Nokea
A patient, age 36, is scheduled for a right modified radical mastectomy. She is withdrawn and does not initiate interaction with the nurse. Which activity is the most appropriate nursing action at this time?
- A. Carefully explain the postoperative activity restrictions.
- B. Show her a diagram of what the orchiectomy will accomplish.
- C. Assure her that she will have adequate future sexual functioning.
- D. Assess her concerns related to her diagnosis and treatment.
Correct Answer: D
Rationale: A common patient problem for a patient with a reproductive disorder is having concerns related to the diagnosis and treatment of breast cancer. It is beneficial to listen to the concerns about this treatment.
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Which instruction will a nurse give a patient with genital herpes who does not have lesions at the present?
- A. Continued use of acyclovir will prevent reinfection by the virus.'
- B. Condoms should be used during all sexual activity to prevent transmission of the virus, even when lesions are not present.'
- C. Acyclovir ointment should be applied to the lesions to increase comfort and speed healing.'
- D. Recurrent genital herpes is promoted by any sexual stimulation.'
Correct Answer: B
Rationale: Sexual transmission of HSV (genital herpes, a virus) has been documented even in the absence of clinical lesions, and the use of condoms should be encouraged. Acyclovir does not cure the disease but makes the attacks less virulent.
The patient, age 52, is recovering from a modified radical mastectomy. For which reason will the nurse ensure postoperative elevation of the patient's arm after this procedure?
- A. To prevent vascular and lymph stasis, thus lymphedema.
- B. To prevent drainage accumulation at the incisional site.
- C. To prevent wound infection and dehiscence.
- D. To prevent pleural effusion and respiratory distress.
Correct Answer: A
Rationale: If the arm is not restricted by dressings, it may be elevated on a pillow with the hand and wrist higher than the elbow and the elbow higher than the shoulder joint. This will facilitate the flow of fluids through the lymph and venous routes and prevent lymphedema.
On the second postoperative day, a patient who has had an abdominal hysterectomy complains of gas and abdominal distention. Which intervention would be most appropriate to stimulate a bowel movement?
- A. Offering carbonated beverages
- B. Encouraging ambulation at least four times per day
- C. Administering a 1000-mL soapsuds enema
- D. Applying an abdominal binder
Correct Answer: B
Rationale: Early ambulation is very helpful to return the bowel to normal function.
On the fourth postoperative day after a modified radical mastectomy, the nurse finds the patient with her back to the nurse. She is crying and tells the nurse she feels ugly and is worried that her husband will not be in love with her anymore. The nurse recognizes the interventions in the plan of care will be based which patient problem?
- A. Difficulty accepting the change in body image
- B. Fear, due to inadequate preoperative education.
- C. Mood swings, due to inability to interact with others
- D. Fear of dying, due to the diagnosis of breast cancer
Correct Answer: A
Rationale: After losing a breast, many patients experience grief over the loss of a body part. The process of grieving is essential for personal adaptation to the loss. The nurse can assist the patient to find helpful coping mechanisms.
The nurse instructs a group of women who attend the health clinic that persons who are particularly at risk for cervical cancer are persons who have which risk factor?
- A. smoke.
- B. wear tampons.
- C. have been sexually active since their teens.
- D. have multiple sexual partners.
- E. had chickenpox as a child.
- F. have a history of sexually transmitted infections (STI).
Correct Answer: A,C,D,F
Rationale: Women who have been sexually active since their teens, have multiple sexual partners, and have a history of STDs are more at risk for cancer of the cervix.