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","C","E"]
Explanation
Choice A reason: Mood and affect are essential components of the mental health status examination, reflecting the patient's emotional state and its expression.
Choice B reason: Memory is a cognitive function that is assessed during the mental health status examination to determine if there are any deficits.
Choice C reason: Judgment is evaluated to understand the patient's decision-making abilities, which can be affected in various mental health conditions.
Choice D reason: "Mood and tone" is not a standard component of the mental health status examination. The term "tone" typically refers to the quality of voice or speech.
Choice E reason: Level of awareness and orientation are assessed to determine the patient's consciousness level and their awareness of time, place, and person.
Correct Answer is D
Explanation
Choice A reason: Thinking/content of thought refers to the logical process of thought and coherence, not directly to the experience of reality.
Choice B reason: Mood and affect pertain to the emotional state and its expression, not the perception of reality.
Choice C reason: Judgment involves decision-making abilities and the evaluation of situations, not the perception of reality.
Choice D reason: Perception is the component that deals with how a person experiences reality, including any hallucinations or delusions they may have.
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