The nurse is providing care for a patient who had a mastectomy for breast cancer 2 days ago. What should the nurse include in the daily care?
Empty the drain device every shift.
Minimize use of the affected arm.
Measure the circumference of both arms.
Place the affected arm below the level of the heart.
The Correct Answer is A
Choice A reason: Emptying the drain device every shift is important to prevent infection and accumulation of fluid, which can impede healing.
Choice B reason: Minimizing use of the affected arm is not recommended; rather, gentle exercises to promote circulation and prevent lymphedema are usually encouraged.
Choice C reason: Measuring the circumference of both arms can be part of monitoring for lymphedema, but it is not the priority in immediate post-mastectomy care.
Choice D reason: Placing the affected arm below the level of the heart is not recommended as it can increase swelling; elevation is usually advised.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","D"]
Explanation
Choice A reason: Deep breathing and coughing exercises help clear the lungs and prevent atelectasis, a common postoperative respiratory complication.
Choice B reason: Incentive spirometry encourages patients to take deep breaths, which can help keep the lungs clear of mucus and prevent pneumonia.
Choice C reason: Leg exercises improve circulation and can help prevent blood clots, which can lead to pulmonary embolism, another serious respiratory complication.
Choice D reason: Early ambulation, or getting the patient moving as soon as possible after surgery, is crucial for preventing respiratory complications by promoting circulation and lung expansion.
Choice E reason: Hand squeezes are not directly related to preventing respiratory complications; they are more associated with preventing circulatory complications.
Correct Answer is C
Explanation
Choice A reason: Neuroticism is a personality trait characterized by anxiety, fear, moodiness, worry, envy, frustration, jealousy, and loneliness. It does not involve pretending to be ill.
Choice B reason: Psychosis refers to a mental disorder in which thought and emotions are so impaired that contact is lost with external reality. It is not associated with deliberately pretending to be ill.
Choice C reason: Malingering is the act of exaggerating or feigning illness for a secondary gain, such as financial compensation or avoidance of work.
Choice D reason: Hypochondriasis is a condition in which a person is excessively and unduly worried about having a serious illness. It does not involve deliberately pretending to be ill.
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