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.

Answer and Explanation

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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Correct Answer is C

Explanation

Choice A reason: Borderline personality disorder is characterized by instability in relationships, self-image, and emotions, not necessarily by being pouty and demanding attention.

Choice B reason: Schizoid personality disorder involves detachment from social relationships and a limited range of emotional expression, which does not align with the patient's behavior.

Choice C reason: Narcissistic personality disorder includes traits such as needing excessive admiration and having a sense of entitlement, which could explain the patient's behavior.

Choice D reason: Antisocial personality disorder is marked by a disregard for and violation of the rights of others, which is not described in the patient's behavior.

A. Use sterile gloves to place gentle pressure on the exposed organs. B. Have the client lie supine with legs straight. C. Gently suction secretions from the wound bed using a 12-gauge sterile catheter. D. Cover the area with saline-soaked sterile dressings.

Correct Answer is D

Explanation

Choice A reason: Applying gentle pressure on the exposed organs is not recommended as it can cause further damage.

Choice B reason: Having the client lie supine with legs straight is part of the correct positioning, but it does not address the need to protect the exposed organs.

Choice C reason: Suctioning secretions from the wound bed is not the immediate priority and can be harmful to the exposed tissues.

Choice D reason: Covering the area with saline-soaked sterile dressings is the correct intervention to keep the organs moist and reduce the risk of organ damage until surgical repair can be performed.

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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?

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