The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema?
Her healthcare provider now prescribes a calcium channel blocker for hypertension.
She sustained an insect bite to her left arm yesterday.
She has lost twenty pounds since the surgery.
Her hobby is playing classical music on the piano.
The Correct Answer is B
Choice A rationale: Her healthcare provider prescribing a calcium channel blocker for hypertension is not directly linked to lymphedema.
Choice B rationale: Sustaining an insect bite to her left arm yesterday - Trauma or injury, such as an insect bite, to the affected limb post-mastectomy can increase the risk of
lymphedema.
Choice C rationale: Losing twenty pounds since the surgery might influence overall health but doesn’t specifically relate to lymphedema.
Choice D rationale: Her hobby of playing classical music on the piano is unrelated to the risk of developing lymphedema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: The 42-yr-old patient with secondary amenorrhea may have menopause, pregnancy, or a hormonal disorder. This is less urgent compared to the 19- year old patient.
Choice B rationale: This patient may have toxic shock syndrome, which is a life- threatening complication of tampon use that can cause organ failure and shock. The nurse should assess the patient's vital signs, remove the tampon, and initiate fluid resuscitation and antibiotic therapy.
Choice C rationale: This patient may have an infection or a complication of the balloon thermotherapy, which is a procedure to destroy the endometrial lining of the uterus and is not an emergency compared to the 19 year old.
Choice D rationale: This patient may have a displacement or perforation of the IUD, which is a contraceptive device that releases progestin into the uterus. However, this is not urgent compared to the 19 year old.
Correct Answer is D
Explanation
Choice A rationale: Asymmetric facial movement might be associated with damage to other cranial nerves, not specifically cranial nerve III.
Choice B rationale: Uvula deviation is a sign of damage to the glossopharyngeal (IX) and vagus (X) nerves, not cranial nerve III.
Choice C rationale: Anosmia, the loss of sense of smell, is not typically associated with cranial nerve III dysfunction.
Choice D rationale: Damage to cranial nerve III (oculomotor nerve) can lead to ptosis, the drooping of the eyelid.
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