Nokea
The nurse is caring for a client who has just undergone a mastectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Encourage arm exercises on the affected side.
- B. Keep the affected arm dependent.
- C. Apply heat to the surgical site.
- D. Restrict fluid intake.
Correct Answer: A
Rationale: Encouraging arm exercises prevents lymphedema and promotes circulation post-mastectomy.
You may also like to solve these questions
You are a home health nurse caring for an elderly client in their home. They have children and grandchildren but they live far from the client and they typically visit with your clients once to two times a year. The elderly man is beginning to show some of the signs of Alzheimer's disease dementia. The wife is also 88 years of age and has had a stroke which has left her with left sided weakness, but she is willing to help her husband and to maintain his safety. What kind of support should you give the wife in terms of her role caring for her husband?
- A. You should advise the couple to move closer to their children so that they can care for their father.
- B. You should teach the wife about this progressive disease and the need to promote as much independence as possible.
- C. You should teach the wife about this progressive disease and the need to do all that she can for the husband to avoid his depression and frustration.
- D. You should advise the couple to decrease their social activities in order to preserve the husband's dignity and self-esteem.
Correct Answer: B
Rationale: Educating the wife about Alzheimer's disease and promoting the husband's independence as much as possible supports safety and dignity while respecting her role as a caregiver with physical limitations.
You are caring for a group of elderly clients, many of whom are affected with multiple chronic disorders and are also, at times, affected with some acute disorders that require medical and nursing attention. As you are caring for these clients some will need a new medication regimen for an acute disorder. You should consider that fact that the elderly population is at risk for more side effects, adverse drug reactions, and toxicity and over dosages of medications because the elderly have a (n):
- A. Increased creatinine clearance.
- B. Impaired immune system.
- C. Decreased hepatic metabolism.
- D. Increased bodily fat.
Correct Answer: C
Rationale: Elderly individuals often have decreased hepatic metabolism due to reduced liver function, which affects drug metabolism and increases the risk of side effects, adverse reactions, and toxicity.
A 1-year-old is brought to the clinic with failure to thrive. Which assessment should the nurse prioritize?
- A. Dietary intake history
- B. Motor milestone development
- C. Head circumference
- D. Skin turgor
Correct Answer: A
Rationale: Dietary intake history is critical in failure to thrive to identify inadequate caloric intake or feeding issues, guiding intervention.
A client with a diagnosis of myasthenia gravis is prescribed pyridostigmine (Mestinon). The nurse should teach the client to take the medication:
- A. On an empty stomach.
- B. With meals to reduce side effects.
- C. At bedtime to promote sleep.
- D. As needed for muscle weakness.
Correct Answer: B
Rationale: Pyridostigmine should be taken with food to reduce gastrointestinal side effects like nausea.
The nurse asks the client to sign a consent form before undergoing surgery. The client indicates that he was not told about the risks of the surgical procedure. Which of the following statements by the nurse is most appropriate?
- A. What are your concerns? I can answer any questions that you have.'
- B. You can go ahead and sign the form. I will be sure to tell the surgeon you have questions.'
- C. It is important that your questions are answered before you consent to the procedure. I will contact the surgeon.'
- D. I'm sure the risks are minimal, so you don't need to worry.'
Correct Answer: C
Rationale: Ensuring the client's questions about risks are answered before signing consent is critical for informed consent, requiring the nurse to contact the surgeon.