A nurse is providing discharge teaching to a client following a modified left radical mastectomy with a breast expander. Which of the following statements by the client indicates an understanding of the teaching?
“will keep my left arm flexed at the elbow as much as possible"
“will have to wait 2 months before additional saline can be added to my breast expander"
“should expect less than 25 ml of secretions per day in the drainage devices."
“will perform strength-building arm exercises using a 15-pound weight."
The Correct Answer is C
Choice A reason:
"will keep my left arm flexed at the elbow as much as possible": This statement is incorrect because after a mastectomy, it's important to promote full range of motion in the affected arm to prevent complications like contractures and lymphedema.
Choice B reason:
“will have to wait 2 months before additional saline can be added to my breast expander" Typically, the process of adding saline to a breast expander begins much sooner, often within a few weeks after surgery, depending on the individual’s healing progress and the surgeon’s protocol.
Choice C reason:
"should expect less than 25 ml of secretions per day in the drainage devices":After a mastectomy, drainage devices are often placed to prevent fluid accumulation. The client should be aware that once the drainage decreases to less than 25 ml per day, it may be an indication that the drain can be removed. This shows an understanding of what to monitor postoperatively.
Choice D reason:
"will perform strength-building arm exercises using a 15-pound weight": This statement is not appropriate, especially shortly after surgery. Gradual and gentle strength-building exercises are recommended, and using a 15-pound weight could be too strenuous and potentially harmful.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Magnesium - While magnesium levels can affect cardiac function, hypomagnesemia is not a primary risk factor for digoxin toxicity.
Choice B Reason:
Potassium. An imbalance of potassium can increase the risk of digoxin toxicity. Hypokalaemia (low potassium levels) enhances the binding of digoxin to its target receptors in the heart, leading to an increased risk of digoxin toxicity. It's essential to monitor potassium levels in clients taking digoxin, as maintaining a stable potassium level helps prevent adverse effects associated with digoxin therapy.
Choice C Reason:
Phosphatase - Phosphate levels are not commonly associated with an increased risk of digoxin toxicity.
Choice D Reason:
Calcium - Calcium levels can affect cardiac function, but they are not a primary factor in the development of digoxin toxicity.
Correct Answer is B
Explanation
Choice A Reason:
Decreased bowel sounds: Hyponatremia (low serum sodium levels) primarily affects the nervous system and can lead to neurological symptoms such as confusion, seizures, and headache. It doesn't typically directly affect bowel sounds. Therefore, this option is not the expected finding.
Choice B Reason:
Increased central venous pressure: As I mentioned earlier, hyponatremia can lead to cerebral edema (swelling of the brain) due to the movement of water into cells. This swelling can increase intracranial pressure and, in turn, affect the central venous pressure by impacting blood return to the heart. While the relationship between hyponatremia and central venous pressure might be complex, it's a more relevant consideration compared to the other options provided.
Choice C Reason:
Hyperreflexia: Hyponatremia can lead to changes in brain function and neurological symptoms, including altered reflexes. Hyperreflexia, which is an exaggerated response to stimuli, can indeed be a manifestation of hyponatremia, making this option a potential expected finding.
Choice D Reason:
Contusion: A contusion is a bruise that results from damage to blood vessels beneath the skin. Hyponatremia is not directly related to the formation of contusions. This option is not the expected finding in a client with low serum sodium levels.
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