The nurse is caring for a client that has undergone a modified left radical mastectomy with lymph node removal. Which intervention would assist in preventing lymphedema?
Avoiding arm exercise in the immediate post-op period
Instruct the client to sleep in the left lateral side lying position
Placing cool compresses on the affected arm
Elevating the affected arm on a pillow above the level of the heart
The Correct Answer is D
A. This statement is not advisable. While it is essential to avoid strenuous activity initially, gentle arm exercises and range-of-motion activities are generally encouraged as soon as possible to promote circulation and help prevent lymphedema. Immobilization can actually increase the risk of lymphedema.
B. This intervention is not recommended for preventing lymphedema. Sleeping on the side of the surgery (in this case, the left side) can put pressure on the affected arm and may not promote proper lymphatic drainage. Clients are often advised to sleep on their back or to position themselves in a way that does not compress the affected arm.
C. This intervention can provide temporary relief if there is swelling or discomfort, but it does not effectively prevent lymphedema. While cool compresses might help reduce inflammation, they are not a primary measure for lymphedema prevention.
D. This is the most effective intervention for preventing lymphedema. Elevating the affected arm helps facilitate lymphatic drainage and reduces the risk of fluid accumulation. Keeping the arm elevated above heart level encourages proper circulation and helps manage swelling.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Limiting fluids with meals is not a recommended practice for preventing prostatitis. Staying hydrated is generally encouraged to promote urinary health. This option does not address the prevention of prostatitis recurrence.
B. This is a good instruction. Frequent voiding helps reduce the risk of urinary stasis and potential bacterial growth in the urinary tract, which can contribute to prostatitis. Encouraging the client to empty their bladder regularly is beneficial in preventing recurrence.
C. While monitoring PSA levels can be important for assessing prostate health, it is not a direct preventive measure for prostatitis recurrence. PSA tests are primarily used to screen for prostate cancer or monitor prostate conditions rather than prevent prostatitis itself.
D. This recommendation is not appropriate for preventing prostatitis. While caffeine may irritate the bladder and prostate, decaffeinated drinks typically do not have the same effect and can be a good source of hydration. Avoiding decaffeinated drinks does not contribute to prostatitis prevention.
Correct Answer is A
Explanation
A. A mass in the mediastinum can compress the trachea or major blood vessels, leading to shortness of breath, particularly when the patient is in a supine position (lying flat). This symptom is indicative of significant obstruction or compression, making it a key sign.
B. While lymphadenopathy (swelling of lymph nodes) is a hallmark of Hodgkin's Lymphoma, it does not specifically indicate the presence of a mediastinal mass. Lymph nodes can swell throughout the body, including cervical, axillary, and inguinal regions, but this symptom is more general and not exclusive to mediastinal involvement.
C. Low-grade fevers can occur in Hodgkin's Lymphoma due to systemic effects of the cancer, such as cytokine release. However, this symptom is nonspecific and does not directly indicate a mediastinal mass. It is more indicative of the body's response to cancer rather than localized effects.
D. Drenching night sweats are another common systemic symptom associated with Hodgkin's Lymphoma. Like low-grade fevers, night sweats are part of the B symptoms that can occur with lymphoma but are not specifically indicative of a mediastinal mass.
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