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 {"A":{"answers":"C"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}
Explanation
Allogeneic Transplant
Matched Donor: This refers to a donor who is not genetically identical to the recipient but has a similar tissue type. This can include unrelated donors who are matched through registries.
Sibling Donor: A sibling can be a potential donor if they have a matching tissue type. Since siblings share genes, there is a higher chance of finding a match.
Autologous Transplant
Self-Donor: In this type of transplant, the patient donates their own stem cells before undergoing treatment (such as chemotherapy or radiation). These cells are then stored and re-infused after treatment to help the body recover.
Syngeneic Transplant
Twin Donor: This involves a donor who is an identical twin. Since identical twins have the same genetic makeup, there is a perfect match, reducing the risk of graft-versus-host disease (GVHD).
Correct Answer is B
Explanation
A. Using a cold compress is typically employed for reducing swelling or discomfort, but it does not address the visual deficits associated with homonymous hemianopia. This intervention would not assist the client in compensating for their visual field loss.
B. Teaching scanning techniques involves training the client to actively search for visual information from their affected side. This can include turning their head and using their eyes to scan to the left (for right homonymous hemianopia) or to the right (for left homonymous hemianopia). This compensatory strategy is crucial for helping the client navigate their environment safely and effectively during rehabilitation.
C. Applying an eye patch is not appropriate for homonymous hemianopia, as it may further limit visual input. In fact, patching could exacerbate difficulties by reducing overall vision and is generally more relevant for conditions like amblyopia or for treating diplopia (double vision), rather than compensating for a visual field deficit.
D. Using eye drops is typically for treating dry eyes, redness, or other ocular conditions, and does not directly address the issues related to homonymous hemianopia. This intervention would not help the client learn to compensate for their visual field loss.
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