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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Choice A reason: This response acknowledges the client's feelings without agreeing with the delusion or challenging their reality, which can help in building trust and rapport.

Choice B reason: Asking "Why do you think you are being lied about and poisoned?" could potentially reinforce the delusion and lead the client to further justify their beliefs.

Choice C reason: Directly telling the client they are mistaken can be confrontational and may damage the therapeutic relationship.

Choice D reason: Asking "Who is lying about you and trying to poison you?" can validate the delusion and is not a therapeutic response.

A. Notify the registered nurse. B. Raise the head of the bed. C. Sit with her and listen to her concerns. D. Ask the patient what is wrong.

Correct Answer is B

Explanation

Choice A reason: Notifying the registered nurse is important but should come after initially assessing the patient's immediate needs.

Choice B reason: Raising the head of the bed may help with breathing but does not address the cause of the patient's distress.

Choice C reason: Sitting with her and listening to her concerns is supportive but should follow an initial assessment of why she is sobbing and gasping for breath.

Choice D reason: Asking the patient what is wrong is the first step in assessing the situation and providing appropriate care.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has schizophrenia. The client states, "They lie about me all the time and are trying to poison my food." Which of the following responses should the nurse make?

Correct Answer is A

Explanation

The nurse is caring for a patient who is one day post-mastectomy and notes that she is sobbing and gasping for breath. What should the nurse do first?

Correct Answer is B

Explanation

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