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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Calling the surgeon to talk to the patient may be helpful in some cases, but it does not directly address the patient's immediate emotional needs. The surgeon can provide detailed information about the procedure, which might alleviate some fears, but this is not always the immediate solution.
Choice B reason:
Offering to call the chaplain for the patient could provide emotional and spiritual support, which is important in holistic care. However, this should be done in addition to addressing the patient's concerns about the surgery itself.
Choice C reason:
Informing the patient that the survival rate for this surgery is very high directly addresses the patient's fear about not surviving the surgery. Providing factual reassurance about the success rate can help to alleviate anxiety and is an appropriate immediate response.
Choice D reason:
Recommending analgesics only during surgery does not address the patient's expressed fear and is not an appropriate response to the emotional concern. Analgesics are for pain management and do not provide reassurance about the outcome of the surgery.
Correct Answer is C
Explanation
Choice A reason: Paranoid personality disorder is characterized by distrust and suspicion, not the behaviors described.
Choice B reason: Dependent personality disorder involves a need to be taken care of and a fear of separation, which does not align with David's behaviors.
Choice C reason: Antisocial personality disorder includes a disregard for and violation of the rights of others, deceitfulness, and impulsivity, which aligns with David's behaviors.
Choice D reason: Schizoid personality disorder is characterized by detachment from social relationships and a restricted range of emotional expression, not matching David's behaviors.
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