A woman who has undergone a right-sided modified-radical mastectomy returns from surgery. Which nursing intervention would be most appropriate for the nurse to include in the client's plan of care at this time?
Encourage her to turn, cough, and deep breathe at frequent intervals.
Ask the client how she feels about having her breast removed.
Attach a sign above her bed to have BP, IV lines, and lab work on her right arm.
Position her right arm below heart level.
The Correct Answer is A
Choice A: Encourage her to turn, cough, and deep breathe at frequent intervals. This intervention is appropriate for the nurse to include in the client's plan of care at this time because it can help prevent respiratory complications such as atelectasis (collapse of lung tissue) or pneumonia after surgery. Turning, coughing, and deep breathing can help expand the lungs, clear the airways, and improve oxygenation.
Choice B: Ask the client how she feels about having her breast removed. This intervention is not appropriate for the nurse to include in the client's plan of care at this time because it may be too intrusive or insensitive. Asking the client how she feels about having her breast removed may trigger emotional distress or anxiety in the client who has just undergone a major surgery that affects her body image and self-esteem. The nurse should wait until the client is more stable and ready to talk about her feelings and concerns.
Choice C: Attach a sign above her bed to have BP, IV lines, and lab work in her right arm. This intervention is not appropriate for the nurse to include in the client's plan of care at this time because it is incorrect and potentially harmful. Attaching a sign above her bed to have BP, IV lines, and lab work in her right arm may cause injury or infection to the arm that has undergone surgery and lymph node removal. The nurse should attach a sign above her bed to have BP, IV lines, and lab work in her left arm instead.
Choice D: Position her right arm below heart level. This intervention is not appropriate for the nurse to include in the client's plan of care at this time because it is incorrect and potentially harmful. Positioning her right arm below heart level may impair the blood circulation and lymphatic drainage of the arm that has undergone surgery and lymph node removal. The nurse should position her right arm above heart level instead.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Sporadic vaginal bleeding accompanied by chronic pelvic pain is not the correct answer because it is not a symptom of cystocele or rectocele. This symptom may indicate other conditions such as endometriosis, fibroids, or cervical cancer.
Choice B: Menstrual irregularities and hirsutism on the chin are not the correct answers because they are not symptoms of cystocele or rectocele. These symptoms may indicate other conditions such as polycystic ovary syndrome (PCOS), thyroid disorder, or menopause.
Choice C: Heavy leukorrhea with vulvar pruritus is not the correct answer because it is not a symptom of cystocele or rectocele. This symptom may indicate other conditions such as bacterial vaginosis, yeast infection, or sexually transmitted infection (STI).
Choice D: Stress incontinence with a feeling of low abdominal pressure is the correct answer because it is a symptom of cystocele or rectocele. Stress incontinence is a condition that causes leakage of urine when there is increased pressure on the bladder, such as during coughing, sneezing, laughing, or lifting. Cystocele or rectocele can cause stress incontinence by weakening the pelvic floor muscles and connective tissue that supports the bladder and urethra. The feeling of low abdominal pressure is also a symptom of cystocele or rectocele, as it indicates that the bladder or rectum is protruding into the vagina.
Correct Answer is A
Explanation
Choice A: "A provider can help you with that after a physical examination." This response is appropriate and respectful because it acknowledges the client's right to choose a contraceptive method that suits her needs and preferences. It also encourages the client to seek professional advice and care from a provider who can assess her health status, medical history, and risk factors, and offer her a range of options and information.
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: "Before I can help you, I need to know more about your sexual activity." This response is inappropriate and intrusive because it asks for personal and sensitive information that may not be relevant or necessary for choosing a contraceptive method. It also violates the client's privacy and may make her feel uncomfortable or embarrassed.
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.