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

Answer and Explanation

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

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Correct Answer is A

Explanation

A. This response is relevant and helps assess the characteristics of the lump. Pain can be an important factor in differentiating between conditions, such as epididymitis, testicular torsion, or tumors. However, while it is a useful question, it may not provide a comprehensive assessment of the situation.
B. This question can be relevant depending on the underlying cause of the lump. Issues with urination may suggest a problem related to the prostate or bladder rather than the testicle itself. While it can help assess urinary tract involvement, it may not directly address the significance of the lump in the testicle.
C. This question is important in the context of sexually transmitted infections (STIs), which can cause scrotal swelling or lumps due to conditions like epididymitis or orchitis. However, it does not directly assess the lump itself, making it less focused on the immediate concern.
D. This question addresses the possibility of an STI and related conditions. While it is relevant, it is not the best immediate question concerning the lump in the testicle. The presence of discharge may not directly correlate with the testicular lump itself.

A. A right sided calcaneal spur B. A blood pressure of 222/112 mmHg C. Glycosylated hemoglobin of 5.9% D. Recent endoscopy

Correct Answer is B

Explanation

A. A calcaneal spur, or heel spur, is a bony growth on the heel bone. This condition is primarily related to foot pain and does not have a direct link to the risk of stroke. It is not relevant in assessing stroke risk.
B. This elevated blood pressure reading indicates hypertension, which is a significant risk factor for both ischemic and hemorrhagic strokes. Chronic high blood pressure can lead to damage of the blood vessels, making them more susceptible to rupture, thus increasing the risk of a hemorrhagic stroke.
C. A glycosylated hemoglobin (HbA1c) level of 5.9% indicates well-managed diabetes, typically within the normal range for most individuals. While uncontrolled diabetes is a risk factor for vascular disease, this level suggests adequate control and does not specifically indicate an increased risk for a hemorrhagic stroke.
D. A recent endoscopy itself does not indicate a direct risk for a hemorrhagic stroke. However, if the endoscopy was performed due to gastrointestinal bleeding or if it resulted in complications, there could be indirect implications, but this option alone does not signify an increased risk for hemorrhagic stroke.

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ABG Value	Normal Range
PH	7.35-7.45
PaCO2	35-45 mm Hg
HCO3-	22-26 mEq/L
Base excess	-2 to +2
PaO2	80-95 mm Hg
SaO2	>95%

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a male patient who complains about a small "lump" that he discovered in his right testicle. What would be the best response by the nurse?

Correct Answer is A

Explanation

Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?

Correct Answer is B

Explanation

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