A nurse is providing discharge teaching for a client who is postoperative following a simple mastectomy. The client is to begin outpatient radiation therapy the next day. Which of the following instructions about maintaining skin integrity should the nurse include?
Do not apply heat to the area of irradiation.
Use an antibiotic ointment to treat skin breakdown.
Lubricate the skin with hypoallergenic lotion.
Do not wash the area of irradiation.
The Correct Answer is A
Choice A: Do not apply heat to the area of irradiation. This instruction is correct and should be included in the teaching. Applying heat to the area of irradiation can increase inflammation, pain, or burning sensation on the skin. The client should avoid heat sources such as hot water, heating pads, or sun exposure in the area of irradiation.
Choice B: Use an antibiotic ointment to treat skin breakdown. This instruction is not correct and should not be included in the teaching. Using an antibiotic ointment to treat skin breakdown can cause allergic reactions, infection, or interference with radiation therapy. The client should consult with her provider before using any topical products in the area of irradiation.
Choice C: Lubricate the skin with hypoallergenic lotion. This instruction is not correct and should not be included in the teaching. Lubricating the skin with hypoallergenic lotion can cause irritation, infection, or interference with radiation therapy. The client should avoid applying any lotions, creams, or oils on the area of irradiation unless prescribed by her provider.
Choice D: Do not wash the area of irradiation. This instruction is not correct and should not be included in the teaching. Washing the area of irradiation can help prevent infection, remove dead skin cells, and reduce odor. The client should wash the area of irradiation gently with mild soap and water, pat it dry, and avoid rubbing or scrubbing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A: Reports of itching, tingling and pain in genital area are the correct answer because they are common symptoms of genital herpes. Genital herpes is a sexually transmitted infection (STI) caused by the herpes simplex virus (HSV). It can cause outbreaks of painful blisters or sores on or around the genitals, anus, or mouth. The blisters or sores usually heal within a few weeks, but the virus remains in the body and can reactivate at any time. Before an outbreak, some people may experience prodromal symptoms such as itching, tingling, or pain in the affected area.
Choice B: Painful urination with a penile discharge present is not the correct answer because it is more likely a symptom of another STI, such as gonorrhea or chlamydia. Gonorrhea and chlamydia are bacterial infections that can affect the urethra, cervix, rectum, or throat. They can cause symptoms such as burning or pain during urination, abnormal discharge from the penis or vagina, or bleeding between periods.
Choice C: Wart-like flesh-colored lesions on the scrotal area are not the correct answer because they are more likely a symptom of another STI, such as human papillomavirus (HPV). HPV is a viral infection that can cause genital warts or cervical cancer. Genital warts are small, soft, flesh-colored growths that can appear on or around the genitals, anus, or mouth. They may be flat, raised, or cauliflower-shaped.
Choice D: A chancre on the penis is not the correct answer because it is more likely a symptom of another STI, such as syphilis. Syphilis is a bacterial infection that can affect various organs and systems of the body. It has four stages: primary, secondary, latent, and tertiary. In the primary stage, syphilis causes a painless sore called a chancre that can appear on or around the genitals, anus, or mouth. The chancre usually heals within a few weeks, but the infection can progress to the next stages if left untreated.
Correct Answer is D
Explanation
Choice A:This response suggests that a physical examination is necessary before providing contraceptive advice. While a healthcare provider may conduct a physical examination as part of comprehensive care, making it a prerequisite for discussing contraception can create barriers for adolescents seeking information. Emphasizing a physical exam may deter open communication, as adolescents might feel apprehensive or judged. Effective contraceptive counseling should prioritize building rapport and understanding the individual's needs and concerns before proceeding to clinical
Choice B: "You are so young. Are you ready for the responsibilities of a sexual relationship?" This response is inappropriate and judgmental because it implies that the client is too immature or irresponsible to have a sexual relationship. It also discourages the client from seeking help or information from the nurse and may make her feel ashamed or guilty about her sexuality.
Choice C: "Because of your age, I think that a barrier method would be the best choice." This response is inappropriate and paternalistic because it assumes that the nurse knows what is best for the client without considering her individual situation or preferences. It also limits the client's options and may not address her specific needs or concerns.
Choice D:This response is appropriate as it seeks to gather more information about the adolescent's sexual activity, which is crucial for providing tailored contraceptive advice. Understanding the individual's sexual behavior, frequency of activity, number of partners, and risk factors allows the healthcare provider to recommend the most suitable contraceptive methods and address any concerns about sexually transmitted infections. The Centers for Disease Control and Prevention highlight the importance of personalized counseling that takes into account the adolescent's specific circumstances to promote effective contraceptive use and sexual health.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.