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 C
Explanation
Choice A: White- or flesh-colored papillary growths in the genital area are not the correct answer because they are more likely a finding of another STI, such as HPV. HPV can cause genital warts that look like small bumps on or around the genitals. Genital herpes does not cause warts, but blisters or sores that may burst and crust over.
Choice B: Green penile discharge is not the correct answer because it is more likely a finding of another STI, such as gonorrhea. Gonorrhea can cause a thick, yellow-green discharge from the penis that may have a foul odor. Genital herpes does not cause discharge from the penis but may cause pain or burning during urination.
Choice C: Influenza-like symptoms are the correct answer because they are a possible finding of genital herpes. Genital herpes can cause systemic symptoms such as fever, headache, muscle aches, or swollen lymph nodes during an outbreak. These symptoms may resemble those of influenza (the flu) but are caused by HSV infection.
Choice D: Anuria is not the correct answer because it is not a finding of genital herpes. Anuria is a condition that causes a complete absence of urine output due to kidney failure or obstruction. Genital herpes does not affect the kidneys directly but may cause urinary retention if there is severe swelling or pain in the genital area.
Correct Answer is ["B","D","E","F"]
Explanation
Choice A: Cardiac complications are not the correct answer because they are not the main cause of the high infant mortality rate. Cardiac complications are problems that affect the heart or blood vessels of the newborn, such as congenital heart defects, arrhythmias, or heart failure. They can cause serious symptoms such as cyanosis, difficulty breathing, or poor feeding. However, they account for only about 5% of all infant deaths in the United States.
Choice B: Necrotizing enterocolitis is the correct answer because it is the main cause of the high infant mortality rate. Necrotizing enterocolitis is a condition that causes inflammation and death of the intestinal tissue of the newborn, leading to infection, perforation, or sepsis. It can cause symptoms such as abdominal distension, bloody stools, or shock. It is more common in premature or low birth weight infants and accounts for about 10% of all neonatal deaths.
Choice C: Viral infections are not the correct answer because they are not the main cause of the high infant mortality rate. Viral infections are diseases that are caused by viruses that invade the cells of the newborn, such as respiratory syncytial virus (RSV), cytomegalovirus (CMV), or herpes simplex virus (HSV). They can cause symptoms such as fever, cough, rash, or blisters. However, they account for only about 2% of all infant deaths in the United States.
Choice D: Prematurity is the correct answer because it is the main cause of the high infant mortality rate. Prematurity is a condition that occurs when a baby is born before 37 weeks of gestation, which is considered full-term. Premature babies are at risk of developing various complications such as respiratory distress syndrome, intraventricular hemorrhage, or retinopathy of prematurity. Prematurity accounts for about 35% of all infant deaths in the United States.
Choice E: Sudden infant death syndrome is the correct answer because it is the main cause of the high infant mortality rate. Sudden infant death syndrome is a condition that causes the unexpected and unexplained death of an apparently healthy baby during sleep. The exact cause of sudden infant death syndrome is unknown, but some risk factors include sleeping on the stomach, overheating, smoking exposure, or soft bedding. Sudden infant death syndrome accounts for about 15% of all infant deaths in the United States.
Choice F: Low birth weight is the correct answer because it is the main cause of the high infant mortality rate. Low birth weight is a condition that occurs when a baby is born weighing less than 2,500 grams (5 pounds 8 ounces). Low birth weight babies are at risk of developing various complications such as hypothermia, hypoglycemia, or jaundice. Low birth weight accounts for about 25% of all infant deaths in the United States.
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