A nurse is providing discharge teaching to a client who is 1 day postoperative following a right modified radical mastectomy. Which of the following instructions should the nurse include in the teaching?
Begin ball squeezing exercises.
Avoid using the affected arm for eating.
Use deodorant under the affected arm.
Wear a bra with wire support.
The Correct Answer is A
A. This is the correct answer. Gentle hand exercises, such as ball squeezing, help promote circulation and prevent lymphedema in the affected arm.
B. Avoiding use of the affected arm for eating is incorrect. Gradual movement is encouraged to prevent stiffness and maintain mobility.
C. Using deodorant under the affected arm is not recommended until healing is complete, as it may cause irritation or infection.
D. A bra with wire support should be avoided initially due to discomfort and potential interference with healing.
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Related Questions
Correct Answer is D
Explanation
A. Asking about body changes is important for understanding the client’s self-perception, but it does not address immediate safety concerns.
B. Inquiring about the duration of feelings of uselessness is helpful for assessing depressive symptoms, but it is not the priority over assessing for suicidal intent.
C. Exploring triggers for these feelings is useful for emotional support and planning interventions but is secondary to assessing for immediate risk of self-harm.
D. This question assesses for suicidal ideation, which is the nurse’s priority because older adults experiencing feelings of uselessness or hopelessness are at higher risk for depression and suicide. Early identification of suicidal thoughts ensures prompt intervention and support.
Correct Answer is C
Explanation
A. Placing the client in Trendelenburg position is incorrect because this position does not reduce tension on the abdominal wound and may increase intra-abdominal pressure.
B. Reinserting the protruding intestinal tissue is incorrect because this can introduce infection and cause further damage.
C. This is the correct answer. The priority action is to cover the wound with a sterile, saline-moistened dressing to prevent tissue drying and reduce infection risk.
D. Monitoring vital signs is important, but the priority is to protect the exposed abdominal contents.
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