are generally required to fast before surgery, which includes not consuming clear liquids, to reduce the risk of aspiration.
Choice D reason: Allowing the client to keep her hearing aids in is important for communication and to reduce anxiety due to hearing impairment.
Correct Answer is C
Explanation
Choice A reason: Conversion typically refers to the expression of psychological distress through physical symptoms, which is not the case here.
Choice B reason: Undoing is a defense mechanism where a person tries to 'undo' an unhealthy thought or behavior with a healthier one, which does not apply to Michael's situation.
Choice C reason: Compensation is a defense mechanism where a person overachieves in one area to make up for deficiencies in another, which describes Michael's actions.
Choice D reason: Sublimation involves channeling unacceptable impulses into socially acceptable activities, which is not explicitly indicated in this scenario.
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